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Cozzi-Lepri A, Peters L, Pelchen-Matthews A, Neesgaard B, De Wit S, Johansen IS, Edwards S, Stephan C, Adamis G, Staub T, Zagalo A, Domingo P, Elbirt D, Kusejko K, Brännström J, Paduta D, Trofimova T, Szlavik J, Zilmer K, Losso M, Van Eygen V, Pai H, Lundgren J, Mocroft A. Observational cohort study of rilpivirine (RPV) utilization in Europe. AIDS Res Ther 2022; 19:38. [PMID: 35933352 PMCID: PMC9357334 DOI: 10.1186/s12981-022-00457-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Data on safety and effectiveness of RPV from the real-world setting as well as comparisons with other NNRTIs such as efavirenz (EFV) remain scarce. METHODS Participants of EuroSIDA were included if they had started a RPV- or an EFV-containing regimen over November 2011-December 2017. Statistical testing was conducted using non-parametric Mann-Whitney U test and Chi-square test. A logistic regression model was used to compare participants' characteristics by treatment group. Kaplan-Meier analysis was used to estimate the cumulative risk of virological failure (VF, two consecutive values > 50 copies/mL). RESULTS 1,355 PLWH who started a RPV-based regimen (11% ART-naïve), as well as 333 initiating an EFV-containing regimen were included. Participants who started RPV differed from those starting EFV for demographics (age, geographical region) and immune-virological profiles (CD4 count, HIV RNA). The cumulative risk of VF for the RPV-based group was 4.5% (95% CI 3.3-5.7%) by 2 years from starting treatment (71 total VF events). Five out of 15 (33%) with resistance data available in the RPV group showed resistance-associated mutations vs. 3/13 (23%) among those in the EFV group. Discontinuations due to intolerance/toxicity were reported for 73 (15%) of RPV- vs. 45 (30%) of EFV-treated participants (p = 0.0001). The main difference was for toxicity of central nervous system (CNS, 3% vs. 22%, p < 0.001). CONCLUSION Our estimates of VF > 50 copies/mL and resistance in participants treated with RPV were similar to those reported by other studies. RPV safety profile was favourable with less frequent discontinuation due to toxicity than EFV (especially for CNS).
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Affiliation(s)
- Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, Rowland Hill St, London, NW3 2PF, UK.
| | - Lars Peters
- CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annegret Pelchen-Matthews
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, Rowland Hill St, London, NW3 2PF, UK
| | | | - Stephane De Wit
- Department of Infectious Diseases, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Simon Edwards
- Mortimer Market Centre, Department of HIV, London, UK
| | - Christoph Stephan
- Infectious Diseases Unit, Goethe-University Hospital, Frankfurt, Germany
| | - Georgios Adamis
- 1St Department of Internal Medicine and Infectious Diseases Unit, General Hospital of Athens G. Gennimatas, Athens, Greece
| | - Therese Staub
- Centre Hospitalier de Luxembourg, Service des Maladies Infectieuses, Luxembourg City, Luxembourg
| | - Alexandra Zagalo
- Department of Infectious Diseases, Santa Maria University Hospital, Lisbon, Portugal
| | - Pere Domingo
- Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Daniel Elbirt
- Allergy, Immunology and HIV Unit
- Kaplan, Medical Center, Rehovot, Israel
| | - Katharina Kusejko
- Division of Infectious Diseases, University Hospital Zürich, Zurich, Switzerland
| | - Johanna Brännström
- Department of Infectious Diseases, Venhälsan Södersjukhuset, Stockholm, Sweden
| | | | - Tatyana Trofimova
- Novgorod Centre for AIDS Prevention and Control, Novgorod the Great, Russia
| | - Janos Szlavik
- South-Pest Hospital Centre-National Institute for Infectiology and Haematology, Budapest, Hungary
| | - Kai Zilmer
- West-Tallinn Central Hospital, Infectious Diseases Clinic, Talinn, Estonia
| | | | | | - Helen Pai
- Janssen Research & Development, Raritan, NJ, USA
| | - Jens Lundgren
- CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, Rowland Hill St, London, NW3 2PF, UK.,CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Castillo-Mancilla JR, Cavassini M, Schneider MP, Furrer H, Calmy A, Battegay M, Scanferla G, Bernasconi E, Günthard HF, Glass TR. Association of Incomplete Adherence to Antiretroviral Therapy With Cardiovascular Events and Mortality in Virologically Suppressed Persons With HIV: The Swiss HIV Cohort Study. Open Forum Infect Dis 2021; 8:ofab032. [PMID: 33604408 PMCID: PMC7880264 DOI: 10.1093/ofid/ofab032] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/18/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Incomplete antiretroviral therapy (ART) adherence, even if sufficient to maintain viral suppression, is associated with enhanced inflammation in persons with HIV (PWH). However, its clinical implications remain