RESUMO
Identification of individuals with acute HIV infection (AHI) and rapid initiation of antiretroviral therapy (ART) are priorities for HIV elimination efforts. Fourth- and fifth-generation HIV-1/HIV-2 antigen (Ag)/antibody (Ab) combination assays can quickly identify patients with AHI, but false-positive results can occur. Confirmatory nucleic acid amplification testing (NAAT) may not be rapidly available. We reviewed the data for 127 patients with positive fourth-generation ARCHITECT and fifth-generation Bio-Plex immunoassay results who had negative or indeterminate confirmatory Ab testing results, which yielded 38 patients with confirmed AHI and 89 patients with false-positive results. The receiver operating characteristic (ROC) curves showed excellent discriminatory power, with an area under the curve (AUC) for the signal-to-cutoff (S/CO) ratio of 0.970 (95% confidence interval [CI], 0.935 to 1.00) and an AUC for the Ag index (AI) of 0.968 (95% CI, 0.904 to 1.00). A threshold of 3.78 for the S/CO ratio would maximize the sensitivity (96.3%) and specificity (93.4%). The threshold for AI was 2.83 (sensitivity of 100% and specificity of 96.4%). The S/CO ratio was significantly correlated with the viral load (Spearman correlation coefficient, 0.486 [P = 0.014]), but the AI was not. The viral loads were all high, with a median of >2.8 million copies/mL. Two false-positive results with AI and S/CO ratio values markedly higher than the medians were observed, indicating that biological false-positive results can occur. Review of the S/CO ratio or AI may be used to improve the accuracy of AHI diagnosis prior to confirmatory NAAT results being available.
Assuntos
Infecções por HIV , HIV-1 , Humanos , Anticorpos Anti-HIV , Antígenos HIV , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , HIV-1/genética , HIV-2 , Imunoensaio/métodos , Sensibilidade e EspecificidadeRESUMO
Community-acquired coinfection in coronavirus disease 2019 (COVID-19) is not well defined. Current literature describes coinfection in 0-40% of COVID-19 patients. In this retrospective report, coinfection was identified in 3.7% of patients and 41% of patients admitted to intensive care (Pâ <â .005). Despite infrequent coinfection, antibiotics were used in 69% of patients.
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COVID-19 , Coinfecção , Coinfecção/epidemiologia , Hospitalização , Humanos , Estudos Retrospectivos , SARS-CoV-2RESUMO
BACKGROUND: Tocilizumab (TCZ) has been used in the management of COVID-19-related cytokine release syndrome (CRS). Concerns exist regarding the risk of infections and drug-related toxicities. We sought to evaluate the incidence of these TCZ complications among COVID-19 patients. METHODS: All adult inpatients with COVID-19 between 1 March and 25 April 2020 that received TCZ were included. We compared the rate of late-onset infections (>48 hours following admission) to a control group matched according to intensive care unit admission and mechanical ventilation requirement. Post-TCZ toxicities evaluated included: elevated liver function tests (LFTs), GI perforation, diverticulitis, neutropenia, hypertension, allergic reactions, and infusion-related reactions. RESULTS: Seventy-four patients were included in each group. Seventeen infections in the TCZ group (23%) and 6 (8%) infections in the control group occurred >48 hours after admission (P = .013). Most infections were bacterial with pneumonia being the most common manifestation. Among patients receiving TCZ, LFT elevations were observed in 51%, neutropenia in 1.4%, and hypertension in 8%. The mortality rate among those that received TCZ was greater than the control (39% versus 23%, P = .03). CONCLUSION: Late onset infections were significantly more common among those receiving TCZ. Combining infections and TCZ-related toxicities, 61% of patients had a possible post-TCZ complication. While awaiting clinical trial results to establish the efficacy of TCZ for COVID-19 related CRS, the potential for infections and TCZ related toxicities should be carefully weighed when considering use.
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Anticorpos Monoclonais Humanizados/uso terapêutico , Infecções Bacterianas/complicações , Tratamento Farmacológico da COVID-19 , COVID-19/complicações , Síndrome da Liberação de Citocina/tratamento farmacológico , Micoses/complicações , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Humanizados/efeitos adversos , Antivirais/efeitos adversos , Antivirais/uso terapêutico , Biomarcadores Farmacológicos/sangue , COVID-19/mortalidade , Síndrome da Liberação de Citocina/virologia , Feminino , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Offering people living with HIV the opportunity to refer partners for HIV testing is an efficient way of identifying new HIV diagnoses. This report describes the outcomes of physician-led partner services at an urban academic center. Patients with HIV VL > 1000 copies/mL in both inpatient and outpatient settings were offered partner notification services (PNS). Of referred partners, 8.7% had a new diagnosis of HIV. New HIV+ partners were as likely to be referred by patients with existing HIV diagnoses as new diagnoses (p = 0.61), and as likely to be referred by patients interviewed while hospitalized as those in the clinic (p = 0.61).
