Infective complications after abdominal surgery in patients infected with human immunodeficiency virus: role of CD4+ lymphocytes in prognosis

Surgical Site Infection in Laparoscopic Hysterectomy versus Abdominal Hysterectomy in Gynecological Disease(s): An Overview

Objective

Surgical site infection (SSI) is an unsettled complication seen in any surgery. The aim of this study is to assess the rate of postoperative SSIs between total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH). Can the rate of SSI be reduced with the use of a laparoscopic mode of hysterectomy over abdominal?

Materials and Methods

It was a retrospective comparative study. The study was conducted in the obstetrics and gynecology department at a tertiary care center from June 2016 to March 2020. A total of 300 patients who underwent hysterectomy either via laparoscopic or abdominal route were included in the study. They were subdivided into two groups: a total of 167 underwent TLH (Group 1) and 133 had TAH (Group 2). The results were compared. It included the age and body mass index of the patient, indication of surgery, size of the uterus, intraoperative blood loss, postoperative SSIs, duration of hospital stay, and readmission rates.

Results

It was found a high rate of SSI in TAH (82.4% vs. 17.6%, P < 0.001, Cramer's V-0.18), the operative time taken (75 ± 25 min vs. 128 ± 52 min, P < 0.001), and the mean blood loss during TLH (110 ± 30 ml vs. 160 ± 116 ml, P < 0.001) was found significant for patients. The hospital stay after TLH was found to be significantly shorter (4 ± 2.47 days vs. 7 ± 2.43, P < 0.001).

Conclusion

TLH has improved the psychological, physical, and financial burden on the health care department. Thus, it has proved a preferred route over TAH.

Outcomes following cholecystectomy in human immunodeficiency virus-positive patients treated with antiretroviral therapy: A retrospective cohort study

The number of the human immunodeficiency virus (HIV)-positive patients are increasing worldwide, and more HIV-positive patients are undergoing urgent or elective cholecystectomy. There is still insufficient evidence on the relationship between surgical complications of cholecystectomy and antiviral status in HIV-positive patients. The purpose of the present study is to evaluate surgical outcomes after cholecystectomy in HIV-positive patients. Records of consecutive HIV-positive patients who underwent cholecystectomy between January 2010 and December 2020 were reviewed retrospectively. Patients were divided into urgent and elective surgery groups. Urgent surgery was defined as surgery within 48 hours of admission. Postoperative complications were evaluated according to the Clavien-Dindo classification. A total of 30 HIV-positive patients underwent urgent (n = 7) or elective (n = 23) cholecystectomy. Four complications (13.3%) occurred, and the rate was significantly higher in the urgent group than in the elective group (p = 0.008). However, all complications were minor (3 cases of grade I and one case of grade II), and there were no severe postoperative complications. There was no significant difference in CD4+ lymphocyte status in all patients and between the 2 groups before and after surgery (p = 0.133). No cases of postoperative deterioration in the control of HIV infection were observed. In conclusion, cholecystectomy in HIV-positive patients with controlled HIV under recent antiretroviral therapy may be performed safely even in an emergency situation.

Perioperative Antiretroviral Regimen for HIV/AIDS Patients Who Underwent Abdominal Surgery

BACKGROUND

A short interruption of antiretroviral therapy (ART) and reduced oral bioavailability of antiretroviral medications could occur in perioperative human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients who undergo abdominal surgery. Therefore, we focused on the changes in HIV viral load and CD4⁺ T lymphocyte count in HIV/AIDS patients after surgery and explored whether the perioperative use of intravenous antiretroviral drugs is beneficial in lowering the viral load and increasing the safety of the surgery.

METHODS

We prospectively collected data from HIV/AIDS patients who underwent abdominal surgery at our institution from January 2019 and April 2019. According to the use of different antiretroviral medications during the perioperative period, the HIV/AIDS patients were divided into four groups: Group I: Patients continued their original antiretroviral medications; Group II: Patients received their original antiretroviral medications plus intravenous administration of the fusion inhibitor albuvirtide (ABT); Group III: Patients received ABT alone; and Group IV: Patients did not receive ART. The primary outcomes considered were the changes in HIV load and CD4⁺ T lymphocyte count and the postoperative complications in the four groups.

