Impact of resistance mutations on efficacy of dolutegravir plus rilpivirine or plus lamivudine as maintenance regimens: a cohort study.

OBJECTIVES: The aim of this study was to evaluate the impact of resistance mutations on efficacy of dolutegravir-based two-drug regimens (2DR). METHODS: Virologically suppressed patients with HIV-1 switching to dolutegravir + lamivudine or rilpivirine or to a dolutegravir-based three-drug regimen (3DR) with pre-baseline genotype were selected. Virological failure (VF) was defined as one HIV-RNA viral load (VL) >200 cps/mL or two consecutive VL >50 cps/mL; treatment failure (TF) was defined as VF or treatment discontinuation (TD). Resistance was defined as at least low-level resistance to at least one drug of the current regimen. Propensity score matching was used to conduct adjusted analyses within a competing risks framework. RESULTS: A total of 971 dolutegravir-based regimens were selected: 339 (34.9%) 2DR and 632 (65.1%) 3DR. The adjusted cumulative 48-week incidence of VF was 4.2% (90% CI 3.1%-5.3%) with 2DR and 4.7% (90% CI 3.5%-5.8%) with 3DR. The cumulative 48-week incidence of TF was 15.8% (90% CI 13.9%-17.9%) with 2DR and 24.5% (90% CI 22.2%-27.0%) with 3DR. For VF, the estimated hazard ratio (HR) for 2DR vs. 3DR was 1.02 (90% CI: 0.78-1.34), with evidence of effect modification by low-level resistance (HR 3.96, 90% CI: 2.10-7.46). The estimated HR of TF for 2DR vs. 3DR was 0.54 (90% CI: 0.48-0.60). The 48-week cumulative incidence of TD was 11.7% (8.7%, 14.6%) in 2DR and 19.6% (16.9%, 22.4%) in 3DR. CONCLUSIONS: Dolutegravir-based 2DR showed high virological efficacy and durability; however, past resistance increased the risk of VF, but not of TD or TF.

Prevalence of resistance-associated substitutions to NS3, NS5A and NS5B inhibitors at DAA-failure in hepatitis C virus in Italy from 2015 to 2019.

Despite the high efficacy of direct-acting antivirals (DAAs), the selection of resistance-associated substitutions (RASs) after virological failure of hepatitis C virus (HCV) DAAs can impair the cure of chronic HCV. The aim of the study was to characterize RASs after virological failure of DAAs in Italy over the years. Within the Italian network VIRONET-C, the change in prevalence of NS3/4A-NS5A-NS5B RASs was retrospectively evaluated in patients who failed a DAA regimen over the years 2015-2019. NS3, NS5A and NS5B Sanger sequencing was performed using homemade protocols and the geno2pheno system was used to define HCV-genotype/subtype and predict drug resistance. The changes in the prevalence of RASs over time were evaluated using the chi-square test for trend. Predictors of RASs at failure were analysed by logistic regression. Among 468 HCV-infected patients, HCV genotype 1 was the most prevalent (1b in 154, 33% and 1a in 109, 23%). DAA regimens were: ledipasvir (LDV)/sofosbuvir (SOF) in 131 patients (28%), daclatasvir (DCV)/SOF in 109 (23%), ombitasvir/paritaprevir/ritonavir+dasabuvir (3D) in 89 (19%), elbasvir (EBR)/grazoprevir (GRZ) in 52 (10.5%), velpatasvir (VEL)/SOF in 53 (11%), glecaprevir (GLE)/pibrentasvir (PIB) in 27 (6%) and ombitasvir/paritaprevir/ritonavir (2D) in 7 (1.5%); ribavirin was administered in 133 (28%). The NS5A fasta sequence was available for all patients, NS5B and NS3/4A both for 93%. The prevalence of NS5A and NS3/4A RASs significantly declined from 2015 to 2019; NS5B RAS remained stable. Independent predictors of any RASs included older age and genotype 1a (vs G2 and vs G4). Notably, at least partial susceptibility to all the agents included in the GLE/PIB and VEL/SOF/Voxilaprevir (VOX) combinations was predicted in >95% of cases. As RASs remain common at the failure of DAAs, their identification could play a crucial role in optimizing re-treatment strategies. In Italy RAS prevalence has been decreasing over the years and susceptibility to the latest developed drug combinations is maintained in most cases.

