Immunization with thiol-binding proteins from Haemonchus contortus adult worms partially protects goats against infection during prepatency

To contribute of the knowledge of the immune mechanisms underlying the response to the immunization of goats with thiol-binding proteins fractions (PBS-TSBP) from Haemonchus contortus (H. contortus) adult worms, this study analyzed the degree of protection and the immune responses developed against the parasite after vaccination with this antigenic complex during the time-elapsing between challenge with L3 of the parasite and the development of adult worms, evidenced by the appearance of first faecal eggs (prepatent period or prepatency). Goat kids immunized with PBS-TBSP generated an immune response during the prepatency which translates into a reduction in the number of worms, as well as a lower reduction on packed cell volume and plasma protein levels in relation to the non-vaccinated animals. As previously described in other studies carried out after the prepatent period, this protection was associated with a systemic humoral response. At the local level, a specific humoral response was also observed, together with an immune-inflammatory infiltrate in the gastric mucosa of MCH-II + cells and CD4⁺ lymphocytes, whose number was associated with a reduction in the number of worms and an increase in plasma proteins. A high peripheral eosinophilia was detected, but no corresponding increased infiltration of the gastric mucosa by eosinophils or globular leukocytes was observed. In agreement with previous data on the immunolocalization of the antigens used here, the results obtained contribute to the idea that these may be excretion/secretion (E/S) products necessary for parasite survival, whose inactivation during the larval and/or pre-adult stages may have contributed to immunoprotection.

Population pharmacokinetics and pharmacodynamics of imipenem in neutropenic adult patients

OBJECTIVE

Imipenem is recommended in patients with chemotherapy-induced febrile neutropenia. Although alterations of antibiotic pharmacokinetic parameters have been reported in such patients, little data is available on imipenem.

METHODS

Prospective, single-center, non-interventional pharmacokinetic cohort study in adults with chemotherapy-induced febrile neutropenia. Critically ill patients were excluded. Imipenem was administered as a 30-min infusion of 1000 mg/8h. Total imipenem plasma concentrations were assayed by high-performance liquid chromatography during neutropenia and just after neutrophil recovery. We estimated population pharmacokinetic parameters of imipenem by non-linear mixed-effect modelling using the SAEM algorithm.

RESULTS

Sixteen patients were included in the study, including nine women (56.3%), median age 37 years (range, 18.3; 78.3). Eight patients had an hematological malignancy (50.0%) and seven had a solid tumor (43.8%). Imipenem pharmacokinetics were best described by a one-compartment model with first-order elimination. Mean values for imipenem were: clearance 14.3L/h and 10.9L/h and volume of distribution 20.7L and 14.5 L during neutropenia and after recovery, respectively. Imipenem plasma area under the curve at steady state was reduced by 23% during neutropenia. However, all patients achieved a pharmacodynamic target of %fT_>MIC ≥ 40% with a regimen of 1000 mg/8 h or 500 mg/6 h, for MICs up to 2 mg/L. The pharmacodynamics profile for a target of %fT > MIC = 100% was however less favorable with 500 mg/6 h or 1000 mg/8 h either during or after neutropenia.

CONCLUSION

Pharmacokinetic/pharmacodynamic goals for imipenem were similar in patients during and after neutropenia, despite reduced plasma exposure.

Treatment with a three-drug regimen for pulmonary tuberculosis based on rapid molecular detection of isoniazid resistance: a non-inferiority randomized trial (FAST-TB)

Background

The rationale behind the use of ethambutol in the standard tuberculosis treatment is to prevent the emergence of resistance to rifampicin in case of primary resistance to isoniazid. We evaluated whether early detection of isoniazid resistance using molecular testing allows the use an ethambutol-free regimen.

Methods

FAST-TB, a phase 4, French, multicenter, open-label, non-inferiority trial, compared 2 strategies: (1) polymerase chain reaction (PCR)-based detection of isoniazid and rifampicin resistance at baseline using Genotype MTBDRplus version 2.0 followed by ethambutol discontinuation if no resistance was detected (PCR arm) and (2) a standard 4-drug combination, pending phenotypic drug-susceptibility results (C arm). Adult patients with smear-positive pulmonary tuberculosis were enrolled. The primary endpoint was the proportion of patients with treatment success defined as bacteriological or clinical cure at the end of treatment. A non-inferiority margin of 10% was used.

Results

Two hundred three patients were randomized, 104 in the PCR arm and 99 in the C arm: 26.6% were female, median age was 37 (interquartile range, 28–51) years, 72.4% were born in Africa, and 5.4% were infected with human immunodeficiency virus. Chest x-ray showed cavities in 64.5% of the cases. Overall, 169 patients met criteria of treatment success: 87 of 104 (83.7%) in the PCR arm and 82 of 99 (82.8%) in the C arm with a difference of +0.8% (90% confidence interval, −7.9 to 9.6), meeting the noninferiority criteria in the intention-to-treat population (P = .02).

Conclusions

In a setting with low prevalence of primary isoniazid resistance, a 3-drug combination with isoniazid, rifampicin, and pyrazinamide, based on rapid detection of isoniazid resistance using molecular testing, was noninferior to starting the recommended 4-drug regimen.