Assuntos
Sorodiagnóstico da AIDS/estatística & dados numéricos , Busca de Comunicante/métodos , Infecções por HIV/diagnóstico , Encaminhamento e Consulta/estatística & dados numéricos , Parceiros Sexuais/psicologia , Sorodiagnóstico da AIDS/métodos , Adulto , Instituições de Assistência Ambulatorial , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Uso Comum de Agulhas e Seringas , Carga ViralRESUMO
Hypogammaglobulinemia (HGG) frequently occurs in recipients after types of (SOT). The incidence and significance of HGG in HIV+ recipients of SOT are just being explored. We reported that 12% of the recipients in the SOT in multi-center HIV-TR (HIV-TR) Study developed moderate or severe HGG at 1 year. In LT recipients, this was associated with serious infections and death. We have now further characterized the decreased antibodies in HIV+ SOT recipients who developed HGG. We measured the levels of pathogen-specific antibodies and poly-specific self-reactive antibodies (PSA) in relation to total IgG levels from serial serum samples for 20 HIV+ SOT recipients who developed moderate to severe HGG following SOT. Serum antibody levels to measles, tetanus toxoid, and HIV-1 were determined by EIA. Levels of PSAs were determined by incubating control lymphocytes with patient serum, staining with anti-human IgG Fab-FITC, and analysis by flow cytometry. Levels of PSA were higher compared to healthy, HIV-uninfected controls at pre-transplant baseline and increased by weeks 12 and 26, but the changes were not significant. Likewise, anti-HIV antibody levels remained unchanged over time. In contrast, antibody levels against measles and tetanus were significantly reduced from baseline by week 12, and did not return to baseline, even after 2 years. For HIV patients who develop moderate to severe HGG after transplant, the reduction in IgG levels is associated with a significant decrease in pathogen-specific antibody titers, while PSA levels and anti-HIV antibodies are unchanged. This may contribute to infectious complications and other clinical endpoints.
Assuntos
Agamaglobulinemia/epidemiologia , Anticorpos Antivirais/sangue , Soropositividade para HIV/complicações , Imunoglobulina G/sangue , Transplante de Órgãos/efeitos adversos , Adulto , Agamaglobulinemia/sangue , Agamaglobulinemia/imunologia , Anticorpos Antivirais/imunologia , Feminino , Soropositividade para HIV/sangue , Soropositividade para HIV/imunologia , Humanos , Imunoglobulina G/imunologia , Incidência , Masculino , Vírus do Sarampo/imunologia , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Estudos Observacionais como Assunto , Estudos Prospectivos , Fatores de Risco , Toxoide Tetânico/imunologiaRESUMO
Emergency department visits provide an opportunity to reengage people living with HIV (PLWH) who are out of care. We developed an electronic medical record-based algorithm to identify PLWH in the emergency department and inpatient settings and utilized a trained HIV care navigator to reengage PLWH in these settings. The algorithm identified 420 PLWH during the 14-month observation period. Of these, 56 patients were out of care. Out-of-care individuals were significantly younger than those in care (mean age: 38.6 ± 15.5 vs 46.3 ±14.8 years, P < .001) and more likely to be uninsured (7.1% [4/56] vs 1.8% [6/337], P = .02). Among out-of-care patients, 66.1% (37/56) were reengaged in care. Only 21.4% (12/56) of out-of-care patients had previously received outpatient HIV care at our institution. This project demonstrates the feasibility of using an electronic medical record alert and HIV care navigator to reengage PLWH seeking emergency medical care.
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Serviço Hospitalar de Emergência/tendências , Infecções por HIV/psicologia , Informática Médica/métodos , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Cooperação e Adesão ao Tratamento/psicologia , Adulto , Algoritmos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Informática Médica/tendências , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricosRESUMO
Multiplex polymerase chain reaction (PCR) tests are useful for the rapid detection of pathogens, though diagnostic challenges may arise. We report 2 immunocompromised patients with Bordetella bronchiseptica respiratory infection misdiagnosed as Bordetella pertussis using PCR, including discussion of transmission, diagnostic testing, clinical implications, and infection control considerations.
