RESUMO
OBJECTIVES: Community viral load (CVL) estimates vary based on analytic methods. We extended the CVL concept and used data from the Veterans Health Administration (VA) to determine trends in the health care system viral load (HSVL) and its sensitivity to varying definitions of the clinical population and assumptions regarding missing data. METHODS: We included HIV-infected patients in the Veterans Aging Cohort Study, 2000-2010, with at least one documented CD4 count, HIV-1 RNA or antiretroviral prescription (n = 37 318). We created 6-month intervals including patients with at least one visit in the past 2 years. We assessed temporal trends in clinical population size, patient clinical status and mean HSVL and explored the impact of varying definitions of the clinical population and assumptions about missing viral load. RESULTS: The clinical population size varied by definition, increasing from 16 000-19 000 patients in 2000 to 23 000-26 000 in 2010. The proportion of patients with suppressed HIV-1 RNA increased over time. Over 20% of patients had no viral load measured in a given interval or the past 2 years. Among patients with a current HIV-1 RNA, mean HSVL decreased from 97 800 HIV-1 RNA copies/mL in 2000 to 2000 copies/mL in 2010. When current HIV-1 RNA data were unavailable and the HSVL was recalculated using the last available HIV-1 RNA, HSVL decreased from 322 300 to 9900 copies/mL. HSVL was underestimated when using only current data in each interval. CONCLUSIONS: The CVL concept can be applied to a health care system, providing a measure of health care quality. Like CVL, HSVL estimates depend on definitions of the clinical population and assumptions about missing data.
Assuntos
Infecções por HIV/diagnóstico , Vigilância da População/métodos , Carga Viral , Adulto , Contagem de Linfócito CD4 , Estudos de Coortes , Feminino , Infecções por HIV/virologia , HIV-1 , Humanos , Masculino , Pessoa de Meia-Idade , RNA Viral/análise , VeteranosRESUMO
OBJECTIVES: Outcomes of community-acquired pneumonia (CAP) among HIV-infected older adults are unclear. METHODS: Associations between HIV infection and three CAP outcomes (30-day mortality, readmission within 30 days post-discharge, and hospital length of stay [LOS]) were examined in the Veterans Aging Cohort Study (VACS) of male Veterans, age ≥ 50 years, hospitalized for CAP from 10/1/2002 through 08/31/2010. Associations between the VACS Index and CAP outcomes were assessed in multivariable models. RESULTS: Among 117 557 Veterans (36 922 HIV-infected and 80 635 uninfected), 1203 met our eligibility criteria. The 30-day mortality rate was 5.3%, the mean LOS was 7.3 days, and 13.2% were readmitted within 30 days of discharge. In unadjusted analyses, there were no significant differences between HIV-infected and uninfected participants regarding the three CAP outcomes (P > 0.2). A higher VACS Index was associated with increased 30-day mortality, readmission, and LOS in both HIV-infected and uninfected groups. Generic organ system components of the VACS Index were associated with adverse CAP outcomes; HIV-specific components were not. Among HIV-infected participants, those not on antiretroviral therapy (ART) had a higher 30-day mortality (HR 2.94 [95% CI 1.51, 5.72]; P = 0.002) and a longer LOS (slope 2.69 days [95% CI 0.65, 4.73]; P = 0.008), after accounting for VACS Index. Readmission was not associated with ART use (OR 1.12 [95% CI 0.62, 2.00] P = 0.714). CONCLUSION: Among HIV-infected and uninfected older adults hospitalized for CAP, organ system components of the VACS Index were associated with adverse CAP outcomes. Among HIV-infected individuals, ART was associated with decreased 30-day mortality and LOS.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/mortalidade , Infecções Comunitárias Adquiridas/mortalidade , Infecções por HIV/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/mortalidade , Veteranos/estatística & dados numéricos , Infecções Oportunistas Relacionadas com a AIDS/imunologia , Biomarcadores , Infecções Comunitárias Adquiridas/imunologia , Infecções por HIV/complicações , Infecções por HIV/imunologia , Humanos , Tempo de Internação/estatística & dados numéricos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Pneumonia/etiologia , Pneumonia/imunologia , Análise de Sobrevida , Estados Unidos/epidemiologiaRESUMO
The chemokine receptor CXCR4 is the major coreceptor used for cellular entry by T cell- tropic human immunodeficiency virus (HIV)-1 strains, whereas CCR5 is used by macrophage (M)-tropic strains. Here we show that a small-molecule inhibitor, ALX40-4C, inhibits HIV-1 envelope (Env)-mediated membrane fusion and viral entry directly at the level of coreceptor use. ALX40-4C inhibited HIV-1 use of the coreceptor CXCR4 by T- and dual-tropic HIV-1 strains, whereas use of CCR5 by M- and dual-tropic strains was not inhibited. Dual-tropic viruses capable of using both CXCR4 and CCR5 were inhibited by ALX40-4C only when cells expressed CXCR4 alone. ALX40-4C blocked stromal-derived factor (SDF)-1alpha-mediated activation of CXCR4 and binding of the monoclonal antibody 12G5 to cells expressing CXCR4. Overlap of the ALX40-4C binding site with that of 12G5 and SDF implicates direct blocking of Env interactions, rather than downregulation of receptor, as the mechanism of inhibition. Thus, ALX40-4C represents a small-molecule inhibitor of HIV-1 infection that acts directly against a chemokine receptor at the level of Env-mediated membrane fusion.
