RESUMO
Despite the huge advance that antiretroviral therapy represents for the prognosis of infection by the human immunodeficiency virus (HIV), opportunistic infections (OIs) continue to be a cause of morbidity and mortality in HIV-infected patients. OIs often arise because of severe immunosuppression resulting from poor adherence to antiretroviral therapy, failure of antiretroviral therapy, or unawareness of HIV infection by patients whose first clinical manifestation of AIDS is an OI. The present article updates our previous guidelines on the prevention and treatment of various OIs in HIV-infected patients, namely, infections by parasites, fungi, viruses, mycobacteria, and bacteria, as well as imported infections. The article also addresses immune reconstitution inflammatory syndrome.
Assuntos
Infecções por HIV/complicações , Infecções Oportunistas/tratamento farmacológico , Infecções Oportunistas/prevenção & controle , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Terapia Antirretroviral de Alta Atividade , Infecções Bacterianas/tratamento farmacológico , Coinfecção , Humanos , Síndrome Inflamatória da Reconstituição Imune/tratamento farmacológico , Síndrome Inflamatória da Reconstituição Imune/prevenção & controle , Infecções por Mycobacterium/tratamento farmacológico , Infecções por Mycobacterium/prevenção & controle , Micoses/tratamento farmacológico , Micoses/prevenção & controle , Infecções Oportunistas/etiologia , Doenças Parasitárias/tratamento farmacológico , Doenças Parasitárias/prevenção & controle , Viroses/tratamento farmacológico , Viroses/prevenção & controleRESUMO
Opportunistic infections continue to be a cause of morbidity and mortality in HIV-infected patients. They often arise because of severe immunosuppression resulting from poor adherence to antiretroviral therapy, failure of antiretroviral therapy, or unawareness of HIV infection by patients whose first clinical manifestation of AIDS is an opportunistic infection. The present article is an executive summary of the document that updates the previous recommendations on the prevention and treatment of opportunistic infections in HIV-infected patients, namely, infections by parasites, fungi, viruses, mycobacteria, and bacteria, as well as imported infections. The article also addresses immune reconstitution inflammatory syndrome. This document is intended for all professionals who work in clinical practice in the field of HIV infection.
Assuntos
Infecções por HIV/complicações , Infecções Oportunistas/tratamento farmacológico , Infecções Oportunistas/prevenção & controle , Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/prevenção & controle , Coinfecção/tratamento farmacológico , Coinfecção/prevenção & controle , Humanos , Síndrome Inflamatória da Reconstituição Imune/diagnóstico , Síndrome Inflamatória da Reconstituição Imune/tratamento farmacológico , Síndrome Inflamatória da Reconstituição Imune/prevenção & controle , Micoses/tratamento farmacológico , Micoses/prevenção & controle , Doenças Parasitárias/tratamento farmacológico , Doenças Parasitárias/prevenção & controle , Viroses/tratamento farmacológico , Viroses/prevenção & controleRESUMO
In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and grade of the recommendation vary depending on the CD4+ T-lymphocyte count, the presence of opportunistic infections or comorbid conditions, age, and the efforts to prevent the transmission of HIV. The objective of ART is to achieve an undetectable plasma viral load (PVL). Initial ART should comprise three drugs, namely, two nucleoside reverse transcriptase inhibitors (NRTI) and one drug from another family. Three of the recommended regimens, all of which have an integrase strand transfer inhibitor (INSTI) as the third drug, are considered a preferred regimen; a further seven regimens, which are based on an INSTI, an non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor boosted with ritonavir (PI/r), are considered alternatives. The reasons and criteria for switching ART are presented both for patients with an undetectable PVL and for patients who experience virological failure, in which case the rescue regimen should include three (or at least two) drugs that are fully active against HIV. The specific criteria for ART in special situations (acute infection, HIV-2 infection, pregnancy) and comorbid conditions (tuberculosis and other opportunistic infections, kidney disease, liver disease, and cancer) are updated.