RESULTS

A total of 64 HIV/AIDS patients were enrolled, and their data were analyzed descriptively. There were no differences between group I and group II in terms of the changes in viral load. The viral load continued to decrease in group III within 30 days after surgery, especially from D7 to D30 (t = 2.179, p = 0.043). However, the viral load showed an upward trend after surgery in group IV. There were statistically significant differences between the two groups in the changes in viral load after surgery (p = 0.022). However, there were no statistically significant differences between group III and group IV in the postoperative changes in the CD4⁺ T lymphocyte count. Seven out of 64 patients had postoperative infective complications. The incidence of complications from high to low was as follows: group IV > group I > group III > group II (p < 0.05).

CONCLUSIONS

A short perioperative interruption of ART may have a small impact on viral load in HIV/AIDS patients on virologic suppression after abdominal surgery. For patients with a detectable viral load, an intravenous injection of ABT in the perioperative period can reduce the viral load quickly, lower the occurrence of postoperative complications, and increase operation safety for both the HIV/AIDS patient and the surgeons.

Optimal timing for elective total hip replacement in HIV-positive patients

INTRODUCTION

Evidence about the optimal timing for total hip replacement (THR) in HIV-positive patients is scant.

HYPOTHESIS

Preoperative criteria: cluster of differentiation 4 (CD4) counts>200cells/mm³ and an undetectable HIV virus load before THR, improve infection rates, aseptic loosenings, and functional outcomes.

MATERIALS AND METHODS

We recruited 16 HIV-positive patients who had undergone 25 THRs between 2003 and 2015. None had hemophilia, and none were intravenous drug users (IVDUs).

RESULTS

Their mean age was 41.2 years (range: 24-60); minimum follow-up was 12 months (mean: 64.6); mean duration of prophylactic antibiotics was 2.9 days (range: 1-5); and mean hospital length of stay was 6.0 days (range: 4-11). No patients were treated with subsequent oral antibiotics. The mean preoperative CD4 count was 464.1±237.0 (range: 235-904)cells/mm³. There were no early superficial surgical site infections, late periprosthetic joint infections, or aseptic loosenings. Post-surgery Harris Hip score was significantly (p<0.001) better.

DISCUSSION

A preoperative CD4 count>200cell/mm³ and an undetectable HIV virus load might indicate optimal timing for elective THRs in HIV-positive patients without hemophilia and not IVDUs.

LEVEL OF EVIDENCE

IV, retrospective or historical series.

The effect of stage of HIV disease as determined by CD4 count on clinical outcomes of surgical sepsis in South Africa

INTRODUCTION This paper reviews the impact of the stage of human immunodeficiency virus (HIV) disease on the outcome of surgical sepsis. METHODS All adult emergency general surgical patients (aged >15 years) who fulfilled the criteria for sepsis or septic shock, with a documented surgical source of infection, and who were HIV positive were reviewed. RESULTS During the 5-year study period, a total of 675 patients with a documented surgical source of sepsis were managed by our service; 142 (21%) of these were HIV positive. Among the individuals who were HIV positive, the CD4 count was <200 cells/µl in 21 patients and ≥200 cells/µl in 121 patients. There was no difference between these two cohorts in terms of demography or spectrum of surgical conditions. The range of surgical procedures and complications was also similar in both groups. Nevertheless, patients with a CD count of <200 cells/µl had a significantly longer length of hospital stay than those in the cohort with ≥200 cells/µl. For HIV positive patients with a CD4 count of <200 cells/µl, the mortality rate was 66.7% (14/21) while the mortality rate for individuals with HIV and a CD4 count of ≥200 cells/µl was 2.5% (2/121). This difference was statistically significant (p<0.001). CONCLUSIONS The clinical presentation and spectrum of surgical sepsis disease in cases with stage 1 and stage 2 HIV is not markedly different. However, in patients with a CD4 count of <200 cells/µl, the length of hospital stay and mortality is significantly higher. Stage of HIV disease must be considered when stratifying patients' risk for surgery.