Assuntos
Fármacos Anti-HIV/farmacologia , HIV-1/efeitos dos fármacos , HIV-1/metabolismo , Oligopeptídeos/farmacologia , Receptores CXCR4/antagonistas & inibidores , Infecções por HIV/imunologia , Infecções por HIV/prevenção & controle , Infecções por HIV/virologia , Humanos , Linfoma de Células T , Oligopeptídeos/metabolismo , Ligação Proteica/efeitos dos fármacos , Receptores CXCR4/metabolismo , Linfócitos T/virologia , Células Tumorais CultivadasRESUMO
BACKGROUND: As those with HIV infection live longer, 'non-AIDS' condition associated with immunodeficiency and chronic inflammation are more common. We ask whether 'non-HIV' biomarkers improve differentiation of mortality risk among individuals initiating combination antiretroviral therapy (cART). METHODS: Using Poisson models, we analysed data from the Veterans Aging Cohort Study (VACS) on HIV-infected veterans initiating cART between 1 January 1997 and 1 August 2002. Measurements included: HIV biomarkers (CD4 cell count, HIV RNA and AIDS-defining conditions); 'non-HIV' biomarkers (haemoglobin, transaminases, platelets, creatinine, and hepatitis B and C serology); substance abuse or dependence (alcohol or drug); and age. Outcome was all cause mortality. We tested the discrimination (C statistics) of each biomarker group alone and in combination in development and validation data sets, over a range of survival intervals, and adjusting for missing data. RESULTS: Of veterans initiating cART, 9784 (72%) had complete data. Of these, 2566 died. Subjects were middle-aged (median age 45 years), mainly male (98%) and predominantly black (51%). HIV and 'non-HIV' markers were associated with each other (P < 0.0001) and discriminated mortality (C statistics 0.68-0.73); when combined, discrimination improved (P < 0.0001). Discrimination for the VACS Index was greater for shorter survival intervals [30-day C statistic 0.86, 95% confidence interval (CI) 0.80-0.91], but good for intervals of up to 8 years (C statistic 0.73, 95% CI 0.72-0.74). Results were robust to adjustment for missing data. CONCLUSIONS: When added to HIV biomarkers, 'non-HIV' biomarkers improve differentiation of mortality. When evaluated over similar intervals, the VACS Index discriminates as well as other established indices. After further validation, the VACS Index may provide a useful, integrated risk assessment for management and research.
Assuntos
Causas de Morte , Infecções por HIV/mortalidade , Sobreviventes de Longo Prazo ao HIV/estatística & dados numéricos , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/imunologia , Idoso , Anemia/sangue , Anemia/epidemiologia , Fármacos Anti-HIV/uso terapêutico , Biomarcadores/metabolismo , Contagem de Linfócito CD4 , Estudos de Coortes , Intervalos de Confiança , Progressão da Doença , Quimioterapia Combinada , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/imunologia , Hepatite Viral Humana/epidemiologia , Hepatite Viral Humana/imunologia , Humanos , Cirrose Hepática/epidemiologia , Cirrose Hepática/metabolismo , Masculino , Pessoa de Meia-Idade , RNA Viral/sangue , Índice de Gravidade de Doença , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Análise de SobrevidaRESUMO
BACKGROUND: Prior research on adherence to hepatitis C treatment has documented rates of dose reductions and early treatment discontinuation, but little is known about patients' dose-taking adherence. AIMS: To assess the prevalence of missed doses of pegylated interferon and ribavirin and examine the correlates of dose-taking adherence in clinic settings. METHODS: One hundred and eighty patients on treatment for hepatitis C (23% coinfected with HIV) completed a cross-sectional survey at the site of their hepatitis C care. RESULTS: Seven per cent of patients reported missing at least one injection of pegylated interferon in the last 4 weeks and 21% reported missing at least one dose of ribavirin in the last 7 days. Dose-taking adherence was not associated with HCV viral load. CONCLUSIONS: Self-reported dose non-adherence to hepatitis C treatment occurs frequently. Further studies of dose non-adherence (assessed by method other than self-report) and its relationship to HCV virological outcome are warranted.