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , HIV-1 , Infecções Oportunistas Relacionadas com a AIDS , Adulto , Fármacos Anti-HIV/administração & dosagem , Fármacos Anti-HIV/efeitos adversos , Terapia Antirretroviral de Alta Atividade , Aleitamento Materno , Contagem de Linfócito CD4 , Comorbidade , Contraindicações , Farmacorresistência Viral , Substituição de Medicamentos , Quimioterapia Combinada , Feminino , Infecções por HIV/imunologia , HIV-1/efeitos dos fármacos , HIV-2 , Humanos , Gravidez , Complicações Infecciosas na Gravidez/tratamento farmacológico , Carga Viral , Viremia/tratamento farmacológicoRESUMO
Background: We compared proportions of participants with target detected, target not detected (TND), and elevated viral load (VL) and assessed baseline variables associated with week 144 inflammatory biomarker levels between dolutegravir-lamivudine (DTG/3TC) and tenofovir alafenamide-based regimens (TBRs) in the TANGO study (post hoc). Methods: TANGO is an open-label, multicenter, phase 3 study that randomized adults with VL <50â copies/mL to switch to once-daily fixed-dose DTG/3TC or continue TBR. At baseline and each study visit, the VL was measured. Elevated VL event frequencies were assessed, including "blips." Interleukin 6, D-dimer, high-sensitivity C-reactive protein, soluble CD14, and soluble CD163 were measured at baseline and at week 144. Loge-transformed week 144 biomarker levels were compared between treatment groups using an analysis of covariance model adjusting for baseline variables. Results: High, comparable proportions of participants had VL <40â copies/mL and TND at week 144 (DTG/3TC, 279 of 369 [76%]; TBR, 267 of 372 [72%], intention-to-treat exposed Snapshot analysis; adjusted difference, 3.9% [95% confidence interval, -2.5% to 10.2%]), with similar TND proportions at all postbaseline visits (123 of 369 [33%] vs 101 of 372 [27%], respectively). Similar proportions of DTG/3TC participants had ≥1 postbaseline VL ≥50â copies/mL (28 of 369 [8%] vs 42 of 372 [11%] for TBR), primarily blips (18 of 369 [5%] and 26 of 372 [7%], respectively). Week 144 inflammatory biomarker levels were low and comparable between groups and associated with multiple demographic and baseline characteristics, including baseline biomarker levels, indicating a multifactorial inflammatory response. Conclusions: Week 144 biomarker levels were low and generally comparable between treatment groups, reflecting similar, robust, and durable viral suppression observed using the stringent TND end point. Trial registration: ClinicalTrials.gov, NCT03446573.
RESUMO
Main cause of severe illness and death in COVID-19 patients appears to be an excessive but ineffectual inflammatory immune response that may cause severe acute respiratory distress syndrome (ARDS). Vitamin D may favour an anti-inflammatory environment and improve cytotoxic response against some infectious diseases. A multicenter, single-blind, prospective, randomized clinical trial was approved in patients with COVID-19 pneumonia and levels of 25-hydroxyvitamin D (25(OH)D) of 14.8 ng/ml (SD: 6.18) to test antiviral efficacy, tolerance and safety of 10,000 IU/day of cholecalciferol (vitamin D3) for 14 days, in comparison with 2000 IU/day. After supplementation, mean serum 25(OH)D levels increased to 19 ng/ml on average in 2000 IU/day versus 29 ng/ml in 10,000 IU/day group (p < 0.0001). Although levels of inflammatory cytokines were not modified by treatment with 10,000 IU/day, there was an increase of anti-inflammatory cytokine IL-10 and higher levels of CD4+ T cells, with predominance of T central memory subpopulation. Cytotoxic response against pseudotyped SARS-CoV-2 infected cells was increased more than 4-fold in patients who received 10,000 IU/day. Moreover, levels of IFNγ were significantly higher in this group. Beneficial effect of supplementation with 10,000 IU/day was also observed in participants who developed ARDS and stayed at the hospital for 8.0 days, whereas those who received 2000 IU/day stayed for 29.2 days (p = 0.0381). Administration of high doses of vitamin D3 as adjuvant of the standard care treatment during hospitalization for COVID-19 may improve the inflammatory environment and cytotoxic response against pseudotyped SARS-CoV-2 infected cells, shortening the hospital stay and, possibly, improving the prognosis.