Discordant Liver Fibrosis Predictors in Virologically Suppressed People Living with HIV without Hepatitis Virus Infection.

Severe liver fibrosis (LF) is associated with poor long-term liver-related outcomes in people living with HIV (PLWH). The study aimed to explore the prevalence and predictors of LF and the concordance between different non-invasive methods for the estimation of LF in HIV-infected individuals without hepatitis virus infection. We enrolled PLWH with HIV-1-RNA <50 copies/mL for >12 months, excluding individuals with viral hepatitis. LF was assessed by transient elastography (TE) (significant >6.65 kPa), fibrosis-4 (FIB-4) (significant >2.67), and AST-to-platelet ratio index (APRI) (significant >1.5). We included 234 individuals (67% males, median age 49 years, median time from HIV diagnosis 11 years, 38% treated with integrase strand transfer inhibitors). In terms of the TE, 13% had ≥F2 stage; FIB-4 score was >1.5 in 7%; and APRI > 0.5 in 4%. Higher body mass index, diabetes mellitus, detectable baseline HIV-1 RNA and longer atazanavir exposure were associated with higher liver stiffness as per TE. Predictors of higher APRI score were CDC C stage and longer exposure to tenofovir alafenamide, while HBcAb positivity and longer exposure to tenofovir alafenamide were associated to higher FIB-4 scores. Qualitative agreement was poor between FIB-4/TE and between APRI/TE by non-parametric Spearman correlation and kappa statistic. In our study, in the group of PLWH without viral hepatitis, different non-invasive methods were discordant in predicting liver fibrosis.

Use of miltefosine in a patient with mucosal leishmaniasis and HIV-coinfection: a challenge in long-term management.

The management of mucosal leishmaniasis in immunocompromised patients is not standardized and limited data are available on the use of miltefosine for treatment and secondary prophylaxis. We describe a case of mucosal leishmaniasis in an HIV-coinfected patient treated with miltefosine due to a severe allergic reaction to liposomal amphotericin B.

Non-granulomatous cerebellar infection by Acanthamoeba spp. in an immunocompetent host.

Acanthamoeba spp. is a free-living amoeba, frequently involved in keratitis by contact lens in immunocompetent hosts. Anecdotal reports associate Acanthamoeba spp. as a cause of severe granulomatous encephalitis in immunocompromised and, less frequently, in immunocompetent subjects. Data regarding clinical and therapeutic management are scanty and no defined therapeutic guidelines are available. We describe an unusual case of non-granulomatous Acanthamoeba cerebellitis in an immunocompetent adult male, with abrupt onset of neurological impairment, subtle hemorrhagic infarction at magnetic resonance imaging, and initial suspicion of cerebellar neoplasm. Histopathological findings of excised cerebellar mass revealed the presence of necrosis and inflammation with structure resembling amoebic trophozoites, but without granulomas. Polymerase chain reaction from cerebellar tissue was positive for Acanthamoeba T4 genotype. Due to gastrointestinal intolerance to miltefosine, the patient was treated with long-term course of fluconazole and trimethoprim/sulphamethoxazole, obtaining complete clinical and neuroradiological resolution.

Accumulation of HIV-1 drug resistance in patients on a standard thymidine analogue-based first line antiretroviral therapy after virological failure: implications for the activity of next-line regimens from a longitudinal study in Mozambique.