Assuntos
Antivirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , HIV-1 , Hepatite C/tratamento farmacológico , Interferons/uso terapêutico , Ribavirina/uso terapêutico , Estudos Transversais , Quimioterapia Combinada , Feminino , Infecções por HIV/complicações , Infecções por HIV/virologia , Hepatite C/virologia , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente/estatística & dados numéricos , Resultado do Tratamento , Carga ViralRESUMO
Although Pneumocystis carinii pneumonia (PCP) usually presents with bilateral interstitial pulmonary infiltrates, many other roentgenographic presentations occur in human immunodeficiency virus-infected patients. To clarify the determinants of atypical presentations of PCP, we evaluated 65 English-language reports that related the roentgenographic manifestations of consecutive cases of PCP. The incidence of PCP-associated upper lobe disease, cysts, and spontaneous pneumothoraxes was increased in human immunodeficiency virus-infected patients receiving aerosolized pentamidine prophylaxis. Normal chest roentgenograms were more common and nodular lesions were less common in human immunodeficiency virus-infected patients than in uninfected patients. However, the roentgenographic manifestations of PCP could not be specifically predicted by a patient's underlying disease. Neither zidovudine therapy nor intravenous drug use apparently affected the roentgenographic presentation of PCP. Unusual pathologic responses to PCP, including granuloma formation, vascular invasion, and microscopic foci of calcification, were present in all patient groups.
Assuntos
Pneumonia por Pneumocystis/diagnóstico por imagem , Infecções por HIV/complicações , Humanos , Pentamidina/uso terapêutico , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/etiologia , RadiografiaRESUMO
BACKGROUND: While strategies for medical care for human immunodeficiency virus-related Pneumocystis carinii pneumonia (PCP) are well established, racial variations in care have not been evaluated. OBJECTIVE: To determine whether sociodemographic characteristics influence patterns of care and patient outcomes, by analyzing the use of diagnostic tests and anti-PCP medications and in-hospital mortality rates for persons who were hospitalized with human immunodeficiency virus-related PCP. METHODS: Retrospective chart review of a cohort of 627 Veterans Administration (VA) patients and 1547 non-VA patients with empirically treated or cytologically confirmed PCP who were hospitalized from 1987 to 1990. Outcomes included representative aspects of the process of care for PCP and short-term mortality rates. RESULTS: Among VA patients, black and Hispanic patients were not significantly different from white patients with regard to in-hospital mortality rates, use and timing of a bronchoscopy, or receipt of timely anti-PCP medications. Among non-VA patients, black and Hispanic patients were more likely to die in the hospital and less likely to undergo a diagnostic bronchoscopy in the first 2 days of hospitalization. These racial and ethnic group differences in the use of a bronchoscopy and in-hospital mortality among non-VA patients were almost fully accounted for by differences in health insurance status and hospital characteristics. CONCLUSIONS: Racial factors do not appear to be an important determinant of the intensity of diagnostic or therapeutic care among patients who are hospitalized with PCP. Variations in care are largely attributable to differences in health insurance and admitting hospital characteristics.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/terapia , Hospitais Urbanos/normas , Grupos Minoritários/estatística & dados numéricos , Planejamento de Assistência ao Paciente/normas , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/terapia , Infecções Oportunistas Relacionadas com a AIDS/etnologia , Infecções Oportunistas Relacionadas com a AIDS/mortalidade , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Chicago , Feminino , Florida , Hispânico ou Latino/estatística & dados numéricos , Hospitalização , Hospitais Urbanos/estatística & dados numéricos , Humanos , Modelos Logísticos , Los Angeles , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Análise Multivariada , Cidade de Nova Iorque , North Carolina , Pneumonia por Pneumocystis/etnologia , Pneumonia por Pneumocystis/mortalidade , Estudos Retrospectivos , Veteranos/estatística & dados numéricos , População Branca/estatística & dados numéricosRESUMO
Among virological responders, the area under the curve of the CD4 count minus baseline (AUCMB) after 3, 9, 15 and 18 months of highly active antiretroviral therapy (HAART) was less in individuals 55 years or older (P < 0.05). Fewer older individuals achieved increases of 50, 100, or over 150 CD4 cells/l. A random quadratic time course model estimated that the AUCMB decreased 35 cells/year for each 10 years of additional age during the first 12 months after HAART (P < 0.005).