Wounds in patients with HIV

Highly active antiretroviral therapy has dramatically reduced morbidity and mortality among patients who are HIV-positive. A retrospective review of the authors' data separated subjects into cohorts based on HIV status and matched them for age and gender. The authors' data reveal a higher fraction of venous ulcers compared with a lower fraction of pressure ulcers in the seropositive population.

Analysis and Outcomes of Cataract Surgery in Patients with Acquired Immunodeficiency Syndrome

PURPOSE

To investigate the surgical outcomes, complications and postoperative progression in HIV patients undergoing cataract surgery in a teaching hospital.

METHODS

A retrospective cohort study of patients with HIV/AIDS who had cataract surgery from January 2000 until December 2011 at a tertiary referral multidisciplinary hospital in Singapore.

RESULTS

We identified 44 eyes from 29 patients. Preoperatively, 41.3% had no ophthalmic manifestations of HIV/AIDS, while 16 eyes had quiescent cytomegalovirus retinitis (CMVR). Postoperatively, 1 eye developed new CMVR, while 1 eye had reactivation of previous CMVR. Of eyes with new or previous CMVR, 1 eye developed rhegmatogenous retinal detachment (RD) postoperatively. Only 3 eyes had prolonged postoperative inflammation. There were no cases of endophthalmitis or cystoid macular edema. Postoperative improvement of at least two Snellen lines was achieved in 86.6% of eyes.

CONCLUSIONS

Cataract surgery in HIV patients is generally safe, regardless of CD4 count, but their general and ocular health should be optimized preoperatively.

HIV and renal cell carcinoma: Experience in an Australian statewide HIV center

AIM

To report on the presentation, management and outcomes of renal cell carcinoma (RCC) among people with human immunodeficiency virus (HIV).

METHODS

We retrospectively reviewed patients with HIV and RCC in a statewide HIV referral center in Australia. Patients' medical records were reviewed to collect data on the HIV parameters at the time of RCC diagnosis, as well as presentation, management and outcomes of RCC.

RESULTS

Seven patients with HIV and RCC were included in the current study. The median age at RCC diagnosis was 56 years (range: 44-62 years). At RCC diagnosis, six patients were on combination antiretroviral therapy (ART), and five had virological suppression. Three patients were symptomatic at presentation, while the rest were diagnosed incidentally. Two patients had metastatic RCC at diagnosis. All five patients with clinically localized RCC had radical/partial nephrectomies, of which two patients with pT3a disease developed recurrence (pulmonary and bone) at 5 and 30 months postnephrectomies. One patient with metastatic RCC was treated with vascular endothelial growth factor (VEGF) inhibitors while continuing on ART. Four patients died of RCC at a median of 9 months (range: 4-16 months) following diagnosis of metastatic disease. Three patients were alive at a median follow-up of 16 months (range: 10-80 months).

CONCLUSION

Our experience suggests that patients with HIV should be offered all treatment options in the same manner as the general population, taking into account their prognosis from HIV. Curative surgery should be considered for localized RCC. Potential drug interactions between ART drugs and targeted therapies for metastatic RCC need to be considered.

CD4 Count is Still a Valid Indicator of Outcome in HIV-Infected Patients Undergoing Major Abdominal Surgery in the Era of Highly Active Antiretroviral Therapy

BACKGROUND

Patients with HIV/AIDS on antiretroviral therapy (ART) live longer and now require surgery for indications similar to those described for the general population. They have been previously reported to carry higher mortality and complication rates, especially septic complications. The aim of this study was to compare the outcome of major abdominal surgery in three groups of patients with different CD4 counts.

METHODS

This is a prospective study comparing HIV-negative patients and two groups of HIV-infected patients on ART with different CD4 counts. The primary outcomes considered were mortality and complication rates after abdominal surgery. We emphasised on the value of CD4 as a predictor of outcome and the impact of the indication for surgery (septic versus non-septic).

RESULTS

We included 63 patients (21 per group). The majority of patients (71 %) were operated on as an emergency and the indications were similar in all groups. The overall and the septic complication rates were both higher in the group with a low CD4 count. This resulted in a significantly longer admission period but did not result in a higher mortality rate. The duration of ART and the World Health Organisation stage of the disease did not significantly influence surgical outcomes.