unknown. METHODS PWH enrolled in the Swiss HIV Cohort Study without a history of cardiovascular disease (CVD) who initiated ART between 2003 and 2018 and had viral suppression (<50 copies/mL) for ≥6 months were evaluated. The association between incomplete self-reported ART adherence (≥1 or ≥2 missed doses in the last month) and (1) any CVD event (myocardial infarction, revascularization, cerebral hemorrhage, stroke, and/or death due to CVD event) or (2) non-CVD-related death was evaluated using adjusted Cox proportional hazards models. RESULTS A total of 6971 PWH (74% male) were included in the analysis (median age [interquartile range {IQR}], 39 [32-47] years). The median (IQR) follow-up was 8 (4-11) years, with 14 (8-23) adherence questionnaires collected per participant. In total, 205 (3%) participants experienced a CVD event, and 186 (3%) died a non-CVD-related death. In an adjusted competing risk model where missing data were imputed, missing ≥1 ART dose showed an increased, but not statistically significant, risk for CVD events (hazard ratio [HR], 1.23; 95% CI, 0.85-1.79; P = .28). Non-CVD-related mortality showed a statistically significantly increased risk with missing ≥1 ART dose (HR, 1.44; 95% CI, 1.00-2.07; P = .05) and missing ≥2 ART doses (HR, 2.21; 95% CI, 1.37-3.57; P = .001). CONCLUSIONS Incomplete ART adherence was significantly associated with an increased risk for non-CVD-related mortality in PWH with virologic suppression. This highlights the potential role of nonadherence to ART as a driver of non-AIDS clinical outcomes.
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Affiliation(s)
| | - Matthias Cavassini
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Marie Paule Schneider
- School of Pharmaceutical Sciences and Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, HIV/AIDS Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Manuel Battegay
- University of Basel, Basel, Switzerland
- Division of Infectious Diseases, University Hospital Basel, Basel, Switzerland
| | - Giulia Scanferla
- Division of Infectious Diseases, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Enos Bernasconi
- Division of Infectious Diseases, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Huldrych F Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Tracy R Glass
- University of Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
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Néant N, Lê MP, Bouazza N, Gattacceca F, Yazdanpanah Y, Dhiver C, Bregigeon S, Mokhtari S, Peytavin G, Tamalet C, Descamps D, Lacarelle B, Solas C. Usefulness of therapeutic drug monitoring of rilpivirine and its relationship with virologic response and resistance in a cohort of naive and pretreated HIV-infected patients. Br J Clin Pharmacol 2020; 86:2404-2413. [PMID: 32374049 PMCID: PMC7688528 DOI: 10.1111/bcp.14344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 04/07/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS The purpose of this study was to assess the antiviral activity of the rilpivirine/emtricitabine/tenofovir disoproxil fumarate combination and to describe the pharmacokinetics of rilpivirine and its association with resistance in clinical routine. METHODS A retrospective multicentre cohort study was performed in both naive and pretreated HIV patients receiving the once-daily rilpivirine/emtricitabine/tenofovir disoproxil fumarate regimen. Immuno-virologic and resistance data, and rilpivirine plasma trough concentrations were collected over the follow-up. Statistical analyses were performed to evaluate the relationship between rilpivirine pharmacokinetics and virological response. Receiver operating characteristic (ROC) curve analysis was performed to determine the best target rilpivirine trough concentration. RESULTS Overall, 379 patients were included. After a median follow-up of 28 months, 26% of patients discontinued mainly due to toxicity and the virological success rate was 65.7%. Virological failure occurred in 5% of patients. A significant proportion of patients with HIV-RNA > 40 copies/mL displayed rilpivirine plasma trough concentrations below the currently used 50 ng/mL efficacy threshold at both M6 (28%) and M12 (31%), in agreement with a significant lower median rilpivirine plasma trough concentration compared with patients virologically suppressed. Half of the patients with virologic failure who acquired rilpivirine resistance mutations had at least one suboptimal rilpivirine trough concentration. The optimal target for rilpivirine trough concentration was 70 ng/mL (sensitivity 75.4%; specificity 61.5%). CONCLUSIONS This study shows the impact of rilpivirine plasma trough concentration on both virological response and the emergence of rilpivirine mutations. Moreover, our results suggest that a higher target of rilpivirine trough concentration could be proposed in clinical practice.