BACKGROUND: We describe the accumulation of HIV-1 drug resistance and its effect on the activity of next-line components in patients with virological failure (HIV-1 RNA >1000 copies/mL) after 1 year (t1) of first-line antiretroviral therapy (ART) not switching to second-line drugs for one additional year (t2) in low-middle income countries (LMIC). METHODS AND RESULTS: We selected 48 patients from the DREAM cohort (Maputo, Mozambique); their median pre-ART CD4+ cell count was 165 cells/µl. At t1 patients were receiving ART since a median of 12.2 months (mainly zidovudine/lamivudine/nevirapine), their median HIV RNA was 3.8 log10 copies/mL, 43 (89.6%) presented at least one resistance-associated mutation (RAM), most frequently for lamivudine/emtricitabine, nevirapine and efavirenz. Resistance to tenofovir, was 10% at 1 year and higher than 20% at 2 years, while projection at 3 years was >30%. At t2, 42 (89.4%) had a predicted low-level or higher resistance to at least 1 s-line drug. At t1, the frequency of RAM in patients with a lower adherence to pharmacy appointments (<95%) was significantly lower (12/20, 60% for NRTI and 14/20, 70% for NNRTI) than in those with a better adherence (26/28, 92.8% for NRTI and 25/28, 89.3% for NNRTI) (OR 0.12, 95% CI 0.02-0.63, p = 0.012 and OR 0.28, 95% CI 0.06-1.29, p = 0.103, respectively). Overall thymidine analogue mutations (TAMs) accumulation rate was 0.32/year, 0.50/year in the subgroup with HIV RNA >10,000 copies/mL; NNRTI RAM accumulation rate was 0.15/year, 0.40/year in the subgroup with HIV RNA >10,000 copies/mL. CONCLUSIONS: While the activity of NNRTIs is compromised early during failure, tenofovir and zidovudine activity are reduced more frequently after 1 year of documented virological failure of thymidine analogue-based first-line ART, with RAMs accumulating faster in patients with higher viral loads. The present observation may help informing decisions on when to switch to a second line ART in patients on virological failure in LMIC.

Seroprevalence of hepatitis E virus (HEV) infection in blood donors and renal transplant recipients: a retrospective study from central Italy.

Autochthonous hepatitis E virus (HEV) is an emerging health issue in developed countries and is thought to be a porcine zoonosis; its spread is underestimated and there is concern about the possibility of chronic infection in immunosuppressed patients; HEV transmission through blood has also been demonstrated. We conducted a retrospective study (2007-2013) on HEV seroprevalence using stored serum samples from 132 blood donors and 118 renal transplant recipients living mainly in central Italy. Anti-HEV IgG was positive in 12/132 (9.1%) of the blood donors and 12/118 (10.2%) of the transplant recipients. All subjects but one were autochthonous and none showed signs of liver disease at the time of sampling. A significant association was documented between mean age of patients and the serology against HEV especially in the group of blood donors. Our study, albeit limited and retrospective, confirms the circulation of autochthonous HEV in central Italy; the presence of antibodies against HEV in particular categories of persons such as blood donors and transplant patients, who are not screened for the infection, raises questions in terms of transfusion safety and health protection of immunocompromised patients.

Petechial rash associated with Parvovirus B19 in children: case report and literature review.

Human Parvovirus B19 (B19V) infection usually causes erythema infectiosum (EI). In recent decades, several uncommon exanthems have been described in association with B19V. Recently, haemorrhagic manifestations such as purpuric-petechial rash have been reported. We describe an unusual paediatric case of B19V associated with generalized petechial eruption, and a review of the recent literature.

Imported dengue fever in Tuscany, Italy, in the period 2006 to 2012.

This report focuses on epidemiological and clinical features of dengue fever (DF) in Tuscany (Italy) between 2006 and 2012. Sixty-one DF cases were diagnosed, 32 of which were in the period of Aedes albopictus activity. Some clinical (arthralgia/myalgia, nausea/vomiting, and skin rash), laboratory (leukopenia and thrombocytopenia), and epidemiological characteristics (travel in a continent other than Africa) significantly distinguished DF cases from other febrile illnesses. Our data stress the importance of increasing awareness on dengue in Italy among clinicians in order to reach an early diagnosis in returning travelers and to implement appropriate clinical and public health interventions.