Assuntos
Terapia Antirretroviral de Alta Atividade , Linfócitos T CD4-Positivos/imunologia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/imunologia , Idoso , Área Sob a Curva , Contagem de Linfócito CD4 , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Although the use of highly active antiretroviral therapy in the treatment of HIV infection has led to considerable improvement in morbidity and mortality, unless patients are adherent to their drug regimen (i.e., at least 90 to 95% of doses taken), viral replication may ensue and drug-resistant strains of the virus may emerge. METHODS: The authors studied the extent to which neuropsychological compromise and medication regimen complexity are predictive of poor adherence in a convenience sample of 137 HIV-infected adults. Medication adherence was tracked through the use of electronic monitoring technology (MEMS caps). RESULTS: Two-way analysis of variance revealed that neurocognitive compromise as well as complex medication regimens were associated with significantly lower adherence rates. Cognitively compromised participants on more complex regimens had the greatest difficulty with adherence. Deficits in executive function, memory, and attention were associated with poor adherence. Logistic regression analysis demonstrated that neuropsychological compromise was associated with a 2.3 times greater risk of adherence failure. Older age (>50 years) was also found to be associated with significantly better adherence. CONCLUSIONS: HIV-infected adults with significant neurocognitive compromise are at risk for poor medication adherence, particularly if they have been prescribed a complex dosing regimen. As such, simpler dosing schedules for more cognitively impaired patients might improve adherence.
Assuntos
Fármacos Anti-HIV/administração & dosagem , Terapia Antirretroviral de Alta Atividade , Transtornos Cognitivos/psicologia , Soropositividade para HIV/tratamento farmacológico , Soropositividade para HIV/psicologia , Cooperação do Paciente/psicologia , Adulto , Idoso , Fármacos Anti-HIV/uso terapêutico , Western Blotting , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/etiologia , Educação , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Testes de Inteligência , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Análise de Regressão , Fatores SexuaisRESUMO
We report the development of severe hepatotoxicity in a patient on zidovudine therapy who received 3.3 g of acetaminophen in less than 36 hours. Three days later, the patient's serum aspartate aminotransferase level was 5,724 U/L, alanine aminotransferase was 3,124 U/L, lactate dehydrogenase was 12,675 U/L, alkaline phosphatase was 84 U/L, and total bilirubin was 20 mumol/L. These values substantially improved over the ensuing 4 days. Serologic results for hepatitis B, hepatitis A, and cytomegalovirus were all negative. The pattern and time sequence of transaminase elevation in this patient are consistent with acute acetaminophen hepatotoxicity, especially since zidovudine-induced hepatotoxicity is described as producing cholestasis rather than acute hepatitis. We hypothesize that our patient's susceptibility to acetaminophen-dependent hepatotoxicity may have been augmented by competitive utilization of glucuronidation by other drugs such as zidovudine and/or trimethoprim-sulfamethoxazole with subsequent increased cytochrome P450-dependent metabolism of acetaminophen. Additionally, due to malnutrition and/or to human immunodeficiency virus infection per se, our patient may have had decreased hepatic reserves of glutathione with which to conjugate the toxic acetaminophen product of the P450 system. Although severe acetaminophen-associated hepatotoxicity has not previously been reported in patients receiving zidovudine, we suggest that clinicians be aware of this potential interaction and counsel malnourished patients, especially those with concomitant hepatic disease, to exercise caution when taking both these medications.
Assuntos
Acetaminofen/efeitos adversos , Doença Hepática Induzida por Substâncias e Drogas/etiologia , Zidovudina/efeitos adversos , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Adulto , Humanos , Fígado/efeitos dos fármacos , MasculinoRESUMO
PURPOSE: Description of the epidemiology, morbidity, and mortality of hospitalized adults with typical measles. PATIENTS AND METHODS: Retrospective case analysis of 33 adults who required acute care for complications of measles in a public hospital in Los Angeles, California. The diagnosis of measles was established on standard clinical or serologic grounds. RESULTS: Of 68 patients (age greater than 14) with signs and symptoms of measles who presented for medical care, 33 (19 males and 14 females) required hospitalization; 18 were natives of the United States. The patient age was 26.1 +/- 7.3 (mean +/- SD) years; four patients, all natives of the U.S., were born before 1957. The duration of hospitalization was 6.8 +/- 8.8 days for all patients and 13.4 +/- 14.2 days for the nine patients who required intensive care unit (ICU) care. Six of the ICU patients required mechanical ventilation for 11.0 +/- 15.0 days; two deaths occurred among these patients. During the course of their illness, 7 of 25 (28%), 11 of 28 (39%), 6 of 28 (21%), and 5 of 16 patients (31%) had peak lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, and creatine kinase values, respectively, that were greater than 5 times the upper limit of normal. Fifteen of 28 patients (54%) developed total serum calcium levels less than or equal to 2.0 mmol/L. Ten cases were serologically confirmed; 23 cases were diagnosed as probable measles on clinical grounds. There were no significant demographic, clinical, or laboratory differences between patients with confirmed and probable measles. No patients had characteristic manifestations of atypical measles. The sole immunocompromised patient died. CONCLUSIONS: Measles in adults may result in severe, life-threatening complications that utilize substantial medical resources. Physicians need to appreciate the clinical presentations and manifestations of severe measles in adults and to provide measles vaccine to nonimmune adults during community-wide outbreaks.