CONCLUSIONS

HIV-infected patients on ART can now safely undergo major abdominal surgery with encouraging results though still relatively poorer than those of HIV-negative subjects. CD4 count remains a significant predictor of outcome and patients with a low CD4 count, however, still require closer pre- and post-operative monitoring.

Does HIV infection have an impact upon dental implant osseointegration? A systematic review

OBJECTIVE

A systematic review is made to determine whether human immunodeficiency virus (HIV) infection has an impact upon dental implant osseointegration.

STUDY DESIGN

A PubMed (MEDLINE) literature search was made of articles published up until 14 April 2014. The systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The quality of the studies included in the review was assessed using the Methodological Index for Nonrandomized Studies (MINORS) and levels of evidence (based on the University of Oxford's Center for Evidence Based Medicine criteria).

RESULTS

The combinations of search terms resulted in a list of 132 titles. Nine studies finally met the inclusion criteria and were selected for inclusion in the systematic review. A total of 173 dental implants were placed in 80 patients (135 implants in 56 HIV-positive subjects and 38 implants in 24 HIV-negative patients), and a single loss of dental implant osseointegration was recorded in an HIV-positive patient.

CONCLUSIONS

Our results suggest that dental implant placement in HIV-positive patients does not increase the dental implant failure rate. Prophylactic antibiotic treatment, the administration of highly active antiretroviral therapy, and control of the CD4+ T lymphocyte counts appear to be the main influencing factors in this respect. Given the few studies included in our systematic review, further prospective studies involving larger sample sizes and longer durations of follow-up are required in order to confirm the results obtained.

Effect of emergency major abdominal surgery on CD4 cell count among HIV positive patients in a sub-Saharan Africa tertiary hospital--a prospective study

Background

Surgery plays a key role in HIV palliative care, specifically in the diagnosis and treatment of HIV related and non-related conditions. Yet major surgery depresses the immune system. Whereas the surgical consequences of HIV infection are well described, there is a paucity of published data, in resource-limited settings, on the effects of major surgery on the immune system. The purpose of this study was to determine the effect of major abdominal surgery on CD4 count in HIV positive and HIV negative patients after emergency major surgery.

Methods

A prospective cohort study was done for patients who underwent emergency major abdominal surgery. Their peri-operative CD4 counts were done for both HIV- and HIV + patients. Median CD4s were used in analysis.

Mann Whitney test of significance was used for continuous data and Fisher’ exact test used for categorical data. IRB approval was obtained.

Results

A total of 101 patients were recruited, 25 HIV positive and 76 HIV negative. The median CD4 cell reduction was higher in the HIV negative group (−68 cells) than HIV positive group (−29 cells) (p = 0.480).

There was a general increase in the median CD4 change by 72 cells for the HIV positives and 95 cells for the HIV negatives (p = 0.44). CD4 change rose in both the HIV positive and negative groups by 27 cells for the HIV positives and 28 cells for the HIV negatives (p = 0.94). Relative Risk was 0.96, {CI 0.60 – 1.53}.

Conclusion

Major emergency abdominal surgery had no significant effect on CD4 cell count among HIV positive patients.

Anti-infective treatment in HIV-infected patients during perioperative period

OBJECTIVE

To investigate anti-infective treatments in HIV-infected surgical patients during the perioperative period.

METHODS

A retrospective study of sepsis and surgical site infections (SSIs) was conducted in 266 HIV-infected patients. The patients were divided into 3 groups based on CD4+ T cells counts in the preoperative period: group A (0-199 cell/ul), group B (200-349 cell/ul) and group C ([greater than or equal to] 350 cell/ul). When the CD4 count was below 350 cells/uL, anti-retrovirus therapy was started. For patients whose preoperative CD4 counts were [less than or equal to] 200 cells/uL, preoperative antibiotic medication was started.

RESULTS

Patients in group A were more likely to get sepsis than patients in the other two groups (p0.01). Among 82 patients with clean wounds, only one patient got SSIs. All patients with dirty wounds had acquired SSIs after surgery. There were only 6 patients dead at 30 days after surgery, a death rate of 2.3%. Sepsis appeared in 110 patients (41%).

CONCLUSIONS

Complete evaluation of surgical risk and suitable perioperative anti-infective treatment may lead to better outcome for HIV-infected surgical patients.