Hepatosplenic candidiasis in patients with hematological malignancies: a 13-year retrospective cohort study

Background

Hepatosplenic candidiasis (HSC) used to be reported in patients with acute myeloid leukemia (AML) without antifungal prophylaxis. The aim was to describe the clinical features and outcomes of HSC over the last 13 years in a single French hematology center.

Methods

All patients diagnosed with HSC between 2008 and 2020 were included in a single-center retrospective cohort study. Data were collected from patient charts, and HSC was classified according to the 2020 European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions.

Results

Sixty patients were included, with 18.3% proven, 3.3% probable, and 78.3% possible HSC according to the 2020 European Organization for Research and Treatment of Cancer Mycoses Study Group classification. Among them, 19 patients were treated for acute myeloid leukemia (AML), 21 for lymphomas, and 14 for acute lymphoblastic leukemia. HSC occurred in 13 patients after autologous stem cell transplantation for lymphoma. At HSC diagnosis, 13 patients were receiving antifungal prophylaxis. Candida colonization was present in 84.2%, with prior candidemia in 36.7% of cases. β-D-glucans was positive in 55.8%, and 45.8% of tissue biopsies were contributive. First-line antifungal therapy was azoles in 61.7%, and steroids were associated in 45% of cases. At 3 months of follow-up, partial response to antifungal therapy was 94.2%. At last follow-up (mean, 22.6 months), 41 patients (68.3%) presented a complete hematological remission and 22 patients were deceased, none because of HSC.

Conclusions

The epidemiology of HSC has changed in the last decade, with fewer cases occurring in the AML setting. A better identification of patients at risk could lead to specific prophylaxis and improved diagnosis.

Eimeria ninakohlyakimovae casts NOX-independent NETosis and induces enhanced IL-12, TNF-α, IL-6, CCL2 and iNOS gene transcription in caprine PMN

Eimeria ninakohlyakimovae represents a highly pathogenic coccidian parasite causing severe haemorrhagic typhlocolitis in goat kids worldwide. NETosis was recently described as an efficient defense mechanism of polymorphonuclear neutrophils (PMN) acting against different parasites in vitro and in vivo. In vitro interactions of caprine PMN with parasitic stages of E. ninakohlyakimovae (i. e. oocysts and sporozoites) as well as soluble oocyst antigens (SOA) were analyzed at different ratios, concentrations and time spans. Extracellular DNA staining was used to illustrate classical molecules induced during caprine NETosis [i. e. histones (H3) and neutrophil elastase (NE)] via antibody-based immunofluorescence analyses. Functional inhibitor treatments with DPI and DNase I were applied to unveil role of NADPH oxidase (NOX) and characterize DNA-backbone composition of E. ninakohlyakimovae-triggered caprine NETosis. Scanning electron microscopy (SEM)- and immunofluorescence-analyses demonstrated that caprine PMN underwent NETosis upon contact with sporozoites and oocysts of E. ninakohlyakimovae, ensnaring filaments which firmly entrapped parasites. Detailed co-localization studies of E. ninakohlyakimovae-induced caprine NETosis revealed presence of PMN-derived DNA being adorned with nuclear H3 and NE corroborating molecular characteristics of NETosis. E. ninakohlyakoimovae-induced caprine NETosis was found to be NOX-independent since DPI inhibition led to a slight decrease of NETosis. Exposure of caprine PMN to vital E. ninakohlyakimovae sporozoites as well as SOA resulted in up-regulation of IL-12, TNF-α, IL-6, CCL2 and iNOS gene transcription in stimulated PMN. Since vital E. ninakohlyakimovae-sporozoites induced caprine NETosis, this effective entrapment mechanism might reduce initial sporozoite epithelial host cell invasion during goat coccidiosis ultimately resulting in less macromeront formation and reduced merozoites I production.

2019 update of the European AIDS Clinical Society Guidelines for treatment of people living with HIV version 10.0

BACKGROUND

The European AIDS Clinical Society (EACS) Guidelines cover key aspects of HIV management with major updates every two years.

GUIDELINE HIGHLIGHTS

The 2019 Guidelines were extended with a new section focusing on drug-drug interactions and other prescribing issues in people living with HIV (PLWH). The recommendations for treatment-naïve PLWH were updated with four preferred regimens favouring unboosted integrase inhibitors. A two-drug regimen with dolutegravir and lamivudine, and a three-drug regimen including doravirine were also added to the recommended initial regimens. Lower thresholds for hypertension were expanded to all PLWH and for cardiovascular disease prevention, the 10-year predicted risk threshold for consideration of antiretroviral therapy (ART) modification was lowered from 20% to 10%. Frailty and obesity were added as new topics. It was specified to use urine albumin to creatinine ratio to screen for glomerular disease and urine protein to creatinine ratio for tubular diseases, and thresholds were streamlined with the Kidney Disease: Improving Global Outcomes (KDIGO) recommendations. Hepatitis C virus (HCV) treatment recommendations were split into preferred and alternative treatment options. The algorithm for management of recently acquired HCV infection was updated and includes recommendations for early chronic infection management. Treatment of resistant tuberculosis (TB) was streamlined with the World Health Organization (WHO) recommendations, and new tables on immune reconstitution inflammatory syndrome, on when to start ART in the presence of opportunistic infections and on TB drug dosing were included.

