Causes of death in persons with human immunodeficiency virus infection

Seropositivity for pathogens associated with chronic infections is a risk factor for all-cause mortality in the elderly: findings from the Memory and Morbidity in Augsburg Elderly (MEMO) Study

Immunostimulation by chronic infection has been linked to an increased risk for different non-communicable diseases, which in turn are leading causes of death in high- and middle-income countries. Thus, we investigated if a positive serostatus for pathogens responsible for common chronic infections is individually or synergistically related to reduced overall survival in community dwelling elderly. We used data of 365 individuals from the German MEMO (Memory and Morbidity in Augsburg Elderly) cohort study with a median age of 73 years at baseline and a median follow-up of 14 years. We examined the effect of a positive serostatus at baseline for selected pathogens associated with chronic infections (Helicobacter pylori, Borrelia burgdorferi sensu lato, Toxoplasma gondii, cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1/2, and human herpesvirus 6) on all-cause mortality with multivariable parametric survival models. We found a reduced survival time in individuals with a positive serostatus for Helicobacter pylori (accelerated failure time (AFT) - 15.92, 95% CI - 29.96; - 1.88), cytomegalovirus (AFT - 22.81, 95% CI - 36.41; - 9.22) and Borrelia burgdorferi sensu lato (AFT - 25.25, 95% CI - 43.40; - 7.10), after adjusting for potential confounders. The number of infectious agents an individual was seropositive for had a linear effect on all-cause mortality (AFT per additional infection - 12.42 95% CI - 18.55; - 6.30). Our results suggest an effect of seropositivity for Helicobacter pylori, cytomegalovirus, and Borrelia burgdorferi sensu lato on all-cause mortality in older community dwelling individuals. Further research with larger cohorts and additional biomarkers is required, to assess mediators and molecular pathways of this effect.

Implementation of a targeted HPV educational program in a population with HIV

Patients living with human immunodeficiency virus (PLWH) are at higher risk of developing human papillomavirus (HPV)-associated malignancies. This prospective, longitudinal study evaluated the baseline knowledge of PLWH regarding HPV infection and its association with head neck cancer, and it aimed to determine whether a focused educational session could promote both short- and long-term knowledge acquisition in this population. Twenty-seven subjects participated in an interactive educational session and completed pre-test and immediate and delayed (4-month) post-test questionnaires. When compared to their pre-test answers, subjects demonstrated significant improvements in all 28 questions immediately following education. Knowledge preservation was demonstrated 4 months after initial evaluation, with subjects performing significantly better than their pre-test scores in 24 of the original 28 questions. These results suggest that short, focused, educational programs for PLWH may promote a better understanding of HPV's association with human immunodeficiency virus (HIV) and HPV risk factors, methods of transmission, and prevention.

AIDS, Emergency Operations, and Infection Control

Acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV) may turn out to be the largest lethal epidemic of infection ever. The estimated global number of HIV-infected adults in 1993 was 13 million, with projections of up to 40 million by the year 2000. Human immunodeficiency virus infections and AIDS are relevant to surgeons with respect to the surgical management of AIDS patients in general, the treatment of the increasingly long list of surgical complications specific to AIDS patients in particular, and the risks of patient-to-surgeon and surgeon-to-patient HIV transmission. Because of migration of individuals and populations throughout the world, even surgeons practicing in relatively unaffected regions should be familiar with the potential surgical implications of AIDS. Ethical considerations arise, as well. Are surgeons obliged to operate on HIV-positive or AIDS patients? Some surgeons adhere strictly to the Hippocratic Oath, whereas others reserve the right to be selective on whom they operate, except in emergencies. Other common ethical considerations in the AIDS patient are similar to those arising in the terminal cancer case: whether to operate or not; whether to provide advanced support such as total parenteral nutrition or hemodialysis. Answers are not simple and require close collaboration between the surgeon, the AIDS specialist, and involved members of other specialties. Emergency operations become necessary to treat AIDS independent disease such as acute cholecystitis and appendicitis or AIDS-related life-threatening conditions such as gastrointestinal bleeding, obstruction, perforation, or ischemia complicating Kaposi's sarcoma, lymphoma, and cytomegalovirus or disseminated nontuberculous mycobacterial infections. Delays and errors in diagnosis are frequent. Poor nutritional state with weight loss, low serum albumin, and leukocyte count prevails in most patients requiring emergency operations and account for a high mortality. By applying solid judgment and selecting management appropriately, the surgeon has the ability to prolong life and to improve the quality of life for these unfortunate patients, and to do so with extremely minimal risk to himself and his team.