Assuntos
Tratamento Farmacológico da COVID-19 , Síndrome do Desconforto Respiratório , Colecalciferol/efeitos adversos , Suplementos Nutricionais , Humanos , Imunidade , Estudos Prospectivos , Síndrome do Desconforto Respiratório/tratamento farmacológico , SARS-CoV-2 , Método Simples-Cego , Vitamina D , Vitaminas/uso terapêuticoRESUMO
INTRODUCTION: Spain was one of the most affected countries during the first wave of COVID-19, having the highest mortality rate in Europe. The aim of this retrospective study is to estimate the impact that remdesivir-the first drug for COVID-19 approved in the EU-would have had in the first wave. METHODS: This study simulated the impact that remdesivir could have had on the Spanish National Health System (SNHS) capacity (bed occupancy) and the number of deaths that could have been prevented, based on two scenarios: a real-life scenario (without remdesivir) and an alternative scenario (with remdesivir). It considered the clinical results of the ACTT-1 trial in hospitalized patients with COVID-19 and pneumonia who required supplemental oxygen. The occupancy rates in general wards and ICUs were estimated in both scenarios. RESULTS: Remdesivir use could have prevented the admission of 2587 patients (43.75%) in the ICUs. It could have also increased the SNHS capacity in 5656 general wards beds and 1700 ICU beds, showing an increase in the number of beds available of 17.53% (95% CI 3.98%-24.42%) and 23.98% (95% CI 21.33%-28.22%), respectively, at the peak of the occupancy rates. Furthermore, remdesivir use could have prevented 7639 deaths due to COVID-19, which implies a 27.51% reduction (95% CI 14.25%-34.07%). CONCLUSIONS: Remdesivir could have relieved the pressure on the SNHS and could have reduced the death toll, providing a better strategy for the management of COVID-19 during the first wave.
Assuntos
Tratamento Farmacológico da COVID-19 , Monofosfato de Adenosina/análogos & derivados , Alanina/análogos & derivados , Antivirais/uso terapêutico , Europa (Continente) , Humanos , Estudos Retrospectivos , SARS-CoV-2 , Espanha/epidemiologiaRESUMO
BACKGROUND: treating infectious diseases in elderly individuals is difficult; patient referral to emergency services often occurs, since the elderly tend to arrive at consultations with advanced, serious symptoms. AIM: it was hypothesized that anticipating an infectious disease diagnosis by a few days could significantly improve a patient's well-being and reduce the burden on emergency health system services. METHODS: vital signs from residents were taken daily and transferred to a database in the cloud. Classifiers were used to recognize patterns in the spatial domain process of the collected data. Doctors reported their diagnoses when any disease presented. A flexible microservice architecture provided access and functionality to the system. RESULTS: combining two different domains, health and technology, is not easy, but the results are encouraging. The classifiers reported good results; the system has been well accepted by medical personnel and is proving to be cost-effective and a good solution to service disadvantaged areas. In this context, this research found the importance of certain clinical variables in the identification of infectious diseases. CONCLUSIONS: this work explores how to apply mobile communications, cloud services, and machine learning technology, in order to provide efficient tools for medical staff in nursing homes. The scalable architecture can be extended to big data applications that may extract valuable knowledge patterns for medical research.
Assuntos
Pesquisa Biomédica , Doenças Transmissíveis , Idoso , Computação em Nuvem , Doenças Transmissíveis/diagnóstico , Doenças Transmissíveis/epidemiologia , Humanos , Aprendizado de Máquina , Casas de SaúdeRESUMO
Little is known about raltegravir removal by hemodialysis in patients with end-stage renal disease (ESRD). We therefore measured raltegravir concentrations in plasma in pre- and postdialyzer blood samples from 2 ESRD HIV-infected patients. The hemodialysis extraction ratio and raltegravir hemodialysis clearance were 5.5% and 9.1 ml/min in patient 1 and 9.5% and 19.1 ml/min in patient 2, respectively. Our results suggest minimal raltegravir removal by hemodialysis with no specific raltegravir dosage adjustments required in HIV-infected patients undergoing hemodialysis.