Assuntos
Sarampo/fisiopatologia , Adolescente , Adulto , California/epidemiologia , Surtos de Doenças , Feminino , Hospitalização , Hospitais Públicos , Humanos , Masculino , Sarampo/sangue , Sarampo/complicações , Sarampo/epidemiologia , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
PURPOSE: We describe the manifestations of spontaneous staphylococcal pyomyositis in patients infected by the human immunodeficiency virus (HIV). PATIENTS AND METHODS: We present the courses of five previously unreported patients infected by HIV who presented to our medical centers with spontaneous staphylococcal pyomyositis. Additionally, we review all previously reported cases of this entity in HIV-infected patients and discuss its possible pathogenesis and importance in the context of HIV infection. RESULTS: All patients presented with gradually developing fever and localized pain and swelling without accompanying leukocytosis. Often only scant evidence of local inflammation was found. None of our patients used intravenous drugs, had a history of trauma, had HIV- or zidovudine-related myositis, or had other conditions known to be associated with serious staphylococcal infections. Two patients studied had normal serum levels of all IgG subclasses. Elevated serum IgE, eosinophilic inflammatory infiltrates, or marked peripheral eosinophilia was observed in two patients. CONCLUSIONS: Staphylococcal pyomyositis in HIV-infected patients presents in an indolent fashion, which may delay appropriate diagnosis and treatment. Since staphylococcal pyomyositis is infrequently reported in the United States, the development of 14 such cases (five in this series and nine previously reported) among the first 140,000 cases of acquired immunodeficiency syndrome in this country implies that this patient population is predisposed to this infectious complication. The pathogenesis of this entity is uncertain, but it is notable that HIV-infected patients are commonly colonized by Staphylococcus aureus and that neutrophils from HIV-infected patients frequently manifest phagocytic, chemotactic, and oxidative defects, diminished expression of Fc tau RIII (CD16) and CR1, and impaired bactericidal activity against S. aureus.
Assuntos
Síndrome da Imunodeficiência Adquirida/complicações , Doenças Musculares/etiologia , Infecções Estafilocócicas/etiologia , Síndrome da Imunodeficiência Adquirida/sangue , Síndrome da Imunodeficiência Adquirida/imunologia , Adulto , Linfócitos T CD4-Positivos/química , Humanos , Imunoglobulina E/química , Imunoglobulina G/química , Masculino , Doenças Musculares/diagnóstico por imagem , Doenças Musculares/patologia , Radiografia , Fatores de Risco , Infecções Estafilocócicas/diagnóstico por imagem , Infecções Estafilocócicas/patologiaRESUMO
PURPOSE: The authors evaluated a geographic and temporal cluster of lower respiratory tract infections due to unencapsulated (serologically nontypeable) Haemophilus influenzae to determine whether this event represented the transmission of a single clone. METHODS AND MATERIALS: H influenzae was recovered from eight patients at a nursing home and from three patients in an adjacent acute care hospital. Serotypes, biotypes, outer membrane protein profiles, and multilocus enzyme genotypes were determined to characterize bacterial isolates. Patient records were retrospectively examined to determine clinical and epidemiologic characteristics. RESULTS: During a 10-day period in September 1991, lower respiratory tract infections caused by H influenzae were diagnosed in four patients residing in a single nursing home unit. Oropharyngeal cultures from four of seven asymptomatic roommates of these patients also grew H influenzae. During the month before and after the nursing home cluster of cases, four other individuals in acute care areas of the hospital had positive sputum cultures for H influenzae. Three of these latter specimens were also available for analysis. All H influenzae isolates were unencapsulated and beta-lactamase-negative. Eight of the nine isolates from the nursing home patients (two morphologically distinct colony types of H influenzae were isolated from one case) had a single outer membrane protein profile arbitrarily designated as X and a single multilocus enzyme genotype arbitrarily designated as A. In contrast, none of the isolates from the acute care cases had this profile (P < or = 0.02; two-tailed Fisher's exact test). The isolates obtained from two of the patients in acute care areas had an outer membrane protein profile arbitrarily designated as Y and a single multilocus enzyme genotype designated as B. These two patients were contemporaneously hospitalized in adjacent intensive care unit cubicles. The remaining isolates displayed an outer membrane protein profile arbitrarily designated as W. All roommates of the four patients in the nursing home were administered oral rifampin 600 mg daily for 4 days. H influenzae was not recovered from follow-up oropharyngeal cultures obtained 1 week after the completion of therapy. No beta-lactamase-negative H influenzae were identified in this unit during the subsequent 9 months. CONCLUSION: This study furnishes strong evidence for the nosocomial transmission of a clone of unencapsulated H influenzae in a nursing home unit. Epidemiologic data showed temporal and geographic clustering of respiratory tract infections and colonization by H influenzae. Outer membrane protein profiles and multilocus enzyme genotype analysis indicated that seven of eight patients at the nursing home carried a single clone of unencapsulated H influenzae. Laboratory and epidemiologic data also demonstrated the presence, and possible nosocomial transmission, of a second clone of unencapsulated H influenzae in a physically separate area of the hospital. Finally, although a causal relationship is not proven, the outbreak ended following the administration of rifampin prophylaxis of asymptomatic carriers.