Screening HIV-infected patients for non-AIDS-defining malignancies

The use of antiretroviral therapy has reduced mortality and shifted the spectrum of malignancies affecting people living with HIV/AIDS (PLWH). We review guidelines and evidence for screening PLWH for non-AIDS-defining malignancies as compared with the general population. Cervical cancer screening clearly differs for HIV-seropositive women, with two Pap tests 6 months apart in the first year and then annually if normal. The role of cervical human papillomavirus screening has not yet been defined in HIV-seropositive women. Anal cancer screening consists of an annual digital rectal examination, and some (but not all) guidelines also recommend annual anal Pap tests. Screening for breast and colorectal cancer should follow standard, age-appropriate screening recommendations that apply to the general population. Screening HIV-infected men for prostate cancer, as with the general population, lacks a clear benefit. Despite increasing rates of hepatocellular carcinoma and lung cancers among PLWH, there is insufficient evidence to support routine screening.

Autopsies in HIV: still identifying missed diagnoses

This study reviews the deaths and autopsies carried out over 23 years, 1983–2005, in a British Infection Unit in HIV patients. Of 115 HIV patients known to have died, we obtained data on 93%. Of this 80% were male, median age 38 (25–68) years; 83% were Caucasian; 12% Black African. Major risk factors were men who have sex with men, 52%; heterosexual in Africa, 17%; and injecting drug use, 8%. The commonest diagnosis pre- and post-autopsy diagnosis was pneumonia. Changes in diagnoses in the 38% who underwent autopsy were high (we requested autopsy in 50%). Primary diagnosis changed in 70%, and 36% of all opportunistic infections were missed. This included six of nine cytomegalovirus, all tuberculosis and 75% of Kaposi's sarcoma. Lymphoma was overdiagnosed. Thus, despite excellent resources, the majority of primary diagnoses were wrong, suggesting inadequacy of current diagnostics. To improve these and improve both epidemiological data and future management autopsy should be considered for all deaths.

Immunotherapy of HIV-infected patients with Gc protein-derived macrophage activating factor (GcMAF)

Serum Gc protein (known as vitamin D3-binding protein) is the precursor for the principal macrophage activating factor (MAF). The MAF precursor activity of serum Gc protein of HIV-infected patients was lost or reduced because Gc protein is deglycosylated by alpha-N-acetylgalactosaminidase (Nagalase) secreted from HIV-infected cells. Therefore, macrophages of HIV-infected patients having deglycosylated Gc protein cannot be activated, leading to immunosuppression. Since Nagalase is the intrinsic component of the envelope protein gp120, serum Nagalase activity is the sum of enzyme activities carried by both HIV virions and envelope proteins. These Nagalase carriers were already complexed with anti-HIV immunoglobulin G (IgG) but retained Nagalase activity that is required for infectivity. Stepwise treatment of purified Gc protein with immobilized beta-galactosidase and sialidase generated the most potent macrophage activating factor (termed GcMAF), which produces no side effects in humans. Macrophages activated by administration of 100 ng GcMAF develop a large amount of Fc-receptors as well as an enormous variation of receptors that recognize IgG-bound and unbound HIV virions. Since latently HIV-infected cells are unstable and constantly release HIV virions, the activated macrophages rapidly intercept the released HIV virions to prevent reinfection resulting in exhaustion of infected cells. After less than 18 weekly administrations of 100 ng GcMAF for nonanemic patients, they exhibited low serum Nagalase activities equivalent to healthy controls, indicating eradication of HIV-infection, which was also confirmed by no infectious center formation by provirus inducing agent-treated patient PBMCs. No recurrence occurred and their healthy CD + cell counts were maintained for 7 years.

Nucleoside analogues are activated by bacterial deoxyribonucleoside kinases in a species-specific manner

OBJECTIVES

To investigate the bactericidal activity of antiviral and anticancer nucleoside analogues against a variety of pathogenic bacteria and characterize the activating enzymes, deoxyribonucleoside kinases (dNKs).

METHODS

Several FDA-approved nucleoside analogue drugs were screened for their potential bactericidal activity against several clinical bacterial isolates and type strains. We identified and subcloned the genes coding for putative deoxyribonucleoside kinases in Escherichia coli, Pasteurella multocida, Salmonella enterica, Yersinia enterocolitica, Bacillus cereus, Clostridium perfringens and Listeria monocytogenes. These genes were tested for their ability to increase the susceptibility of a dNK-deficient E. coli strain to various analogues. We overexpressed, purified and characterized the substrate specificity and kinetic properties of the recombinant enzymes from S. enterica and B. cereus.

RESULTS

The tested Gram-negative bacteria were susceptible to 3'-azido-3'-deoxythymidine (AZT) in the concentration range 0.032-31.6 microM except for a single E. coli isolate and two Pseudomonas aeruginosa isolates which were resistant to the tested AZT concentrations. Purified recombinant S. enterica thymidine kinase phosphorylated AZT efficiently with a Km of 73.3 microM and k(cat)/Km of 6.6 x 10(4) s(-1) M(-1) and is the activator of this drug in vivo. 2',2'-Difluoro-2'-deoxycytidine (gemcitabine) was a potent antibiotic against Gram-positive bacteria in the concentration range between 0.001 and 1.0 microM. The B. cereus deoxyadenosine kinase had a Km for gemcitabine of 33.5 microM and k(cat)/Km of 5.1 x 10(3) s(-1) M(-1) and activates gemcitabine in vivo. S. enterica and B. cereus are now amongst the first bacteria with a completely characterized set of dNK enzymes.