Surgical aspects of bacterial infection in African children

Infections and their complications requiring surgical intervention are a frequent presentation in African children. Surgical site infection (SSI) is common with rates over 20%, even after clean procedures. The high rates of SSI are due in part to lack of infection control and surveillance policies in most hospitals in Africa. SSI is attended by complications, long hospital stay, and some mortality, but the economic consequences are unestimated. Typhoid fever and typhoid intestinal perforation are major problems with perforation rates of approximately 10%, which is higher in older children. The ideal surgical treatment is arguable, but simple closure and segmental resection are the present effective surgical options. Because of delayed presentation, complications after surgical treatment are high with a mortality approaching 41% in some parts of Africa. Nutrition for these patients remains a challenge. Acute appendicitis, although not as common in African children, often presents rather late with up to 50% of children presenting with perforation and other complications, and mortality is approximately 4% is some settings. Pyomyositis and necrotizing fasciitis are the more common serious soft-tissue infections, but early recognition and prompt treatment should minimize the occasional mortality. Though common in Africa, the exact impact of human immunodeficiency virus infection on the spectrum and severity of surgical infection in African children is not clear, but it may well worsen the course of infection in these patients.

Surgical implications of human immunodeficiency virus infections

Pediatric HIV (human immunodeficiency virus) is a pandemic predominantly in sub-Saharan Africa. Approximately 2.2 million children aged less than 15 years are infected with HIV, representing almost 95% of the total number of children globally infected with HIV. Therefore, increasing numbers of HIVi or -exposed but uninfected children can be expected to require a surgical procedure to assist in the diagnosis of an HIV/acquired immune deficiency syndrome-related complication, to address a life-threatening complication of the disease, or for routine surgery encountered in HIV-unexposed children. HIVi children may present with both conditions unique to HIV infection and surgical conditions routine in pediatric surgical practice. HIV exposure confers an increased risk of complications and mortality for all children after surgery, whether they are HIV infected or not. This risk of complications is higher in the HIVi group of patients. These findings seem to be independent of whether patients undergo an elective or emergency procedure, but the risk of an adverse outcome is higher for a major procedure. Surgical implications of HIV infection are comprehensively reviewed in this article.

Complications of tunneled cuffed hemodialysis catheters in patients with human immunodeficiency virus infection

PURPOSE

Although increased infectious and thrombotic complications have been reported in patients with human immunodeficiency virus (HIV), little is known regarding hemodialysis catheter-related complications in HIV patients. In this report, we reviewed our experience and complication rates for tunneled cuffed catheters (TCCs) in HIV patients requiring hemodialysis.

METHODS

A total of 85 patients with HIV infection underwent TCC placement for hemodialysis between 1996 and 2009. Hospital records were reviewed to determine causes and risk factors for TCC-related complications in HIV patients. For comparison, we studied 85 age- and sex-matched low-risk HIV case controls who received TCC for hemodialysis during the same period.

RESULTS

A total of 119 and 102 TCCs were inserted in the HIV and control group, respectively. Total numbers of catheter days in the HIV and control groups were 17,321 and 15,620 days, respectively. The primary unassisted TCC patency rates at 6 months in the HIV and control groups were 74% ± 11% and 86% ± 8%, respectively (NS). There was an increased TCC bacteremia rate in HIV patients compared with control subjects (5.38 vs. 2.66 per 1,000 TCC days, p=0.03). There was also a higher TCC tunnel infection rate in HIV patients compared with control cohorts (3.72 vs. 1.87 per 1,000 TCC days, p=0.04). Factors associated with increased catheter infection rate in HIV patients were 1) low CD4+ lymphocyte counts (<200/mm3), 2) low albumin level (<2.5 g/dl), and 3) history of illicit intravenous drug use.

CONCLUSION

TCCs are associated with an increased risk of infection in HIV patients requiring hemodialysis. Moreover, HIV infection is associated with an increased risk of mortality among hemodialysis patients. Hypoalbuminemia, history of intravenous drug use, and low CD4+ lymphocyte counts are associated with increased risk of catheter infection in HIV patients requiring hemodialysis.