Five-year retrospective Italian multicenter study of visceral leishmaniasis treatment.

The treatment of visceral leishmaniasis (VL) is poorly standardized in Italy in spite of the existing evidence. All consecutive patients with VL admitted at 15 Italian centers as inpatients or outpatients between January 2004 and December 2008 were retrospectively considered; outcome data at 1 year after treatment were obtained for all but 1 patient. Demographic characteristics, underlying diseases, diagnostic procedures, treatment regimens and outcomes, as well as side effects were recorded. A confirmed diagnosis of VL was reported for 166 patients: 120 (72.3%) immunocompetent, 21 (12.6%) patients with immune deficiencies other than HIV infection, and 25 (15.1%) coinfected with HIV. Liposomal amphotericin B (L-AmB) was the drug almost universally used for treatment, administered to 153 (92.2%) patients. Thirty-seven different regimens, including L-AmB were used. The mean doses were 29.4 ± 7.9 mg/kg in immunocompetent patients, 32.9 ± 8.6 mg/kg in patients with non-HIV-related immunodeficiencies, and 40.8 ± 6.7 mg/kg in HIV-infected patients (P < 0.001). The mean numbers of infusion days were 7.8 ± 3.1 in immunocompetent patients, 9.6 ± 3.9 in non-HIV-immunodeficient patients, and 12.0 ± 3.4 in HIV-infected patients (P < 0.001). Mild and reversible adverse events were observed in 12.2% of cases. Responsive patients were 154 (93.3%). Successes were 98.4% among immunocompetent patients, 90.5% among non-HIV-immunodeficient patients, and 72.0% among HIV-infected patients. Among predictors of primary response to treatment, HIV infection and age held independent associations in the final multivariate models, whereas the doses and duration of L-AmB treatment were not significantly associated. Longer treatments and higher doses of L-AmB were not able to significantly modify treatment outcomes either in the immunocompetent or in the immunocompromised population.

HCMV infection in renal transplant recipients: a retrospective cohort study.

Human Cytomegalovirus (HCMV) represents the most common viral complication affecting solid organ transplant recipients (SOTRs) and its management is still debated. This study analyzes the association between HCMV infection and renal transplant recipients' outcomes. From January 2008 through December 2009, 97 consecutive renal transplant recipients were retrospectively studied. HCMV disease prevention was pursued by pre-emptive therapy, reserving long-term prophylaxis for high-risk patients. A total of 32/97 patients (32.9%) developed HCMV positivity in blood for a cumulative estimated proportion at 3 months post-transplantation of 0.21. HCMV disease developed in 7 patients (7.2%), while 25 patients had asymptomatic infection (25.7%). No patient died from HCMV. HCMV disease, older graft age and post-transplant renal dysfunction were independent predictors of rejection while HCMV infection without disease was associated with a higher number of other complications. The use of basiliximab was independently associated with a reduced hazard of HCMV infection/ disease. In renal transplant recipients HCMV infection still represents a major issue influencing the outcome, not only because of the potential to develop the disease and its link to graft rejection, but also in terms of higher number of complications. The choice of different immunosuppressive strategies might be associated with HCMV replication.

Large oligoclonal outbreak due to Klebsiella pneumoniae ST14 and ST26 producing the FOX-7 AmpC ß-lactamase in a neonatal intensive care unit.