CONCLUSIONS

Bacterial dNKs efficiently activate nucleoside analogues in a species-specific manner. Therefore, nucleoside analogues have a potential to be employed as antibiotics in the fight against emerging multiresistant bacteria.

Pathogenic significance of alpha-N-acetylgalactosaminidase activity found in the envelope glycoprotein gp160 of human immunodeficiency virus Type 1

Serum vitamin D3-binding protein (Gc protein) is the precursor for the principal macrophage-activating factor (MAF). The precursor activity of serum Gc protein was lost or reduced in HIV-infected patients. These patient sera contained alpha-N-acetylgalactosaminidase (Nagalase), which deglycosylates serum Gc protein. Deglycosylated Gc protein cannot be converted to MAF and thus loses MAF precursor activity, leading to immunosuppression. Nagalase in the blood stream of HIV-infected patients was complexed with patient immunoglobulin G, suggesting that this enzyme is immunogenic, seemingly a viral gene product. In fact, Nagalase was inducible by treatment of cultures of HIV-infected patient peripheral blood mononuclear cells with a provirus-inducing agent. This enzyme was immunoprecipitable with polyclonal anti-HIV but not with anticellular constitutive enzyme or with antitumor Nagalase. The kinetic parameters (km value of 1.27 mM and pH optimum of 6.1), of the patient serum Nagalase were distinct from those of constitutive enzyme (km value of 4.83 mM and pH optimum of 4.3). This glycosidase should reside on an envelope protein capable of interacting with cellular membranous O-glycans. Although cloned gp160 exhibited no Nagalase activity, treatment of gp160 with trypsin expressed Nagalase activity, suggesting that proteolytic cleavage of gp160 to generate gp120 and gp41 is required for Nagalase activity. Cloned gp120 exhibited Nagalase activity while cloned gp41 showed no Nagalase activity. Since proteolytic cleavage of protein gp160 is required for expression of both fusion capacity and Nagalase activity, Nagalase seems to be an enzymatic basis for fusion in the infectious process. Therefore, Nagalase appears to play dual roles in viral infectivity and immunosuppression.

[Cancer and HIV infection: any association?]

PURPOSE

Morbidity and mortality related to neoplasia are increasing in HIV-infected patients. CURRENT KNOWLEDGE AND KEY-POINTS: The incidence of AIDS opportunistic infections dramatically decreased since the introduction of highly active antiretroviral therapy (HAART). Among AIDS-cancers, the incidences of Kaposi sarcoma and of cerebral lymphoma decreased in a same way than AIDS infections but the incidences of systemic non-Hodgkin lymphoma and of cervical cancer decreased less than the others and remain higher than in the general population. This suggests that other factors than the quantitative immune reconstitution could be implicated. The most recent and large studies have also shown a 1.7 to 3 fold increased risk of developing non-AIDS cancers in HIV-infected patients when compared to the general population without significant impact of HAART on incidence curves. These malignancies include Hodgkin disease, lung, anal, head and neck cancers, hemopathies, and conjunctival cancers.

PERSPECTIVES

Epidemiologic survey will help to define priorities in terms of prevention and screening in this specific population and to evaluate interventions which should be systematically proposed (alcohol and tobacco cessation programs, viral coinfection). The own roles of HIV itself and of antiretrovirals as prooncogenic factors need to be assessed.

[Infectious pulmonary complications in HIV-infected patients in the high by active antiretroviral therapy era in Spain]

Pulmonary complications in HIV-infected patients are at present a first-rate problem. They are the main cause of hospital admission of these patients in our country. Most HIV-patients have a pulmonary complication during the evolution of the infection. The main etiologic diagnosis is bacterial pneumonia, especially pneumococcal pneumonia; the second most frequent cause is Pneumocystis jiroveci (previously named P. carinii) pneumonia and the third cause is mycobacteriosis, particularly Mycobacterium tuberculosis. From early studies, important changes in the epidemiology of HIV-related pulmonary complications have occurred. General prescription of P. jiroveci primary prophylaxis is probably one of the main causes, and, more recently, the use of highly active antiretroviral therapy may also be an underlying explanation. In this review, epidemiology, diagnosis and outcome of HIV-related pulmonary complications in our country are update.

Incidence and risk factors for the occurrence of non-AIDS-defining cancers among human immunodeficiency virus-infected individuals

BACKGROUND

The objective of this study was to determine the rates and predictors of non-AIDS-defining cancers (NADCs) among a cohort of human immunodeficiency virus (HIV)-infected individuals.

METHODS

The authors conducted a retrospective study of 4144 HIV-infected individuals who had 26,916 person-years of follow-up and who had open access to medical care at 1 of the United States military HIV clinics during the years 1988-2003. Cancer incidence rates were race specific and were adjusted for age; these were compared with national rates using logistic regression to assess predictors of NADC development.