CD4 count is predictive of outcome in HIV-positive patients undergoing abdominal operations

BACKGROUND

The impact of immune status and surgical outcome in patients with HIV and acquired immunodeficiency syndrome (AIDS) remains unknown.

METHODS

Clinical variables of HIV/AIDS patients undergoing abdominal surgery were examined for their impact on outcome.

RESULTS

Major abdominal procedures were performed in 77 patients with a diagnosis of HIV/AIDS (55 males, mean age 41.1 years, mean CD4 count 210 mg/dL). A majority of operations (53%) were performed on an urgent basis. Patients undergoing urgent procedures had lower CD4 counts (129 ± 121 vs 303 ± 324, P = .002). The mean CD4 count was lower for patients with complications (146 ± 156 vs 288 ± 319, P = .013) and for those who died (112 ± 113 vs 251 ± 283, P = .026). On multivariate analysis, CD4 count was independently associated with an increased risk for complication, and urgent operation was associated with an increased risk for mortality.

CONCLUSION

Patients with HIV/AIDS who had lower CD4 counts were more likely to require an urgent operation and experience a complication with increased mortality.

Risk factors for surgical wound infection in HIV-positive patients undergoing surgery for orthopaedic trauma

PURPOSE

To identify risk factors associated with surgical wound infection in patients infected with human immunodeficiency virus (HIV) undergoing surgery for orthopaedic trauma.

METHODS

Records of 29 male and 7 female HIV-positive patients aged 18 to 47 years who underwent surgery for orthopaedic trauma were reviewed. Data on HIV-specific variables (HIV clinical classification, CD4+ lymphocyte count) and highly active antiretroviral therapy were retrieved, as were data on wound class, fracture type, surgery type, surgical wound infections, and outcomes. Possible risk factors associated with surgical wound infection were analysed.

RESULTS

The median follow-up period was 27 (range, 19-41) months. Of the 36 patients, 14 (39%) developed surgical wound infections (4 were deep and 10 superficial). 89% and 67% of them were in HIV clinical category B and in CD4+ T-lymphocyte category 3, respectively. 12 of these infections resolved after debridement and prolonged antibiotic treatment, and 2 developed chronic osteomyelitis. Four of the patients had non-union. Surgical wound infections were associated with HIV clinical category B (p<0.001), CD4+ T-lymphocyte category of more than or equal to 2 (p=0.041), and contaminated wounds (p=0.003).

CONCLUSION

Identification of risk factors may help minimise morbidity in HIV-positive patients.

Diverticulitis in immunosuppressed patients

The differential diagnosis of abdominal pain should not rank diverticulitis any differently in immunosuppressed transplant or AIDS patients than in other patients of the same sex and age and with the same clinical presentation. Immunocompromised patients have increased postoperative infectious risks in direct proportion to the degree of their immune deficiency.

Impact of highly active antiretroviral therapy on outcome of cholecystectomy in patients with human immunodeficiency virus infection

BACKGROUND

Highly active antiretroviral therapy (HAART) reduces virus proliferation and significantly decreases the rate of septic and opportunistic complications in patients infected with human immunodeficiency virus (HIV). Although surgery is performed routinely on patients receiving HAART, the effect of this treatment on surgical outcome has not been examined in detail.

METHODS

This retrospective study reviewed 54 consecutive patients with HIV infection who underwent surgical cholecystectomy: 31 patients were on HAART, 13 on nucleoside analogue reverse transcriptase inhibitors (NRTIs) and ten were receiving no specific therapy. Characteristics of HIV-1 infection, laboratory investigations, characteristics of the gallbladder disease, type of operation, postoperative course, morbidity and mortality were recorded. Univariable analysis and unconditional logistic regression were performed to determine factors related to postoperative complications and death.

RESULTS

The three groups were similar in terms of HIV-1 infection characteristics. In univariable analysis HAART and laparoscopic cholecystectomy were associated with a significantly lower complication rate, whereas only HAART was shown to be protective by logistic regression analysis. A low HIV RNA load and a high CD4(+) cell count were significant predictors of uncomplicated surgical outcomes.

CONCLUSION

HAART significantly reduces the risk of complications after cholecystectomy in patients with HIV infection or acquired immune deficiency syndrome.