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Affiliation(s)
- Nadège Néant
- Laboratoire de Pharmacocinétique et ToxicologieAix Marseille Univ, APHM, INSERM, CNRS, CRCM SMARTc, Hôpital La TimoneMarseilleF‐13005France
| | - Minh Patrick Lê
- APHP, Hôpital Bichat‐Claude Bernard, Laboratoire de Pharmacologie‐Toxicologie, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERMParisF‐75018France
| | - Naïm Bouazza
- Université Paris DescartesEA7323, Sorbonne Paris CitéFrance
- Unité de Recherche Clinique Paris Descartes Necker Cochin, AP‐HPFrance
- CIC‐1419 Inserm, Cochin‐NeckerParisFrance
| | | | - Yazdan Yazdanpanah
- Univ Paris Diderot, APHP, IAME‐UMR 1137, Hôpital Bichat‐Claude Bernard, Service des Maladies Infectieuses et TropicalesParisF‐75018France
| | - Catherine Dhiver
- IHU Méditerranée Infection, Aix Marseille Univ., AP‐HM, URMITE UM 63 CNRS 7278 IRD 198 INSERM 1095MarseilleF‐13005France
| | - Sylvie Bregigeon
- APHM, Hôpital Sainte‐MargueriteService d'Immuno‐hématologie cliniqueMarseilleF‐13009France
| | - Saadia Mokhtari
- IHU Méditerranée Infection, Aix Marseille Univ., AP‐HM, URMITE UM 63 CNRS 7278 IRD 198 INSERM 1095MarseilleF‐13005France
| | - Gilles Peytavin
- APHP, Hôpital Bichat‐Claude Bernard, Laboratoire de Pharmacologie‐Toxicologie, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERMParisF‐75018France
| | - Catherine Tamalet
- IHU Méditerranée Infection, Aix Marseille Univ., AP‐HM, URMITE UM 63 CNRS 7278 IRD 198 INSERM 1095MarseilleF‐13005France
| | - Diane Descamps
- APHP, Hôpital Bichat‐Claude Bernard, Laboratoire de Virologie, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERMParisF‐75018France
| | - Bruno Lacarelle
- Laboratoire de Pharmacocinétique et ToxicologieAix Marseille Univ, APHM, INSERM, CNRS, CRCM SMARTc, Hôpital La TimoneMarseilleF‐13005France
| | - Caroline Solas
- Aix Marseille Univ, APHM, INSERM 1207, IRD 190, UVE, Hôpital La Timone, Laboratoire de Pharmacocinétique et ToxicologieMarseilleF‐13005France
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Schüttfort G, Philipp K, de Leuw P, Herrmann E, Kann G, Khaykin P, Stephan C, Wolf T, Haberl A. Sex and Gender Differences in Rilpivirine based ART - Data from the HIVCENTER Frankfurt. Curr HIV Res 2020; 17:368-374. [PMID: 31686639 DOI: 10.2174/1570162x17666191104112557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/22/2019] [Accepted: 10/29/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE While Rilpivirine has shown high overall response rates in treatment-naïve patients without sex and gender specific differences in clinical trials, Sex and gender specific data in treatment experienced patients receiving rilpivirine are still limited. We conducted a 48 week efficacy and safety analysis in naïve and treatment experienced men and women using retrospective data from the HIVCENTER Frankfurt. MATERIALS AND METHODS In this retrospective observational study data of all patients who received a rilpivirine based regimen at the HIVCENTER between March 2011 and December 2015 were analyzed. Primary endpoint was the proportion of patients with any discontinuation until week 48. Virologic response rates (FDA snapshot analysis; HIV-1 RNA <50 copies/mL) were assessed at week 48. RESULTS 194 patients (34% female) were included in the analysis. 74% were treatment-experienced and 26% naïve, respectively. Discontinuations were observed in 31 (15.9%) patients. Regarding sex differences, the proportion of discontinuations was significantly higher in women than in men (24.2% vs. 11.7%; p=0.024; ODDS-Ratio = 2.41; CI 1.12 - 5.18). Virologic failure occurred in 8 PLWHIV (4.1%). CONCLUSION While virologic overall response rates to rilpivirine based ART were high for both treatment-experienced and -naïve patients the proportion of discontinuations was significantly higher in women (24.2% vs. 11.7%; p = 0.024; ODDS-Ratio = 2.41; CI 1.12 - 5.18). Although the total number of patients with virologic failure was low (4.1%), the higher rate of ART discontinuations in female patients receiving RPV require close monitoring in the first months of treatment addressing special needs of women living with HIV.