RESULTS

One hundred thirty-three NADCs were diagnosed with a rate of 980 diagnoses per 100,000 person-years. The most frequent NADCs were skin carcinomas (basal cell and squamous cell), Hodgkin disease, and anal carcinoma. The results showed that there were higher rates of melanoma, basal and squamous cell skin carcinomas, anal carcinoma, prostate carcinoma, and Hodgkin disease among the HIV-infected cohort compared with age-adjusted rates for the general United States population. Predictors of NADCs included age older than 40 years (odds ratio [OR], 12.2; P < 0.001), Caucasian/non-Hispanic race (OR, 2.1; P < 0.001), longer duration of HIV infection (OR, 1.2; P < 0.001), and a history of opportunistic infection (OR, 2.5; P < 0.001). The use of highly active antiretroviral therapy (HAART) was associated with lower rates of NADCs (OR, 0.21; P < 0.001). A low CD4 nadir or CD4 count at diagnosis (< 200 cells/mL) was not predictive of NADCs.

CONCLUSIONS

The most frequent NADCs were primary skin malignancies. Melanoma, basal and squamous cell skin carcinomas, anal carcinoma, prostate carcinoma, and Hodgkin disease occurred at higher rates among HIV-infected individuals. The implementation of screening programs for these malignancies should be considered. Most risk factors for the development of NADCs are nonmodifiable; however, the use of HAART appeared to be beneficial in protecting against the development of malignant disease.

Pathogenic significance of alpha-N-acetylgalactosaminidase activity found in the hemagglutinin of influenza virus

Serum vitamin D3-binding protein (Gc protein) is the precursor for the principal macrophage activating factor (MAF). The precursor activity of serum Gc protein was reduced in all influenza virus-infected patients. These patient sera contained alpha-N-acetylgalactosaminidase (Nagalase) that deglycosylates Gc protein. Deglycosylated Gc protein cannot be converted to MAF, thus it loses the MAF precursor activity, leading to immunosuppression. An influenza virus stock contained a large amount of Nagalase activity. A sucrose gradient centrifugation analysis of the virus stock showed that the profile of Nagalase activity corresponds to that of hemagglutinating activity. When these gradient fractions were treated with 0.01% trypsin for 30 min, the Nagalase activity of each fraction increased significantly, suggesting that the Nagalase activity resides on an outer envelope protein of the influenza virion and is enhanced by the proteolytic process. After disruption of influenza virions with sodium deoxycholate, fractionation of the envelope proteins with mannose-specific lectin affinity column along with electrophoretic analysis of the Nagalase peak fraction revealed that Nagalase is the intrinsic component of the hemagglutinin (HA). Cloned HA protein exhibited Nagalase activity only if treated with trypsin. Since both fusion capacity and Nagalase activity of HA protein are expressed by proteolytic cleavage, Nagalase activity appears to be an enzymatic basis for the fusion process. Thus, Nagalase plays dual roles in regulating both infectivity and immunosuppression.

Malignancy-related causes of death in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy

BACKGROUND

Before the introduction of highly active antiretroviral therapy (HAART), malignancies accounted for less than 10% of all deaths among human immunodeficiency virus (HIV)-infected patients. This figure may have increased, and the observed types of malignant disease may have been modified, as a result of decreased occurrence of opportunistic infections, the chronicity of HIV infection, the possible oncogenic role of HIV itself, and the aging of the HIV-infected population.

METHODS

All French hospital wards involved in the management of HIV infection were asked to prospectively document the deaths of HIV-infected patients in the year 2000. Underlying causes of death were defined using a standardized questionnaire.

RESULTS

Of a total of 964 deaths, 269 (28%) were attributable to malignancies. Acquired immunodeficiency virus (AIDS)-related malignancies were the underlying cause of 149 deaths (15%); among these malignancies were non-Hodgkin lymphoma (n = 105 [11%]), noncerebral lymphoma (n = 78 [median CD4 count, 86 x 10(6) per liter; interquartile range [IQR], 35-231 x 10(6) per liter), and primary cerebral lymphoma (n = 27 [median CD4 count, 20 x 10(6) per liter; IQR, 4-109 x 10(6) per liter). Kaposi sarcoma was associated with 40 deaths (4%), and cervical carcinoma was associated with 5 (0.5%). Non-AIDS-related malignancies were the underlying cause of 120 deaths (13%); these non-AIDS-related malignancies included 103 solid tumors (50 respiratory tumors, 19 hepatocarcinomas, 9 digestive tumors, and 6 anal tumors; median CD4 count, 218 x 10(6) per liter; IQR, 108-380 x 10(6) per liter) and 17 hemopathies (12 Hodgkin lymphomas, 4 myeloid leukemias, and 1 myeloma; median CD4 count, 113 x 10(6) per liter; IQR, 56-286 x 10(6) per liter). Compared with patients who died of other causes, patients who died of solid tumors were more likely to be male, to smoke, to be older, and to have higher CD4 counts.

CONCLUSIONS

Malignant disease has been a major cause of death among HIV-infected patients in industrialized nations since the introduction of HAART. Whereas lethal hemopathies and Kaposi sarcoma are associated with advanced immunosuppression, lethal solid tumors can occur in patients with controlled HIV infection.