Assuntos
Infecções por HIV/sangue , Infecções por HIV/tratamento farmacológico , Inibidores de Integrase de HIV/sangue , Inibidores de Integrase de HIV/uso terapêutico , Falência Renal Crônica/sangue , Falência Renal Crônica/terapia , Pirrolidinonas/sangue , Pirrolidinonas/uso terapêutico , Diálise Renal/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Raltegravir PotássicoRESUMO
INTRODUCTION: There is a growing increase in prosthetic joint infection (PJI) incidence due to cephalosporin-resistant bacteria, used in surgical prophylaxis. The replacement of these with glycopeptides has not been shown to improve the results, but they have been shown to improve with their combination. METHODS: Comparative study of combination of teicoplanin and cefazolin before arthroplasty surgery against cefazolin alone from a previous control group. RESULTS: During the control period, there were 16 PJIs from 585 surgeries, while in the intervention group there were 6 from 579 (incidence 2.7% vs. 1.03%, RR 0.4, P=.04). In control group, 11 of the infections were caused by Gram-positive bacteria versus 4 in the intervention group (1.8% vs. 0.7%, P=.08). CONCLUSIONS: The addition of teicoplanin to cefazolin in the prophylaxis of arthroplasty surgery was associated with a reduction in the incidence of PJI, thanks to a decrease in infections caused by Gram-positive bacteria.
Assuntos
Antibioticoprofilaxia , Artrite Infecciosa/prevenção & controle , Infecções Bacterianas/prevenção & controle , Cefazolina/uso terapêutico , Infecções Relacionadas à Prótese/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Teicoplanina/uso terapêutico , Idoso , Artrite Infecciosa/epidemiologia , Artrite Infecciosa/etiologia , Artrite Infecciosa/microbiologia , Artroplastia , Infecções Bacterianas/epidemiologia , Infecções Bacterianas/microbiologia , Cefazolina/administração & dosagem , Cefazolina/efeitos adversos , Resistência às Cefalosporinas , Farmacorresistência Bacteriana Múltipla , Substituição de Medicamentos , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/microbiologia , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/microbiologia , Teicoplanina/administração & dosagem , Teicoplanina/efeitos adversosRESUMO
OBJECTIVES: Sexualized intravenous drug use, also known as slamsex, seems to be increasing among HIV-positive men who have sex with men (MSM). Physical and psychopathological symptoms have previously been reported in this population, although research on the subject of slamsex is scarce. The objectives of our study were to describe the psychopathological background of a sample of HIV-positive MSM who engaged in slamsex during the previous year and to compare physical, psychopathological, and drug-related symptoms between these participants and those who engaged in non-injecting sexualized drug use. DESIGN AND METHODS: Participants (HIV-positive MSM) were recruited from the U-Sex study in 22 HIV clinics in Madrid during 2016-17. All participants completed an anonymous cross-sectional online survey on sexual behavior and recreational drug use. When participants met the inclusion criteria, physicians offered them the opportunity to participate and gave them a card with a unique code and a link to access the online survey. The present analysis is based on HIV-positive MSM who had engaged in slamsex and non-injecting sexualized drug use. RESULTS: The survey sample comprised 742 participants. Of all the participants who completed the survey, 216 (29.1%) had engaged in chemsex, and of these, 34 (15.7%) had engaged in slamsex. Participants who engaged in slamsex were more likely to have current psychopathology (depression, anxiety, and drug-related disorders) than participants who engaged in non-injecting sexualized drug use. In addition, participants who engaged in slamsex more frequently reported high-risk sexual behaviors and polydrug use and were more often diagnosed with sexually transmitted infections (STIs) and hepatitis C than those who did not inject drugs. Compared with participants who did not inject drugs, participants who engaged in slamsex experienced more severe drug-related symptoms (withdrawal and dependence), symptoms of severe intoxication (loss of consciousness), and severe psychopathological symptoms during or after slamsex (eg, paranoid thoughts and suicidal behaviors). CONCLUSION: Slamsex is closely associated with current psychiatric disorders and severe drug-related and psychiatric symptoms.