Assuntos
Infecção Hospitalar/transmissão , Infecções por Haemophilus/transmissão , Haemophilus influenzae/classificação , Infecções Respiratórias/transmissão , Proteínas da Membrana Bacteriana Externa/análise , Técnicas de Tipagem Bacteriana , California/epidemiologia , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Surtos de Doenças/estatística & dados numéricos , Genótipo , Infecções por Haemophilus/epidemiologia , Infecções por Haemophilus/microbiologia , Haemophilus influenzae/química , Haemophilus influenzae/isolamento & purificação , Hospitais de Veteranos , Humanos , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/microbiologia , Estudos Retrospectivos , SorotipagemRESUMO
PURPOSE: Following implementation of special measures to control a nosocomial outbreak of methicillin-resistant Staphylococcus aureus (MRSA), we used immunoblot typing in conjunction with antimicrobial susceptibility testing to investigate the epidemiology of this event and to determine whether this outbreak represented the failure of infection control measures to limit the spread of previously endemic MRSA strains or the introduction of a new strain of MRSA. MATERIALS AND METHODS: Isolates of MRSA recovered from hospitalized patients were initially categorized on the basis of antimicrobial susceptibility results. Organisms susceptible to ciprofloxacin and/or trimethoprim/sulfamethoxazole were recovered from patients at a relatively constant rate prior to December 1988 and were categorized as endemic isolates. Subsequently, there was an outbreak due to organisms resistant to both of these antibiotics; these were therefore categorized as outbreak isolates. Isolates were later characterized by immunoblot typing. Prior to this analysis, isolates were given code numbers so that clinical and epidemiologic data as well as resistance patterns were not known until this testing was complete. RESULTS: Between January 1986 and November 1988, an average of 3.9 patients per month acquired nosocomial MRSA in the Sepulveda Veterans Administration Medical Center. In contrast, from December 1988 to October 1989, 369 MRSA isolates were collected from 125 patients (an average of 11.4 patients per month). Prior to December 1988, all tested nosocomial isolates of MRSA were susceptible to ciprofloxacin and/or to trimethoprim/sulfamethoxazole. In contrast, the outbreak was due to spread of MRSA isolates resistant to these antibiotics. Immunoblot typing of 204 isolates from 98 individuals identified five distinct immunoblot types of which types B and C were by far the most common. Type B was highly associated with outbreak isolates, whereas type C was associated with endemic isolates (p less than 0.001). All sequential isolates from single patients that belonged to different susceptibility categories demonstrated discordant immunoblot types. In contrast, concordant immunoblot types were observed for 25 of 27 sequential isolates that displayed minor variations in antimicrobial resistance. The institution of more stringent infection control measures was followed by the return of nosocomial MRSA acquisition rates to pre-outbreak levels. Although novobiocin and trimethoprim/sulfamethoxazole were extensively used to treat patients harboring outbreak and endemic isolates, respectively, in no instance was the initial MRSA isolate from any patient resistant to novobiocin and only 6% of initial endemic isolates displayed trimethoprim/sulfamethoxazole resistance. A modest, significant increase in the resistance of endemic isolates to various other antimicrobial agents was noted however. CONCLUSION: Immunoblot analyses provided strong, corroborative evidence that at least two separate strains of MRSA were present during the outbreak and that a newly introduced strain with a distinctive antimicrobial resistance pattern was primarily responsible for the rapid spread of MRSA during the outbreak. The observation that previously effective infection control measures failed to prevent the nosocomial spread of a newly introduced community-acquired MRSA strain suggests that a single set of control measures may not be equally efficacious against all strains of MRSA. In this regard, previously reported variations in resistance to topical antimicrobials and/or antiseptics, and differences in virulence factors such as colonization potential, invasiveness, and survival on fomites, may warrant further study. Control of the outbreak strain of MRSA in our institution did occur after the implementation of more strenuous isolation procedures.(ABSTRACT TRUNCATED)
Assuntos
Portador Sadio/epidemiologia , Infecção Hospitalar/epidemiologia , Surtos de Doenças/estatística & dados numéricos , Resistência a Meticilina , Infecções Estafilocócicas/epidemiologia , Staphylococcus aureus , California/epidemiologia , Portador Sadio/microbiologia , Portador Sadio/prevenção & controle , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Surtos de Doenças/prevenção & controle , Estudos de Avaliação como Assunto , Hospitais de Veteranos , Humanos , Immunoblotting , Incidência , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Testes de Sensibilidade Microbiana , Novobiocina/uso terapêutico , Doenças Profissionais/epidemiologia , Doenças Profissionais/microbiologia , Doenças Profissionais/prevenção & controle , Política Organizacional , Recursos Humanos em Hospital , Prevalência , Estações do Ano , Sorotipagem , Infecções Estafilocócicas/microbiologia , Infecções Estafilocócicas/prevenção & controle , Resistência a Trimetoprima , Combinação Trimetoprima e Sulfametoxazol/uso terapêuticoRESUMO