[Predictors of progression and death in patients with advanced HIV infection in the era of highly active antiretroviral therapy]

INTRODUCTION

To assess the factors associated with progression of infection and death in HIV-positive patients with severe immunodepression in the era of highly active antiretroviral therapy (HAART).

METHODS

We studied 146 HIV-infected patients with < 100 x 10(6)/L CD4+ lymphocytes and positive cytomegalovirus (CMV) serology enrolled between December 1997 and October 1998 and prospectively followed a median of 12.1 months. The main outcome measures were progression of HIV infection, defined as the appearance of a new AIDS-defining disease (CDC category C) or death. HIV viral load, lymphocyte count (CD4+ and CD8+), HAART administration and other clinical variables were evaluated at baseline. CMV viremia (determined by PCR) and HAART efficacy were recorded during follow-up.

RESULTS

Progression was observed in 40% of patients and 17% died. Factors associated with progression or death were CD4+ lymphocyte count less than 50 x 10(6)/L, CD8+ lymphocyte count less than 500 x 10(6)/L, HIV viral load more than 300,000 copies RNA/mL, CMV viremia, and absence or inefficacy of HAART. In the multivariate model, absence of HAART and low CD4+ and CD8+ counts remained statistically associated with progression, but the only variable associated with death was CMV viremia.

CONCLUSIONS

In patients with advanced HIV infection, CD4+ and CD8+ cell count and HAART were the most important factors related to progression, and CMV viremia was the strongest predictor of death.

Causes of death among HIV-infected patients in the era of highly active antiretroviral therapy, Bordeaux, France, 1998-1999

OBJECTIVES

To describe the causes of death in HIV-infected patients in the era of highly active antiretroviral therapy (HAART).

METHOD

A retrospective survey conducted in Bordeaux, France. Medical records of all deaths that had occurred in 1998 and 1999 amongst patients followed within the Aquitaine cohort were reviewed by the same physician. Immediate and underlying causes of death were described, taking into account the morbidity at the time of death.

RESULTS

Sixty-six deaths occurred in 1998, and 41 in 1999. Sixty-seven per cent of deceased patients were male. Median age at time of death was 43 years (range 25-71), median CD4 was 162 cells/microL (0-957); 28% of patients had a CD4 count > 200 cells/microL and 7% plasma viral load < 500 HIV-RNA copies/mL. Amongst morbidity present at the time of death, there were 23 bacterial infections, 16 non-Hodgkin's lymphomas, 16 cirrhoses, 15 non HIV-related malignancies, 13 central nervous system diseases and 10 myocardiopathies. The main immediate causes of death were: multiple organ failure (21%), coma (18%), septic shock (15%) and acute respiratory failure (14%). Underlying causes of death were AIDS-defining events (48%), non AIDS HIV-related infection (3%), hepatitis B- or C-associated cirrhosis (14%), non HIV-related malignancies (11%), cardiovascular events (10%), suicide and overdose (6%), treatment-related fatalities (4%), injury (2%) and unknown (2%). Patients dying from AIDS-related events were more often female, had a lower CD4 count, a higher level of HIV-RNA, a shorter history of HIV infection and were less often coinfected with hepatitis B and C viruses than those dying from other underlying causes.

CONCLUSIONS

AIDS-related events are no longer the major causes of death of HIV-infected patients in the era of HAART. This evolving mortality pattern justifies an adaptation of both the epidemiological surveillance and the clinical monitoring of HIV-infected patients.

Changes in bloodstream infections in HIV-positive patients in a university hospital in Spain (1995-1997)

OBJECTIVES

The Hospital Universitario Germans Trias i Pujol is a 600-bed center serving 700,000 inhabitants including 1800 patients with HIV infection in Catalonia (Spain). Highly active antiretroviral therapy (HAART) became available at the end of 1996. Thus, the period 1995 1997 was considered appropriate for evaluating possible epidemiological changes in bloodstream infections (BSI) in HIV-infected patients.

METHODS

All significant bloodstream infections, including mycobacteremia and fungemia, observed in HIV-positive patients from January, 1995 to December, 1997 have been included in the study.

RESULTS

One hundred and eighty six cases were evaluated, in whom a decrease in BSI was observed (68 in 1995, 86 in 1996, 32 in 1997). Over time, we observed an improvement in the immunologic situation of the patients (1995: CD4 <50/mm3 73.8% vs 1997: CD4 <50/mm3 45.5% (P=0.05)). The source of BSI was known in 80.7% of the episodes. BSI secondary to catheter and respiratory infections prevailed in 1995, whereas an increase in bacteremias related to intravenous drug use, with or without endocarditis, was seen in 1997. The most frequent isolates were Mycobacterium avium intracellulare (23) (MAI), M. tuberculosis (20), Staphylococcus aureus (20), coagulase-negative staphylococci (16), Salmonella spp. (16) and Streptococcus pneumoniae (15). In 1997, a decrease was observed in the isolation of Gram-negatives and Mycobacterium spp. with S. aureus and enterococci prevailing.