Assuntos
Infecções por HIV/patologia , Infecções por HIV/psicologia , HIV/efeitos dos fármacos , Homossexualidade Masculina/estatística & dados numéricos , Psicopatologia , Comportamento Sexual/psicologia , Abuso de Substâncias por Via Intravenosa/complicações , Adulto , Estudos Transversais , Infecções por HIV/etiologia , Humanos , Masculino , Assunção de RiscosRESUMO
BACKGROUND: Problems associated with lifelong antiretroviral therapy, such as need for strict adherence, drug-related toxic effects, difficulties with treatment schedules, and cost, mean that simplification strategies should be sought. We aimed to explore the efficacy and safety of dual treatment with atazanavir-ritonavir plus lamivudine as an option to switch to from standard combination antiretroviral therapy in patients with an HIV-1 infection who are virologically suppressed. METHODS: In this randomised, open-label, non-inferiority trial, we recruited patients aged 18 years and older with chronic HIV-1 infection and no previous treatment failure or resistance, and with HIV-1 RNA of less than 50 copies per mL for at least 6 months, negative hepatitis B virus surface antigen, and good general health, from 30 hospitals in Spain. Exclusion criteria were switch in antiretroviral therapy during the previous 4 months, previous virological failure, pregnancy or breastfeeding, Gilbert's syndrome, use of contraindicated drugs, grade 4 laboratory abnormalities, and previous intolerance to any of the study drugs. We randomly assigned patients (1:1; stratified by active hepatitis C virus infection and previous treatment; computer-generated random number sequence) to dual treatment with oral atazanavir (300 mg once daily) and ritonavir (100 mg once daily) plus lamivudine (300 mg once daily) or triple treatment with oral atazanavir (300 mg once daily) and ritonavir (100 mg once daily) plus two nucleos(t)ide reverse transcriptase inhibitors at the discretion of the investigators. The primary endpoint was virological response, defined as HIV-1 RNA of less than 50 copies per mL at week 48, in the per-protocol population, with a non-inferiority margin of 12%. We included patients who received at least one dose of the study drug in the safety analysis. This study is registered at ClinicalTrials.gov, number NCT01307488. FINDINGS: Between Sept 29, 2011, and May 2, 2013, we randomly assigned 286 patients (143 [50%] to each group). At week 48 in the per-protocol population, 112 (84%) of 133 patients had virological response in the dual-treatment group versus 105 (78%) of 135 in the triple-treatment group (difference 6% [95% CI -5 to 16%), showing non-inferiority at the prespecified level. 14 (5%) patients developed severe adverse events (dual treatment six [4%]; triple treatment eight [6%]), none of which we deemed related to the study drug. Grade 3-4 adverse events were similar between groups (dual treatment 77 [55%] of 140; triple treatment 78 [55%] of 141). Treatment discontinuations were less frequent in the dual-treatment group (three [2%]) than in the triple-treatment group (ten [7%]; p=0·047). INTERPRETATION: In our trial, dual treatment was effective, safe, and non-inferior to triple treatment in patients with an HIV-1 infection who are virologically suppressed who switch antiretroviral therapy because of toxic effects, intolerance, or simplification. This combination has the potential to suppress some of the long-term toxic effects associated with nucleos(t)ide reverse transcriptase inhibitors, preserve future treatment options, and reduce the cost of antiretroviral therapy. FUNDING: Bristol Myers-Squibb and Fundación SEIMC-GESIDA.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Inibidores da Protease de HIV/uso terapêutico , HIV-1 , RNA Viral/sangue , Inibidores da Transcriptase Reversa/uso terapêutico , Adenina/análogos & derivados , Adenina/uso terapêutico , Adulto , Fármacos Anti-HIV/efeitos adversos , Sulfato de Atazanavir , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapêutico , Substituição de Medicamentos , Quimioterapia Combinada/efeitos adversos , Quimioterapia Combinada/métodos , Emtricitabina , Feminino , Infecções por HIV/virologia , Inibidores da Protease de HIV/efeitos adversos , Humanos , Lamivudina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Oligopeptídeos/uso terapêutico , Organofosfonatos/uso terapêutico , Piridinas/uso terapêutico , Inibidores da Transcriptase Reversa/efeitos adversos , Ritonavir/uso terapêutico , Tenofovir , Carga Viral , Zidovudina/uso terapêuticoRESUMO