Disease-specific registries have many important applications in epidemiologic, clinical and health services research. Since 1989 the Department of Veterans Affairs has maintained a national HIV registry. VA's HIV registry is national in scope, it contains longitudinal data and detailed resource utilization and clinical information. To describe the structure, function, and limitations of VA's national HIV registry, and to test its accuracy and completeness. The VA's national HIV registry contains data that are electronically extracted from VA's computerized comprehensive clinical and administrative databases, called Veterans Integrated Health Systems Technology and Architecture (VISTA). We examined the number of AIDS patients and the number of new patients identified to the registry, by year, through December 1996. We verified data elements against information obtained from the medical records at five VA sites. By December 1996, 40,000 HIV-infected patients had been identified to the registry. We encountered missing data and problems with data classification. Missing data occurred for some elements related to the computer programming that creates the registry (e.g., pharmacy files), and for other elements because manual entry is required (e.g., ethnicity). Lack of a standardized data classification system was a problem, especially for the pharmacy and laboratory files. In using VA's national HIV registry we have learned important lessons, which, if taken into account in the future, could lead to the creation of model disease-specific registries.
Assuntos
Infecções por HIV/epidemiologia , Sistema de Registros/normas , Veteranos , Humanos , Projetos Piloto , Avaliação de Programas e Projetos de Saúde , Projetos de Pesquisa , Estados Unidos , United States Department of Veterans AffairsRESUMO
We retrospectively studied the acute toxicity of corticosteroid therapy in 23 episodes of PCP occurring in the setting of AIDS and determined the incidence of HIV-related complications following these and 16 other contemporaneous episodes of AIDS-related PCP treated with antimicrobials alone. The mean duration of corticosteroid therapy was 5.4 days and the mean total dose was 660 mg of methylprednisolone. Cryptococcus neoformans and Listeria monocytogenes infection each occurred once within one month of therapy in corticosteroid-treated patients; no other noteworthy acute corticosteroid toxicity was noted. Since all patients with imminently lethal PCP received corticosteroids, we could not assess the effect of these agents on acute mortality. After six months the rates of new AIDS-related diagnoses and of post-hospitalization mortality were equivalent in the two groups. We also have critically reviewed the available literature regarding this use of corticosteroids.
Assuntos
Síndrome da Imunodeficiência Adquirida/complicações , Corticosteroides/efeitos adversos , Febre/epidemiologia , Pneumonia por Pneumocystis/tratamento farmacológico , Adulto , Humanos , Incidência , Pessoa de Meia-Idade , Infecções Oportunistas/epidemiologia , Pneumonia por Pneumocystis/etiologia , Pneumonia por Pneumocystis/mortalidade , Recidiva , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Despite awareness of HIV-related tuberculosis (TB), nosocomial outbreaks of multidrug-resistant TB among HIV-infected individuals occur. OBJECTIVE: To investigate delays in TB isolation and suspicion among HIV-infected inpatients discharged with TB or Pneumocystis carinii pneumonia (PCP), common HIV-related pneumonias. DESIGN: Cohort study during 1995 to 1997. SETTING: For PCP, 1,227 persons who received care at 44 New York City, Chicago, and Los Angeles hospitals. For TB, 89 patients who received care at five Chicago hospitals. MEASUREMENTS: Two-day rates of TB isolation/suspicion. RESULTS: For HIV-related PCP, Los Angeles hospitals had the lowest 2-day rates of isolation/suspicion of TB (24.3%/26.6% vs 65.5%/66.4% for New York City and 62.8%/58.3% for Chicago, respectively; p < 0.001 for overall comparison by chi(2) test for each outcome measure). Within cities, hospital isolation/suspicion rates varied from < 35 to > 70% (p < 0.001 for interhospital comparisons in each city). The Chicago hospital with a nosocomial outbreak of multidrug-resistant TB from 1994 to 1995 isolated 60% of HIV-infected individuals who were discharged with a diagnosis of HIV-related TB and 52% discharged with HIV-related PCP, rates that were among the lowest of all Chicago hospitals in both data sets. CONCLUSION: Low 2-day rates of TB isolation/suspicion among HIV-related PCP patients were frequent. One Chicago hospital with low 2-day rates of TB isolation/suspicion among persons with HIV-related PCP also had low 2-day rates of isolation/suspicion among confirmed TB patients. That hospital experienced a nosocomial multidrug-resistant TB outbreak. Educational efforts on the benefits of early TB suspicion/isolation among HIV-infected pneumonia patients are needed.