CONCLUSIONS

The prevalence of bloodstream infections in HIV-positive patients has decreased since the introduction of HAART and the immunologic state has improved. Furthermore there is a trend to a decrease or disappearance of microorganisms, such as Pseudomonas spp., Mycobacterium tuberculosis, MAI or fungi related to severe immunosuppression. Lastly, bacteremia caused by the active use of intravenous drugs remains stable with the highest percentage in Spain.

Bacteremia in hospitalized patients with human immunodeficiency virus: A prospective, cohort study

BACKGROUND

Bacterial infections complicate the course of patients with human immunodeficiency virus infection. The purpose of this study was to describe the bacterial pathogens causing blood stream infection, identify the risk factors for the development of blood stream infection and determine the impact of blood stream infection on the outcome of patients infected with human immunodeficiency virus.

METHODS

The incidence, etiology, risk factors and outcome of bacterial blood stream infection were prospectively determined in 1,225 consecutive hospitalizations of adults with human immunodeficiency virus infection.

RESULTS

Blood stream infection occurred in 88 hospitalizations (7%); 73 of 89 infections (82%) were community acquired. The most commonly isolated gram-positive organism was Streptococcus pneumoniae (21); gram-negative, Escherichia coli (14). Blood stream infection was detected in 8% of African Americans and 22% of Hispanics compared with 2% of whites (P = 0.0013). Patients with blood stream infection had higher white blood cell counts (median, 6.5 vs. 4.9 x 109/L; P = 0.0002) and mortality (18% vs. 4%; P < 0.0001) than patients without infection.

CONCLUSIONS

In patients with human immunodeficiency virus, blood stream infection is associated with an increased mortality rate. Recognition of the incidence, etiology, and risk factors of blood stream infection in patients with human immunodeficiency virus infection could lead to measures that reduce the increased mortality.

Impact of prophylaxis for Mycobacterium avium complex on bacterial infections in patients with advanced human immunodeficiency virus disease

The epidemiology and natural history of bacterial infections among ambulatory patients with advanced human immunodeficiency virus (HIV) disease has not been well described. In this prospective study, 394 subjects were enrolled and followed at 8-week intervals for a median of 21 months. During follow-up, 164 (42%) of 394 patients developed at least 1 bacterial infection. The most common infections were sinusitis, bacterial pneumonia, skin and soft tissue infection, and bronchitis. Serious bacterial infections (defined as bacterial pneumonia, bacteremia, or deep visceral abscess) were reported by 56 subjects (14%). Female sex, age of <40 years, and Karnofsky score of < or =80 were independent risk factors for bacterial infections. Prophylaxis with clarithromycin, trimethoprim and sulfamethoxazole, or both had significant protective effect. The occurrence of any confirmed bacterial infection was associated with a significantly increased risk of mortality. This study documents that bacterial infections are common among patients with advanced HIV disease, especially among women.

[Reduction of hematogenous infection in HIV positive patients following highly active antiretroviral therapy]

BACKGROUND

Bloodstream infections have probably decreased in HIV patients since highly active antiretroviral therapy (HAART) usage.

PATIENTS AND METHOD

Hematogenous infections, including mycobacteria and fungi in HIV patients, stratified into two periods (I: 1995-1996 and II: 1997-1998) were included to evaluate changes attributable to HAART.

RESULTS

226 episodes were attended (incidence: 38.8 in period I and 15.3 in period II; p < 0.01). A significant decrease was observed in immunosuppression related microorganisms. HAART usage increased from 6.4% in period I to 31.2% in period II. Immunological parameters of HIV patients significantly improved in period II.

CONCLUSIONS

Hematogenous infections have significantly decreased in HIV patients since the use of HAART.

Human immunodeficiency virus-related mortality in infants and children: data from the pediatric pulmonary and cardiovascular complications of vertically transmitted HIV (P(2)C(2)) Study

OBJECTIVES

To identify the causes of mortality in children with vertically transmitted human immunodeficiency virus (HIV) infection and to study age-related mortality trends.

METHODS

In the multicenter P(2)C(2) HIV Study, 816 children born to HIV-infected mothers were followed for a median of 3.6 years. Two hundred five study participants with HIV infection were enrolled at a median age of 23 months; 611 were enrolled either prenatally or in the neonatal period before their HIV infection status was known. There were 121 deaths in study patients. The cause of death for all patients, its relationship to HIV infection, and pulmonary or cardiac involvement were determined. Age trends in disease-specific mortality were summarized for the HIV-related deaths.

RESULTS

Ninety-three children died of HIV-related conditions. Infection was the most prevalent cause of death for children under 6 years of age with 32.3% caused by pulmonary infection and another 16.9% caused by nonpulmonary infection. The frequency of pulmonary disease as the underlying cause of death decreased significantly with increasing age: 5/9 (55.6%) by age 1, 1/12 (8.3%) after age 10 years. The frequency of chronic cardiac disease as the underlying cause increased with age-0% by age 1 year, 3/12 (25.0%) after age 10 years, as did the frequency of wasting syndrome with disseminated Mycobacterium avium complex-0% by age 1 year, 6/12 (50.0%) after age 10 years.