INTRODUCTION: Clinical trials (CT) on triple therapy against HCV infection in HIV-infected patients including TVR plus pegylated interferon and ribavirin (PR) have reported considerably higher response rates than with PR alone. This study was aimed to evaluate the efficacy and safety of triple therapy including TVR in HIV/HCV-coinfected patients in real-life conditions. MATERIALS AND METHODS: HIV/HCV genotype 1 patients seen at four Hospitals in Madrid who received therapy including TVR plus PR for at least two weeks were included. The response was evaluated during treatment, and sustained viral response (SVR) was evaluated 12 and 24 weeks after the end of the treatment. RESULTS: Fifty-eight patients have been included; 79% male, median age 48 y.o.; 38% were IL28B rs12979860 genotype CT or TT, 58.6% of patients presented cirrhosis and 24.1% presented fibrosis F3. Infection with genotype 1a was observed in 53.4% of patients. Median baseline HCV-RNA was 3,282,263 IU/mL (77.5% had >800,000 IU/mL). The most commonly used antiretroviral (ARV) drugs were tenofovir/emtricitabine [36 (62%) patients], etravirine [21 (36%) patients], abacavir/lamivudine [18 (31%) patients], boosted protease inhibitors [16 (27.5%) patients] and raltegravir [12 (20.6%) patients]. Of the 42 (72.4%) patients who had received previous HCV treatment, 13.7% were null responders, 25.8% were partial responders and 31% had relapsed. In an ITT approach, proportions of patients with undetectable HCV RNA were 67.8% (38/56) at TW4, 83.3% (40/48) at TW12, 80% (36/45) at TW24, 79.4% at TW36 (31/39) and 72% (26/36) at TW48. Fifteen (25.8%) patients discontinued HCV therapy [8 (13.8%) because they fulfilled stopping rules, 5 (8.6%) individuals due to adverse events and 2 (3.4%) were lost to follow-up]. Rash associated with TVR (grade 1) was observed in two cases (3.4%) and all the patients showed anaemia at some point of treatment. In an analysis by ITT in the 31 patients who had a 60 week follow-up after starting therapy, SVR-12 was observed in 21 (67.7%) patients. And in the analysis by ITT in 28 patients who had a 72 week follow-up after starting therapy, SVR-24 was observed in 17 (60.7%) patients. CONCLUSIONS: Response to triple therapy with TVR plus PR in HIV/HCV-patients under real-life conditions, and therefore, including a high proportion of difficult to treat patients, is similar to that found in CT. The safety profile of TVR-based therapy is also comparable to that shown in CT, with only a rate of discontinuation of 8.6% of individuals related to toxicity.
RESUMO
We analyzed the incidence of lower extremity amputations (LEAs) in the 3rd Health Care Area of Madrid before and after the March 2008 introduction of a multidisciplinary team for managing diabetic foot disease. We compared the amputation rates in people with and without diabetes during 2 periods: before (2001-2007) and after (2008-2011) the introduction of a Multidisciplinary Diabetic Foot Unit (MDFU). We also analyzed the trend of the amputation rates by joinpoint regression analysis and measured the annual percentage change (APC). During the study period, 514 nontraumatic LEAs were performed, 374 (73%) in people with diabetes and 140 (27%) in people without the disease. The incidence of LEAs showed a significant reduction in major amputations in people with diabetes, from 6.1 per 100 000 per year (95% confidence interval [CI] = 4.9 to 7.2), in the 2001 to 2007 period, to 4.0 per 100 000 per year (95% CI = 2.6 to 5.5) in the 2008 to 2011 period (P = .020). There were no changes in incidence of minor or total amputations in the diabetic population or in amputations in the nondiabetic population during the study period. Joinpoint regression analysis showed a significant reduction in the incidence of major LEAs in diabetic population with an APC of -6.6% (95% CI = -10.2 to -2.8; P = .003), but there were no other significant changes. This study demonstrates that the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease is associated with a reduction in the incidence of major amputations in patients with diabetes.