Assuntos
Infecções por Bordetella/diagnóstico , Erros de Diagnóstico , Infecções Respiratórias/diagnóstico , Idoso , Infecções por Bordetella/tratamento farmacológico , Infecções por Bordetella/microbiologia , Bordetella bronchiseptica/genética , Bordetella bronchiseptica/isolamento & purificação , Bordetella pertussis/genética , Bordetella pertussis/isolamento & purificação , Reações Cruzadas , DNA Bacteriano/genética , Reações Falso-Positivas , Feminino , Humanos , Hospedeiro Imunocomprometido , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase Multiplex , Infecções Respiratórias/microbiologiaAssuntos
Anticorpos Antibacterianos/sangue , Borrelia burgdorferi/imunologia , Doença de Lyme/diagnóstico , Guias de Prática Clínica como Assunto , Adulto , Doenças Assintomáticas , Criança , Diagnóstico Diferencial , Humanos , Doença de Lyme/sangue , Doença de Lyme/imunologia , Fatores de Risco , Picadas de CarrapatosRESUMO
Black men who have sex with men (BMSM) are highest risk for HIV seroconversion in the United States. Little attention has been paid to marijuana use among BMSM and potential for HIV risk. A sample of 202 BMSM was generated through respondent driven sampling. The relationship between differential marijuana use and both HIV risk behavior and social network factors were examined using weighted logistic regression. Of the BMSM in this sample 60.4 % use marijuana in general and 20.8 % use marijuana as sex-drug. General marijuana use was significantly associated with participation in group sex (AOR 3.50; 95 % CI 1.10-11.10) while marijuana use as a sex drug was significantly associated with both participation in condomless sex (AOR 2.86; 95% CI 1.07-7.67) and group sex (AOR 3.39; 95% CI 1.03-11.22). Respondents with a moderate or high perception of network members who use marijuana were more likely to use marijuana both in general and as a sex-drug. Network member marijuana use, while not associated with risk behaviors, is associated with individual marijuana use and individual marijuana use in the context of sex is associated with risk practices. Targeting interventions towards individuals and their respective networks that use marijuana as a sex drug may reduce HIV risk.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Infecções por HIV/etnologia , Homossexualidade Masculina/etnologia , Fumar Maconha/etnologia , Rede Social , Adolescente , Adulto , População Negra , Chicago/epidemiologia , Estudos Transversais , Infecções por HIV/prevenção & controle , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Prevalência , Assunção de Riscos , Fatores Socioeconômicos , Sexo sem Proteção/estatística & dados numéricos , Adulto JovemRESUMO
Accurate, timely human immunodeficiency virus (HIV) diagnosis is critical. Routine HIV screening program data were examined before and after reflex HIV type 1 RNA testing. Reflex testing facilitated confirmation of reactive HIV screening assays (as true or false positives) (odds ratio, 23.7 [95% confidence interval, 6.7-83.4]; P < .0001), improving detection of acute HIV and reducing unconfirmed discordant results.
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BACKGROUND: The COVID-19 pandemic caused disruptions in access to routine HIV screening. SETTING: We assess HIV and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing across 6 emergency departments (EDs) in Cook County, Illinois. METHODS: We retrospectively analyzed the number of SARS-CoV-2 tests, HIV screens, and the proportion of concurrent tests (encounters with both SARS-CoV-2 and HIV testing), correlating with diagnoses of new and acute HIV infection. RESULTS: Five sites reported data from March 1, 2020, to February 28, 2021, and 1 site from September 1, 2020, to February 28, 2021. A total of 1,13,645 SARS-CoV-2 and 36,094 HIV tests were performed; 17,469 of these were concurrent tests. There were 102 new HIV diagnoses, including 25 acute infections. Concurrent testing proportions ranged from 6.7% to 37% across sites (P < 0.001). HIV testing volume correlated with the number of new diagnoses (r = 0.66, P < 0.01). HIV testing with symptomatic SARS-CoV-2 testing was strongly correlated with diagnosis of acute infections (r = 0.87, P < 0.001); this was not statistically significant when controlling for HIV testing volumes (r = 0.59, P = 0.056). Acute patients were more likely to undergo concurrent testing (21/25) versus other new diagnoses (29/77; odds ratio = 8.69, 95% CI: 2.7 to 27.8, P < 0.001). CONCLUSIONS: Incorporating HIV screening into SARS-CoV-2 testing in the ED can help maintain HIV screening volumes. Although all patients presenting to the ED should be offered opt-out HIV screening, testing individuals with symptoms of COVID-19 or other viral illness affords the opportunity to diagnose symptomatic acute and early HIV infection, rapidly link to care, and initiate treatment.