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Affiliation(s)
- G Schüttfort
- HIVCENTER, Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - K Philipp
- HIVCENTER, Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - P de Leuw
- HIVCENTER, Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - E Herrmann
- Department of Biostatistics and Mathematical Modelling, Frankfurt, Germany
| | - G Kann
- HIVCENTER, Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | | | - C Stephan
- HIVCENTER, Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - T Wolf
- HIVCENTER, Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - A Haberl
- HIVCENTER, Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
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Munderi P, Were E, Avihingsanon A, Mbida PA, Mohapi L, Moussa SB, Jansen M, Bicer C, Mohammed P, van Delft Y. Switching at Low HIV-1 RNA into Fixed Dose Combinations: TDF/FTC/RPV is non-inferior to TDF/FTC/EFV in first-line suppressed patients living with HIV. South Afr J HIV Med 2019; 20:949. [PMID: 31392036 PMCID: PMC6676968 DOI: 10.4102/sajhivmed.v20i1.949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/23/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In low- and middle-income countries (LMICs), a substantial unmet need for affordable single-tablet regimen (STR) options remains. Rilpivirine (RPV, TMC278) is formulated in a low-cost STR with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC). OBJECTIVES Switching at Low HIV-1 RNA into Fixed Dose Combinations (SALIF) compared RPV with efavirenz (EFV), both as STRs with TDF and FTC, in maintaining virologic suppression. METHODS SALIF was a phase 3b, randomised, open-label, non-inferiority study in virologically suppressed adults (HIV-1 RNA < 50 copies/mL) on non-nucleoside reverse transcriptase inhibitor (NNRTI)-based first-line antiretroviral therapy (ART) in Cameroon, Kenya, Senegal, South Africa, Uganda and Thailand. Patients (N = 426), stratified by NNRTI use, were randomised 1:1 to receive TDF/FTC/RPV (300/200/25 mg qd) or TDF/FTC/EFV (300/200/600 mg qd). Primary endpoint was proportion of patients with virologic suppression (HIV-1 RNA < 400 copies/mL) at week 48 (intent-to-treat, modified Food and Drug Administration Snapshot, 10% non-inferiority margin). RESULTS Patients received TDF/FTC/RPV (n = 213) or TDF/FTC/EFV (n = 211). At week 48, virologic suppression was maintained in 200/213 (93.9%) patients in the RPV arm and 203/211 (96.2%) in the EFV arm (difference -2.3%; 95% confidence interval: -6.4, +1.8), demonstrating non-inferiority of TDF/FTC/RPV. One patient in each arm experienced virologic failure without treatment-emergent resistance. Twenty-seven patients discontinued prematurely (8.0% RPV vs. 4.7% EFV), the most frequent reasons being adverse events (3.3% vs. 0.5%, respectively), site closure (1.9% vs. 0.5%), loss to follow-up (0.9% vs. 1.4%) and consent withdrawal (0.9% vs. 1.4%). CONCLUSION In adults with suppressed viral load on first-line NNRTI-based ART in LMICs, switching to an STR of TDF/FTC/RPV was non-inferior to TDF/FTC/EFV in maintaining high rates of viral suppression with a comparable tolerability profile.