CONCLUSIONS

Children with HIV who survive longer are less likely to die of pulmonary disease or infection and more likely to die of cardiac causes or with wasting syndrome.pediatric acquired immunodeficiency syndrome, mortality, human immunodeficiency virus.

Impact of HAART on causes of death of persons with late-stage AIDS

CONTEXT

The increasing use of highly active antiretroviral therapies (HAARTs) has changed the course of AIDS-related illnesses and enhanced the quality of life of patients infected with human immunodeficiency virus (HIV) and may have changed the causes of deaths in patients with acquired immunodeficiency syndrome (AIDS).

OBJECTIVE

The aim of the present study was to investigate causes of deaths in long-term care hospital patients with late-stage AIDS who expired at the Coler-Goldwater Memorial Hospital in New York City in 1995, and in 1998 and 1999, that is, immediately before and the two most recent years after the advent of HAART.

METHODS

Analysis of causes of deaths as recorded on the death certificates of 232 AIDS patients.

RESULTS

The overall mortality rate declined from 75.6 deaths per 100 person-years in 1995 to 33.2 deaths per 100 person-years in 1998-1999 (P < .001). The number of AIDS patients who expired because of sepsis and opportunistic infections, which included Pneumocystis carinii pneumonia (PCP), decreased significantly from 30 (26.1%) and 24 (20.9%) in 1995 to 15 (12.8%) and 10 (8.5%) in 1998-1999, respectively (P < .05). In contrast, deaths from hepatic failure increased from 0 (0%) in 1995 to 7 (6%) in 1998-1999 (P < .05). Increases, although not significant statistically, were associated with pneumonias excluding PCP, end-stage AIDS, renal failure, and malignancies. Analysis of cause-specific mortality by gender between 1995 and 1998-1999 revealed very little difference between men and women. This analysis showed, however, that the infectious processes taken together (pneumonias excluding PCP, sepsis, and opportunistic infections including PCP) were significantly less frequent causes of death in 1998-1999 than in 1995 (P < .01).

CONCLUSION

These findings indicate that HAART affected the causes of deaths in patients with AIDS, with "traditional" opportunistic infections diminishing in importance relative to chronic medical conditions and malignancies.

Prevalence and route of transmission of infection with a novel DNA virus (TTV), hepatitis C virus, and hepatitis G virus in patients infected with HIV

OBJECTIVES

To evaluate the prevalence, route of transmission and clinical significance that current co-infection with TT virus (TTV), hepatitis C virus (HCV), and hepatitis G virus (HGV) have in HIV-1-infected patients.

DESIGN

Presence of TTV, HCV, and HGV was analyzed in plasma samples from 160 HIV-1-infected patients with parenteral (38 intravenous drug users [IVDUs] and 41 patients with hemophilia) or sexual (39 homosexuals and 42 heterosexuals) risk of exposure, and in 168 volunteer blood donors. Alanine aminotransferase (ALT) levels and CD4+ counts were also analyzed.

METHODS

HCV and HGV RNA were detected by specific reverse transcriptase (RT) nested polymerase chain reaction (PCR) and TTV DNA by specific heminested PCR.

RESULTS

TTV DNA was detected in 39% of the patients and in 14% of the volunteer blood donors. HCV and HGV infections were detected in 42% and in 14% of the patients, and in 0% and 3% of the blood donors, respectively. Prevalences of TTV and HCV infection were higher among patients with parenteral (62% and 68%) than in those with sexual (17% and 16%) risk of exposure. A higher prevalence of TTV infection (but not of HCV or HGV infection) was observed among patients with hemophilia (76%) than IVDUs (47%), and among homosexuals (26%) than among heterosexuals (10%). Abnormal ALT levels were related with the presence of HCV infection, independently of the detection of TTV DNA. TTV infection did not seem to alter the levels of CD4+ T cells.

CONCLUSIONS

Prevalence of current TTV infection is high among HIV-infected patients with parenteral risk of exposure, but TTV is also transmitted through sexual routes; detection of TTV does not seem to influence the clinical or immune status of HIV-infected patients.

Pseudomonas aeruginosa infection in human immunodeficiency virus infected patients

OBJECTIVES

(1) To determine the incidence and outcome of Pseudomonas aeruginosa infection in HIV-infected patients. (2) To study the antimicrobial susceptibility of P. aeruginosa isolates in this particular population. (3) To identify risk factors for these infections.

PATIENTS AND METHODS

A retrospective case-control study performed in a 28-bed infectious-diseases unit in a 940-bed university hospital. All cases were defined as HIV-infected patients with severe infections due to P. aeruginosa, including bacteremia, lower or upper respiratory tract infections, infections related to a central venous catheter, and cutaneous/muscular infection. Each case was matched with an HIV-seropositive control not infected by P. aeruginosa and hospitalized on the same dates as the cases.