Assuntos
Amputação Cirúrgica/tendências , Pé Diabético/cirurgia , Comunicação Interdisciplinar , Extremidade Inferior/cirurgia , Equipe de Assistência ao Paciente , Idoso , Pé Diabético/epidemiologia , Endocrinologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Ortopedia , Podiatria , Estudos Retrospectivos , Espanha/epidemiologiaRESUMO
INTRODUCCIÓN: Existe un creciente aumento de las infecciones de prótesis articular (IPA) por bacterias resistentes a las cefalosporinas utilizadas en la profilaxis quirúrgica. La sustitución de estas por glucopéptidos no ha demostrado mejorar los resultados pero sí su asociación. MÉTODOS: Estudio comparativo de la asociación de teicoplanina y cefazolina antes de la cirugía de artroplastia frente a cefazolina sola de un grupo control previo. RESULTADOS: En el periodo control hubo 16 IPA de 585 cirugías, mientras que en el grupo de intervención fueron 6 de 579 (incidencia 2,7% vs. 1,03%; RR 0,4, p = 0,04). En el grupo control, 11 de las infecciones fueron causadas por bacterias grampositivas frente a 4 en el de intervención (1,8% vs. 0,7%, p = 0,08). CONCLUSIONES: La adición de teicoplanina a cefazolina en la profilaxis de la cirugía de artroplastia se asoció a una reducción de la incidencia de IPA, a expensas de un descenso de las causadas por grampositivos
INTRODUCTION: There is a growing increase in prosthetic joint infection (PJI) incidence due to cephalosporin-resistant bacteria, used in surgical prophylaxis. The replacement of these with glycopeptides has not been shown to improve the results, but they have been shown to improve with their combination. METHODS: Comparative study of combination of teicoplanin and cefazolin before arthroplasty surgery against cefazolin alone from a previous control group. RESULTS: During the control period, there were 16 PJIs from 585 surgeries, while in the intervention group there were 6 from 579 (incidence 2.7% vs. 1.03%, RR 0.4, P = .04). In control group, 11 of the infections were caused by Gram-positive bacteria versus 4 in the intervention group (1.8% vs. 0.7%, P = .08). CONCLUSIONS: The addition of teicoplanin to cefazolin in the prophylaxis of arthroplasty surgery was associated with a reduction in the incidence of PJI, thanks to a decrease in infections caused by Gram-positive bacteria
Assuntos
Humanos , Feminino , Idoso , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/prevenção & controle , Prótese Articular/microbiologia , Antibioticoprofilaxia , Teicoplanina/administração & dosagem , Cefazolina/administração & dosagem , Fatores de RiscoRESUMO
BACKGROUND: The advent of combined antiretroviral therapy (ART) in the past decade has led to HIV suppression in most cases. Virological failure was the main reason for ART switch a few years ago; however, toxicity and treatment simplification have now gained importance due to the availability of more effective and convenient drugs. This study assessed the reasons for ART switch in daily practice. MATERIAL AND METHODS: Observational retrospective study that included patients whose ART was switched between January 2011 and July 2012. Patients with any other switch during the follow-up period (until September 2013) were excluded. RESULTS: A total of 246 patients were included. Main reasons for ART switch were simplification (33%) and toxicity (31%), followed by clinical trial inclusion (13%), virological failure (6%), drug interaction (4%), patient decision (3%), lack of adherence (2%), pregnancy (1%) and other (8%). Eighty patients switched to a simpler regimen (median age 48 [40-53], mean CD4 count 608±265 cells/cl, 89% <50 copies/ml, mean number of previous regimens 6±5, mean time on previous ART 3±2 years). In this case, previous ART mostly included 2NRTI+1PI/r (54%) (Figure 1). The simplification strategy mainly contained nuke-sparing regimens (60%) based on PI (DRV/r 48%): monotherapy 46%, dual therapy 13% (PI/r+maraviroc 9%, PI/r+NNRTI 4%) and triple therapy 1% (PI/r+maraviroc+raltegravir). The second preferred simplification option was 2NRTI+1NNRTI (24%). Seventy-seven patients switched due to toxicities (median age 47 [43-53], mean CD4 count 606±350 cells/µl, <50 copies/ml 82%, mean number of previous regimens 4±3, mean time on previous ART 3±3 years). Renal (25%) and CNS (18%) toxicities were the main reasons for ART switch, followed by diarrhoea (16%), liver enzyme elevation (ALT 10%; AST 9%; bilirubin 7%), lipid elevation (cholesterol 5%; triglycerides 8%), nausea (7%) and other (=5%) (Figure 2). All patients with renal toxicity were under TDF and in most cases this drug was removed from the new regimen (with 3TC/ABC or nuke-sparing). Among patients with CNS toxicity, 79% were taking EFV; the main new treatment was a second-generation NNRTI (ETR)+2NRTI. Toxicities were completely resolved in 66% of patients, partially resolved in 22% and not resolved in only 12%; the median time from ART switch to toxicity resolution was 4 (2-8) months. CONCLUSIONS: The main reasons for ART switch in daily practice are simplification and toxicities, renal and CNS toxicities being the most prevalent. The preferred simplification strategies are nuke-sparing regimens, mainly DRV/r-based monotherapy and dual therapy. ART switch leads to a complete resolution of toxicities in most cases in the short term.