Assuntos
COVID-19 , Infecções por HIV , Humanos , Estados Unidos/epidemiologia , COVID-19/diagnóstico , COVID-19/epidemiologia , SARS-CoV-2 , Teste para COVID-19 , Infecções por HIV/complicações , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Pandemias , Estudos Retrospectivos , Serviço Hospitalar de EmergênciaRESUMO
OBJECTIVE: Various HIV testing models have been described, but widespread implementation has lagged. We describe a clinical HIV testing program notable for its use of conventional (nonrapid) assays, native hospital personnel, and an electronic system to aid targeted patient selection. METHODS: Clinical HIV testing program records and hospital emergency department (ED) and laboratory records were reviewed and linked for the period from January 2007 until November 5, 2008. RESULTS: There were 103,475 visits to the ED, for which 1,258 (1.2%) resulted in HIV testing, and 54 (4.3%) were positive for HIV antibody. Result notification was successful for 52 (96%) individuals with positive test results. After reporting to the health department, it was determined that 28 (2.2%) individuals had received a new diagnosis, of whom 89% were linked with care. Mean baseline CD4 counts for new diagnoses for periods 1 through 3, respectively, were (1) unavailable, (2) 138 cells/µL (95% confidence interval [CI] 34 to 242 cells/µL), and (3) 222 cells/µL (95% CI 119 to 325 cells/µL). Overall, mean calculated to be 180 cells/µL (95% CI 16 to 345 cells/µL). CONCLUSION: This ED HIV testing model successfully expanded new patient identification, result notification, and linkage to care. Although this effort falls short of Centers for Disease Control and Prevention recommendations, the model can be implemented widely without external funding for parallel staffing or rapid assays.
Assuntos
Sorodiagnóstico da AIDS/métodos , Serviço Hospitalar de Emergência , Sorodiagnóstico da AIDS/estatística & dados numéricos , Chicago/epidemiologia , Continuidade da Assistência ao Paciente , Registros Eletrônicos de Saúde , Soropositividade para HIV/diagnóstico , Soropositividade para HIV/epidemiologia , Hospitais Urbanos , Humanos , Avaliação de Resultados em Cuidados de Saúde , Estudos RetrospectivosRESUMO
Lung transplantation has lower survival rates compared to other than other solid organ transplants (SOT) due to higher rates of infection and rejection-related complications, and bacterial infections (BI) are the most frequent infectious complications. Excess morbidity and mortality are not only a direct consequence of these BI, but so are subsequent loss of allograft tolerance, rejection, and chronic lung allograft dysfunction due to bronchiolitis obliterans syndrome (BOS). A wide variety of pathogens can cause infections in lung transplant recipients (LTRs), including a number of nosocomial pathogens and other multidrug-resistant (MDR) pathogens. Although pneumonia and intrathoracic infections predominate, LTRs are at risk of a number of types of infections. Risk factors include altered anatomy and function of airways, impaired immunity, the microbial flora of the donor and recipient, underlying medical conditions, and genetic factors. Further work on immune monitoring has the potential to improve outcomes. The infecting agents can be derived from the donor lung, pre-existing recipient flora, or acquired from the environment over time. Certain infections may preclude lung transplantation, but this varies from center to center, and more recent studies suggest fewer patients should be disqualified. New molecular methods allow microbiome studies of the lung, gut, and other sites that may further our knowledge of how airway colonization can result in infection and allograft loss. Surveillance, early diagnosis, and aggressive antimicrobial therapy of BI is critical in LTRs. Antibiotic resistance is a major barrier to successful management of these infections. The availability of new agents for MDR Gram-negatives may improve outcomes. Other new therapies, such as bacteriophage therapy, show promise for the future. Finally, it is important to prevent infections through peri-transplant prophylaxis, vaccination, and infection control measures.