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Infecção Hospitalar/prevenção & controle , Hospitalização , Isolamento de Pacientes , Pneumonia por Pneumocystis/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/prevenção & controle , Tuberculose Pulmonar/prevenção & controle , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/transmissão , Chicago/epidemiologia , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/transmissão , Surtos de Doenças/prevenção & controle , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Los Angeles/epidemiologia , Cidade de Nova Iorque/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/transmissão , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/transmissãoRESUMO
OBJECTIVES: To assess the degree to which, from 1987 to 1990, physicians suspected tuberculosis (TB) in the first 2 hospital days in human immunodeficiency virus (HIV)-infected patients with pulmonary disease. DESIGN: Retrospective cohort study. SETTING: 96 hospitals in five US cities. PATIENTS: 2,174 adult patients with acquired immunodeficiency syndrome discharged with a diagnosis of Pneumocystis carinii pneumonia from 1987 to 1990. The diagnosis generally was not known on admission. RESULTS: Physicians suspected TB in the first 2 hospital days in 66% of these patients in 1987, a rate that increased steadily to 74% in 1990. However, the extent to which physicians considered TB among female patients decreased from 76% to 71% over the 4 years. Controlling for confounding variables by multiple logistic regression, the odds that TB would be suspected early increased 1.8-fold among men (odds ratio [OR], 1.8; 95% confidence interval [CI95], 1.4-2.4), but not in women (OR, 0.6; CI95, 0.2-1.9). Among the five cities, the odds of early suspicion of TB increased most in New York City (OR, 3.9; CI95, 2.0-7.9). CONCLUSIONS: Physicians considered TB in a timely manner in an increasing majority of male, but not female, high-risk patients during the first years of TB resurgence in the United States. Physicians must be aware of the changing epidemiology of HIV and TB, as well as their practice patterns, to prevent nosocomial transmission of this disease.
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Síndrome da Imunodeficiência Adquirida/complicações , Surtos de Doenças/estatística & dados numéricos , Tuberculose/diagnóstico , Tuberculose/epidemiologia , Síndrome da Imunodeficiência Adquirida/epidemiologia , Síndrome da Imunodeficiência Adquirida/psicologia , Adulto , Idoso , Atitude do Pessoal de Saúde , Intervalos de Confiança , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores Sexuais , Estados Unidos/epidemiologiaRESUMO
Toxoplasma gondii most often causes encephalitis in HIV-infected patients; infections of other organs are much less often clinically apparent. In particular, peritonitis caused by T. gondii in an Human Immunodeficiency Virus (HIV)-infected patient has been reported only once previously. Herein we report a second case.
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Soropositividade para HIV/complicações , Peritonite/etiologia , Toxoplasmose/complicações , Adulto , Humanos , MasculinoRESUMO
BACKGROUND: While scholarship on alcohol use and homelessness has focused on the impact of alcohol abuse and dependence, little is known about the effects of lower levels of misuse such as hazardous use. Veterans receiving care in the Department of Veterans Affairs Health Care System (VA) constitute a population that is vulnerable to alcohol misuse and homelessness. This research examines the effects of hazardous drinking on homelessness in the Veterans Aging Cohort Study, a sample of 2898 older veterans (mean age=50.2), receiving care in 8 VAs across the country. METHODS: Logistic regression models examined the associations between (1) hazardous drinking at baseline and homelessness at 1-year follow-up, (2) transitions into and out of hazardous drinking from baseline to follow-up and homelessness at follow-up, and (3) transitioning to hazardous drinking and transitioning to homelessness from baseline to follow-up during that same time-period. RESULTS: After controlling for other correlates including alcohol dependence, hazardous drinking at baseline increased the risk of homelessness at follow-up (adjusted odds ratio [AOR]=1.39, 95% confidence interval [CI]=1.02, 1.88). Transitioning to hazardous drinking more than doubled the risk of homelessness at follow-up (AOR=2.42, 95% CI=1.41, 4.15), while more than doubling the risk of transitioning from being housed at baseline to being homeless at follow-up (AOR=2.49, 95% CI=1.30, 4.79). CONCLUSIONS: Early intervention that seeks to prevent transitioning into hazardous drinking could increase housing stability among veterans. Brief interventions which have been shown to be effective at lower levels of alcohol use should be implemented with veterans in VA care.