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Affiliation(s)
- Paula Munderi
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | - Anchalee Avihingsanon
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Lerato Mohapi
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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Moorhouse MA, Cohen K. The role of rilpivirine in Southern Africa. South Afr J HIV Med 2019; 20:825. [PMID: 31205774 PMCID: PMC6556917 DOI: 10.4102/sajhivmed.v20i1.825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/03/2019] [Indexed: 11/10/2022] Open
Abstract
Rilpivirine, a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI), is included as an option in first-line antiretroviral therapy (ART) for antiretroviral-naïve individuals in treatment guidelines in high-income countries, including the United States and many European countries. Rilpivirine is available in a single-tablet fixed-dose combination, has a favourable tolerability profile and is of relatively low cost. However, rilpivirine has reduced efficacy in patients commencing ART at high viral loads. Therefore, baseline viral load testing is required before commencing rilpivirine, and it is not recommended for patients commencing therapy with a viral load greater than 100 000 copies/mL. Rilpivirine is not included in the treatment regimens recommended by the World Health Organization (WHO), which form the basis of treatment guidelines in many lower- and middle-income countries. Some patients commencing standard first-line regimens experience treatment-limiting toxicity. A low-cost rilpivirine-containing fixed-dose combination would potentially be a useful addition to treatment options available in South Africa and other countries in the region, for patients who do not tolerate standard first-line ART. In this article, we explore the utility of rilpivirine as an option in ART in South Africa and the region in the context of current public-sector regimens. We consider what role rilpivirine might play if first-line therapy moves to a dolutegravir-based regimen, as has already happened in some lower- and middle-income countries, including Botswana, Kenya and Brazil. Finally, we describe emerging evidence for rilpivirine in the prevention of HIV transmission.
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Affiliation(s)
- Michelle A Moorhouse
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Properzi M, Magro P, Castelli F, Quiros-Roldan E. Dolutegravir-rilpivirine: first 2-drug regimen for HIV-positive adults. Expert Rev Anti Infect Ther 2018; 16:877-887. [PMID: 30392419 DOI: 10.1080/14787210.2018.1544491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION New strategies for HIV treatment are being investigated to reduce drug-exposure, toxicities, and costs. Dolutegravir (DTG) 50 mg/rilpivirine (RPV) 25 mg was approved in November 2017 by FDA and in May 2018 by the European Medicines Agency (EMA). It is indicated as a complete regimen for HIV-1 infected adults with undetectable plasmatic HIV-RNA for at least 6 months on their current HIV treatment combination. Its approval was based on the data of two randomized, multicenter, non-inferiority trials (SWORD-1 and SWORD-2). Areas covered: We reviewed data from literature about DTG and RPV. We mainly focused on the efficacy and on the safety of this new dual therapy. Its impact on renal function, its bone and cardiovascular profile, its reservoir penetration and its role on inflammation were also evaluated. Expert commentary: Dual therapies may be an attractive alternative to standard triple regimens in terms of tolerability and simplicity. Long-term efficacy of DTG and RPV dual regimen need to be confirmed, where only the extensive use of this new treatment and a longer follow-up will give us the answers.
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Affiliation(s)
- Martina Properzi
- a Department of Infectious and Tropical Diseases , University of Brescia and ASST Spedali Civili Hospital , Brescia , Italy
| | - Paola Magro
- a Department of Infectious and Tropical Diseases , University of Brescia and ASST Spedali Civili Hospital , Brescia , Italy
| | - Francesco Castelli
- a Department of Infectious and Tropical Diseases , University of Brescia and ASST Spedali Civili Hospital , Brescia , Italy
| | - Eugenia Quiros-Roldan
- a Department of Infectious and Tropical Diseases , University of Brescia and ASST Spedali Civili Hospital , Brescia , Italy
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