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Candida species are a common cause of bloodstream infection among hospitalized patients. Increasingly these infections are caused by strains resistant to commonly used antifungal agents. The aim of this study was to assess the association between exposure to specific antimicrobial agents and subsequent bloodstream infection with fluconazole-non-susceptible and fluconazole-susceptible Candida strains. A retrospective case-case-control study was performed. From 2002 to 2006, 50 consecutive patients with hospital-acquired bloodstream infection caused by Candida strains not fully susceptible to fluconazole were identified (case group 1). For comparison, 54 patients with fluconazole-susceptible candidaemia (case group 2) and a control group of 104 patients without candidaemia were studied. Models were adjusted for demographic and clinical risk factors. The risk for candidaemia associated with exposure to specific antimicrobial agents was assessed. Piperacillin/tazobactam (odds ratio (OR) 6.8, 95% confidence interval (CI) 1.4-32.2) and ciprofloxacin (OR 8.0, 95% CI 1.5-42.5), but not fluconazole, were significant risk factors for bloodstream infection with fluconazole-non-susceptible Candida. Only ciprofloxacin (OR 7.8, 95% CI 1.2-50.7) was associated with bloodstream infection with fluconazole-susceptible Candida. Despite adjustment for prior exposure to fluconazole, exposure to specific antibacterial agents was associated with hospital-acquired bloodstream infection with fluconazole-non-susceptible Candida.
Assuntos
Antifúngicos/farmacologia , Candida/efeitos dos fármacos , Candidíase/epidemiologia , Farmacorresistência Fúngica/efeitos dos fármacos , Fluconazol/farmacologia , Fungemia/epidemiologia , Adulto , Antifúngicos/uso terapêutico , Candidíase/tratamento farmacológico , Ciprofloxacina/farmacologia , Ciprofloxacina/uso terapêutico , Fluconazol/uso terapêutico , Fungemia/tratamento farmacológico , Humanos , Modelos Logísticos , Razão de Chances , Ácido Penicilânico/análogos & derivados , Ácido Penicilânico/farmacologia , Ácido Penicilânico/uso terapêutico , Piperacilina/farmacologia , Piperacilina/uso terapêutico , Combinação Piperacilina e Tazobactam , Estudos Retrospectivos , Fatores de RiscoRESUMO
There are many unknowns with regard to COVID-19 clinical management, including the role of Infectious Diseases Consultation (IDC). As hospitalizations for COVID-19 continue, hospitals are assessing how to optimally and efficiently manage COVID-19 inpatients. Typically, primary teams must determine when IDC is appropriate, and ID clinicians provide consultation upon request of the primary team. IDC has been shown to be beneficial for many conditions; however, the impact of IDC for COVID-19 is unknown. Herein, we discuss the potential benefits and pitfalls of automatic IDC for COVID-19 inpatients. Important considerations include the quality of care provided, allocation and optimization of resources, and clinician satisfaction. Finally, we describe how automatic IDC changed throughout the COVID-19 pandemic at a single academic medical center.
RESUMO
BACKGROUND: Anti-inflammatory therapies such as IL-6 inhibition have been proposed for COVID-19 in a vacuum of evidence-based treatment. However, abrogating the inflammatory response in infectious diseases may impair a desired host response and predispose to secondary infections. METHODS: We retrospectively reviewed the medical record of critically ill COVID-19 patients during an 8-week span and compared the prevalence of secondary infection and outcomes in patients who did and did not receive tocilizumab. Additionally, we included representative histopathologic post-mortem findings from several COVID-19 cases that underwent autopsy at our institution. RESULTS: 111 patients were identified, of which 54 had received tocilizumab while 57 had not. Receiving tocilizumab was associated with a higher risk of secondary bacterial (48.1% vs. 28.1%, p=0.029 and fungal (5.6% vs. 0%, p=0.112) infections. Consistent with higher number of infections, patients who received tocilizumab had higher mortality (35.2% vs. 19.3%, p=0.020). Seven cases underwent autopsy. In 3 cases who received tocilizumab, there was evidence of pneumonia on pathology. Of the 4 cases that had not been given tocilizumab, 2 showed evidence of aspiration pneumonia and 2 exhibited diffuse alveolar damage. CONCLUSIONS: Experimental therapies are currently being applied to COVID-19 outside of clinical trials. Anti-inflammatory therapies such as anti-IL-6 therapy have the potential to impair viral clearance, predispose to secondary infection, and cause harm. We seek to raise physician awareness of these issues and highlight the need to better understand the immune response in COVID-19.