RESULTS

One thousand and thirty-five HIV-infected patients were hospitalized during the study period. A first severe P. aeruginosa infection was documented in 41 patients, giving an overall annual incidence note of 2.51 episodes per 100 admissions. Forty of the 41 case notes were available for analysis. They consisted of 17 cases of bacteraemia, four upper respiratory tract infections, 10 lower respiratory tract infections, three catheter-related infections, and six cutaneous/muscular infections. Of these 40 cases, 60% were nosocomial and the remainder were community-acquired. The overall mortality rate was 22% (47% in bacteraemic forms). Twenty five percent of patients relapsed after an average of 37 days. The case-control comparison showed that AIDS was more frequent among the cases (92% vs. 74%, P = 0.04), who also had a lower PN count (P = 0.005), and a lower CD4 cell count (15.7 +/- 18.8/mm3 vs. 118 +/- 211/mm3; P = 0.0007). The number of days spent in hospital in the previous 3 months (29.3 +/- 20.7 vs. 19.7 +/- 14, P = 0.04) was significantly higher among the cases. In a multivariate analysis, examining treatments received in the previous month, only co-trimoxazole [OR = 5.5 (1.1-26.9)], penicillins [OR = 5.2 (1.1-25.3)], steroids [OR = 5.5, (1.2-25.5)] and a CD4 cell count below 50/mm3 [OR = 13.2 (1.4-129.4)] were identified as risk factors.

CONCLUSION

P. aeruginosa infection is a not frequent bacterial disease in highly immunodeficient HIV-infected patients. It is frequently fatal and must be borne in mind in the advanced stages of HIV disease, especially when patients have received co-trimoxazole (trianthoprim-sulphamethoxazole), penicillins or steroids.

Prevalence and genotypes of GB virus C/hepatitis G virus (GBV-C/HGV) and hepatitis C virus among patients infected with human immunodeficiency virus: evidence of GBV-C/HGV sexual transmission

The development of new antiretroviral agents may improve survival of HIV-infected individuals, and therefore chronic viral hepatitis may become more relevant in these patients. The presence of GBV-C/HGV and hepatitis C virus (HCV) RNA were investigated by reverse transcriptase-nested polymerase chain reaction in plasma from 168 Spanish HIV-infected patients belonging to four different risk groups: intravenous drug users (IVDUs), hemophiliacs, homosexuals, and heterosexuals. GBV-C/HGV-RNA and HCV-RNA were detected in 18% and 43% of the patients, respectively. The prevalence of current infection with these viruses was notably high, 19% for GBV-C/HGV and 69% for HCV, among individuals with parenteral risk of infection (intravenous drug abusers and hemophiliacs), but sexual transmission with GBV-C/HGV was also suggested because 16.5% of patients with sexual risk, either homosexual or heterosexual, had GBV-C/HGV-RNA in plasma. Although investigation of GBV-C/HGV-RNA possibly underestimates the actual prevalence of infection with GBV-C/HGV, the above data suggest that sexual contact may play a relevant role in the spread of this virus. Phylogenetic analysis showed no evidence for clustering of NS3 sequences into different genotypes or subtypes of GBV-C/HGV.

Bacterial infections

Non-opportunistic bacterial infections are an important cause of morbidity and mortality for HIV-infected adults and children. Factors associated with increased risk of these include altered B- and T-cell function; altered phagocytic cell function; skin and mucous membrane defects; and use of indwelling vascular catheters, antibiotics, or cytotoxic agents. The pathogens encountered most frequently are S. aureus, S. pneumoniae, H. influenzae, Salmonella sp., and Pseudomonas aeruginosa. Less commonly encountered organisms include Rhodococcus equi, Listeria monocytogenes, Shigella sp., and Nocardia asteroides, Strategies for prevention as well as diagnosis and treatment of these are discussed.

Secondary bacterial infections in HIV-infected patients: an alternative ambulatory outpatient treatment utilizing intravenous cefotaxime

The purpose of this study was to determine the safety and efficacy of home intravenous antibiotic therapy in treating secondary bacterial infections in patients infected with the human immunodeficiency virus (HIV). This study was a subset analysis of 22 patients with HIV, enrolled in two centers of a multicenter, open-label, prospective study. When necessary, patients were stabilized as inpatients, followed by home therapy. Enrolled patients had diagnoses of pneumonia, skin and soft-tissue infections, bacteremia/septicemia, or other infections requiring parenteral therapy. A third-generation cephalosporin, cefotaxime, 1-2 g every 8 hours, was delivered intravenously using an ambulatory delivery system (ADS). Home therapy with cefotaxime/ADS produced a clinical response rate of 95% and bacteriologic response of 88.2%. The requirement for and duration of inpatient therapy was markedly reduced compared with diagnosis-related group (DRG) allotments. In conclusion, home intravenous antibiotic therapy with cefotaxime in patients infected with HIV is effective and safe. It may improve quality of life by reducing the length of hospital stay.