A large outbreak caused by expanded-spectrum cephalosporin-resistant Klebsiella pneumoniae (ESCRKP) was observed in a neonatal intensive care unit (NICU) in central Italy. The outbreak involved 127 neonates (99 colonizations and 28 infections, with seven cases of sepsis and two deaths) over a period of more than 2 years (February 2008 to April 2010). Characterization of the 92 nonredundant isolates that were available for further investigation revealed that all of them except one produced the FOX-7 AmpC-type ß-lactamase and belonged to either sequence type 14 (ST14) or ST26. All of the FOX-7-positive isolates were resistant to cefotaxime, ceftazidime, and piperacillin-tazobactam, while 76% were susceptible to cefepime, 98% to ertapenem, 99% to meropenem, and 100% to imipenem. The two carbapenem-nonsusceptible isolates had alterations in the genes encoding outer membrane proteins K35 and K36, which resulted in truncated and likely nonfunctional proteins. The outbreak was eventually controlled by the reinforcement of infection control measures based on a multitiered interventional approach. This is the first report of a large NICU outbreak caused by ESCRKP producing an AmpC-type enzyme. This study demonstrates that AmpC-type enzyme-producing strains can cause large outbreaks with significant morbidity and mortality effects (the mortality rate at 14 days was 28.5% for episodes of sepsis), and it underscores the role of laboratory-based surveillance and infection control measures to contain similar episodes.

[Which screening for Leishmania infantum in asymptomatic blood donors?]. / Leishmania infantum e donatori di sangue: quale screening?

Leishmaniasis is a protozoan infection endemic in Italy with a greatly underestimated prevalence. The recent documentation of parasitaemia in blood donors is a cause of concern for blood safety. Because there is no screening against leishmania, we performed a study to assess the presence of protozoa in blood donors of Siena district (Tuscany) during the seasonal activity of the vector. From June to October 2007, 162 patients were screened for Leishmania infantum by indirect immunofluorescence serology (IFAT) and PCR for kinetoplast (kDNA). No subject was positive for antibodies, while 11 samples (6.8%) were positive for kDNA. A second PCR (nested-PCR) was negative for all kDNA positive individuals and other subjects for a total of 55 samples (33% of total subjects). The sequence analysis of three samples positive for kDNA was compatible with mitochondrial DNA. Through the techniques used, we were unable to confirm the presence of leishmania in the blood of the subjects studied. The choice of the diagnostic protocol in blood donors remains an open issue as molecular analysis (kDNA) seems to suggest, in our experience, limits of specificity.

Toscana virus epidemiology: from Italy to beyond.

Toscana virus (TOSV) is an arthropod-borne virus which is transmitted to humans by Phlebotomus spp sandflies. Infection is the cause of brain injuries, such as aseptic meningitis and meningoencephalitis, in Italy mainly during the summer. More recently some unusual clinical manifestations due to TOSV with severe sequelae, such as ischemic complications and hydrocephalus, have been reported. TOSV represents an important emerging pathogen and its presence is being investigated in several European countries on the Mediterranean basin, including Italy, France, Spain, Portugal and Cyprus. Phylogenetic analysis has distinguished two genotypes of TOSV, A and B; the first is circulating mainly in Italy and the second in Spain, indicating a different geographic distribution possibly related to the vector. This distribution, evolving with the climate, globalization and habitat modification, has implications for the epidemiology of TOSV.

Dicrocoelium dendriticum: a true infection?

Dicrocoelium dendriticum is a liver parasite of ruminants. Humans are occasionally infected by ingestion of intermediate hosts. We report a rare case of dicrocoeliasis in a 55-year-old woman who presented with eosinophilia and elevated bilirubin. Therapy with albendazole eradicated the parasite and normalized blood parameters.

Outbreak and persistence of Chlamydia pneumoniae infection in an Italian family.

We describe an outbreak of familial infection of Chlamydia pneumoniae, an etiological agent for respiratory tract infections. In a family member detection of C. pneumoniae on a pharyngeal swab by polymerase chain reaction was positive until four months after the onset of symptoms, despite a course of antibiotics known to be effective against Chlamydia species

Sternoclavicular joint infection in an adult without predisposing risk factors.

Septic arthritis of the sternoclavicular joint (SCJ) is an uncommon condition and it has been associated with numerous predisposing factors. We describe a rare case of SCJ infection due to Staphylococcus aureus in an adult without known underlying predisposing conditions and in which recovery was achieved with medical therapy alone.