Radical prostatectomy in patients infected with human immunodeficiency virus

OBJECTIVE

To present the complications and early outcomes in a small series of men infected with human immunodeficiency virus (HIV) and treated with radical prostatectomy (RP) for prostate cancer, and to review reports on surgery in HIV-positive patients.

PATIENTS AND METHODS

During 2002-2005, seven men infected with HIV underwent RP at our institution. For the five patients whose HIV status was known before surgery, we retrospectively examined preoperative variables, including HIV-specific data (clinical category, CD4+ lymphocyte count, viral load, duration of HIV diagnosis, and opportunistic infections), and the complications and early outcomes after RP.

RESULTS

Before RP all the patients were in the Center for Disease Control clinical category A (asymptomatic HIV infection). The CD4+ counts before RP ranged from 269-870 cells/microL and viral loads ranged from <50-18 700 copies/mL. Three patients were on highly active anti-retroviral therapy (HAART) at the time of surgery. After RP, two patients had incisional wound infections, including one requiring re-hospitalization for intravenous antibiotics. During the follow-up (median 26 months) none of the patients progressed to acquired immunodeficiency syndrome or developed biochemical recurrence of prostate cancer. One healthcare worker was exposed to contaminated urine and placed on prophylactic therapy, but has not sero-converted.

CONCLUSIONS

The risk of peri-operative complications in HIV-positive patients can be minimized by carefully selecting the patient and procedure, and by measuring routine and HIV-specific preoperative variables. The two infectious complications in this series were in patients with less favourable preoperative factors, i.e. the lowest CD4+ count and the highest viral load. Further experience is needed to determine whether the risk of surgical infections is higher in this cohort. However, our results are consistent with reports from other surgical specialities that surgery in asymptomatic HIV-positive patients is safe and effective.

Spectrum of spine infections in patients with HIV: a case report and review of the literature

Because of the increase in patients with human immunodeficiency virus, practitioners are likely to see a concordant increase of infections. Spontaneous spinal infections can result from a variety of organisms. A common pathogen is Staphylococcus aureus, which is the most frequent cause of pyogenic spinal infection in patients who test positive for the human immunodeficiency virus. Human immunodeficiency virus has caused a resurgence of spinal tuberculosis and other infections. The pandemic of human immunodeficiency virus has caused a rise in extremely rare spinal infections caused by fungus, virus, and atypical bacteria that usually are nonpathogenic. As the number of elective and emergent spinal surgeries become more frequent, spinal practitioners also must become more familiar with the particularities of preoperative and perioperative decision making. Patients' CD4 cell counts are a useful preoperative parameter to stratify the risk for postoperative wound infection because counts less than 200/mm3 seem to be a critical threshold. A case of a patient with the human immunodeficiency virus is presented. The patient had a chronic, postoperative infection and posttraumatic post-laminectomy kyphosis; he was successfully treated with staged procedures including debridement, deformity correction, stabilization, and appropriate antibiotic therapy.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

Total hip arthroplasty in patients with human immunodeficiency virus infection: pathologic findings and surgical outcomes

BACKGROUND

An increased incidence of osteonecrosis of the femoral head has been reported in patients infected with human immunodeficiency virus (HIV). The purpose of this study was to review the pathologic specimens of HIV-positive patients who had undergone total hip arthroplasty (THA) and compare them with those of THA patients who were HIV-negative. The surgical outcomes of these HIV-positive patients were also reviewed.

METHODS

40 HIV-positive patients who underwent 54 THAs at our institution were identified. The primary pathologic diagnosis for the femoral heads of these patients was osteonecrosis in 35 cases, degenerative joint disease in 11 cases, and other diagnoses in 8 cases.

RESULTS

There was a higher incidence of osteonecrosis in HIV-positive patients. At the most recent follow-up, 4 patients had died and 1 patient had a significant Staphylococcus aureus infection of the hip.

INTERPRETATION

There was a significant difference in the pathologic diagnoses of the HIV-positive group and the HIV-negative group, implicating HIV infection as a risk factor for osteonecrosis. Also, the risk of infectious complications is lower in our study than previously reported in other studies of HIV-positive patients who have undergone THA.

Elective spinal surgery in asymptomatic HIV-seropositive persons: perioperative complications and outcomes

STUDY DESIGN

This is a retrospective study consisting of medical records review and evaluation of pertinent radiographs.

OBJECTIVES

In this study, complications and outcomes are reviewed in a series of HIV-positive patients undergoing spinal surgery. Surgery was performed for conditions that were unrelated to HIV infection.

METHODS

From the period 1996 to 2000, we identified 10 seropositive patients who underwent spinal procedures for conditions that did not arise as a complication of HIV infection. A retrospective review was done, which included inpatient and out patient records.

RESULTS

A total of 6 women and 5 men who were HIV-positive underwent spinal surgery during the time period reviewed. Surgery was performed for a variety of conditions, including lumbar disc herniaition, degenerative disc disease, cervical disc herniation, spinal fractures, and Arnold-Chiari malformation. The mean CD4 count was 279 cells/mm3 before surgery. All patients had at least 6 months of conservative management before surgery, except in the case of those who had spinal fractures. Two patients sustained postoperative complications: 1 patient developed a superficial wound infection, which was successfully treated with antibiotics, and 1 patient experienced prolonged fever (7 days) after surgery, which resolved without a clear diagnosis. All patients were improved after surgery (mean follow-up, 29.3 months)

CONCLUSIONS

Many physicians have held a nihilistic approach, when it comes to the treatment of HIV-positive persons. However, our results in this small series of patients suggest that spinal surgery may be appropriate and can be performed with acceptable outcomes in selected patients.

Abdominal aortic surgery in patients with human immunodeficiency virus infection

PURPOSE

Human immunodeficiency virus (HIV) infection is known to cause acquired immune deficiency syndrome, which has been associated with a wide array of cardiovascular pathologies. This report examined the clinical outcome of patients infected with HIV who underwent abdominal aortic reconstruction for aneurysm or occlusive disease.

METHODS

Hospital and clinic records of all patients with HIV infection who underwent an abdominal aortic operation were reviewed during an 11-year period. Relevant risk factors and clinical variables were assessed for surgical outcome.

RESULTS

Forty-eight HIV patients (mean age 54 +/- 13 years) were identified who underwent abdominal aortic bypass grafting during the study period. Indications for aortic operation included aneurysm (n = 20) and aortoiliac occlusive disease (n = 28). All patients underwent successful aortic reconstructions without intraoperative mortality. Postoperative complications and in-hospital mortality occurred in 16 patients (33%) and 7 patients (15%), respectively. The mean follow-up period was 41 months. Life-table survival rates in aneurysm and occlusive patients at 60 months were 43.2% +/- 5.3% and 46.3% +/- 7.4% (not significant), respectively. Multivariate analysis showed that low CD4 lymphocyte counts (< 200/microL, P <0.05) and hypoalbuminemia (<3.5 g/dL, P <0.05) were risk factors for postoperative complications.

CONCLUSION

Perioperative morbidity and mortality rates are high in HIV patients undergoing an abdominal aortic operation. Low CD4 lymphocyte counts and hypoalbuminemia are associated with poor clinical outcomes in HIV patients undergoing abdominal aortic reconstruction.

Complications associated with cesarean section in HIV-infected patients

OBJECTIVE

To document complications associated with cesarean section in HIV-infected women.

METHOD

A cross-sectional study was done on 307 women who delivered by cesarean section. All these patients, irrespective of their HIV-status, were managed according to the same preset protocol.

RESULT

Of the 307 women, 59 (19%) were HIV-positive. The only significant differences were a higher prevalence of positive serology for syphilis (32% vs. 12%, P=0.0014) as well as more cases of post-operative endometritis in the HIV-positive group (24% vs. 7%, P=0.0003). Post-operative endometritis was documented in 44% of HIV-infected patients with a CD4 count below 400. However, the severity of endometritis, measured by antibiotic treatment and duration of hospital stay, was similar in the two groups. Overall, there was no difference in the duration of hospital stay, post-operative anemia, wound infection, birth weight and perinatal mortality between the two groups.

CONCLUSION

HIV-infected patients undergoing cesarean section are at increased risk for post-operative endometritis, but the severity of the infection is not different from that in HIV-negative patients.