CONCLUSIONS

The EACS Guidelines underwent major revisions of all sections in 2019. They are available in four different formats including a new interactive web-based version and are translated into Chinese, French, German, Japanese, Portuguese, Russian and Spanish.

First year of pre-exposure prophylaxis implementation in France with daily or on-demand tenofovir disoproxil fumarate/emtricitabine

BACKGROUND

In January 2016, the French Medicine Agency initiated a Temporary Recommendation for Use (TRU) to allow the use of oral intake of tenofovir disoproxil fumarate and emtricitabine for pre-exposure prophylaxis (PrEP) in adults at high risk of HIV. We report the results of the first year of PrEP implementation in France.

METHODS

Data were collected by physicians using a secured web subject-monitoring interface, with two forms: an initiation form, with patients' baseline characteristics, and an HIV seroconversion form. Univariate and adjusted multivariate analysis using a logistic regression model were performed to identify baseline factors associated with on-demand PrEP regimen prescription.

RESULTS

From 4 January 2016 to 28 February 2017, 3405 subjects were enrolled, with 2774 initiation forms completed; 98.1% were male and 96.9% were MSM. An on-demand regimen was prescribed to 57% of subjects. Older age (OR for participants older than 50 years = 1.76, 95% CI 1.35-2.3, P < 0.001) and site of prescription (OR of former IPERGAY sites = 2.28, 95% CI 1.84-2.83, P < 0.001) were associated with on-demand prescription. Those reporting sexually transmitted infection (STI) and condomless anal sex with at least two different partners were less likely to receive on-demand PrEP (OR = 0.68, 95% CI 0.57-0.82 and 0.75, 95% CI 0.57-0.98, respectively; P < 0.05 for all). Four breakthrough HIV infections were reported during the study, in the context of PrEP interruption or acute infection at the time of PrEP initiation.

CONCLUSIONS

In a real-life setting in France, PrEP was used, either daily or on-demand, mostly by MSM, with breakthrough infections being rare.

Knowledge and practices of Parisian family physicians for the management of men who have sex with men in the era of HIV pre-exposure prophylaxis

INTRODUCTION

The optimal management of men who have sex with men (MSM) requires active involvement of family physicians (FP). We assessed knowledge and practices of Parisian FPs related to the management of MSM for sexually transmitted infections (STIs) and pre-exposure prophylaxis for HIV (PrEP).

METHOD

We conducted an observational prospective study between June 20 and July 31, 2017, with a sample of FPs practicing in Paris. The questionnaire posted via the Google Form website included 42 questions on sexual health management of MSM patients. A statistical analysis was then performed.

RESULTS

One hundred and four FPs took part in the study. The median age was 34 and 68% were women. Overall, 86.5% of FPs had already heard about PrEP, but only 36% of them were familiar with the indication for therapy and 77.9% of FPs declared to be willing to renew PrEP prescription. Overall, 89.4% of respondents declared to be willing to attend additional training on sexual health of MSM patients, including 73% on PrEP.

CONCLUSION

FPs have an important role in the management of MSM patients. They showed strong interest in PrEP despite limited knowledge of indications and methods of administration. They declared to be willing to attend additional training for further involvement.

How PrEP users constitute a community in the MSM population through their specific experience and management of stigmatization. The example of the French ANRS-PREVENIR study

The ANRS-PREVENIR (2017-2020) prospective cohort study aims to reduce the number of new HIV infections in the "Ile-de-France" region in France, by enrolling individuals at high risk of HIV infection and proposing daily and on-demand pre-exposure prophylaxis (PrEP). The qualitative component of the ANRS-PREVENIR study aimed to investigate social and relational evolutions associated with PrEP use in men who have sex with men (MSM). In 2018, 12 focus groups with MSM (n = 68) were conducted by a social sciences researcher in Paris. A thematic analysis was performed. Results showed that stigma concerning PrEP use is a complex issue, with various kinds of stigmatization being practiced, sometimes even by the wider MSM population and PrEP users themselves. All types of stigma identified were expressed in forms of verbal abuse which made PrEP use taboo. Inside the wider MSM population a PrEP-user "community" was identified which shared a certain complicity in terms of values and a positive attitude towards PrEP. The emergence of new intragroup and intergroup social norms should be taken into account by policy makers to promote a more positive image of PrEP users.

Utility of anaerobic bottles for the diagnosis of bloodstream infections

BACKGROUND

Obligate anaerobes usually account for less than 10% of bacteria recovered from blood cultures (BC). The relevance of routine use of the anaerobic bottle is under debate. The aim of this study was to evaluate the utility of anaerobic bottles for the diagnosis of bloodstream infections (BSI).

METHODS

We conducted a 6-month, retrospective, monocentric study in a tertiary hospital. All positive BC were grouped into a single episode of bacteremia when drawn within 7 consecutive days. Bacteremia were classified into contaminants and BSI. Charts of patients with BSI due to obligate anaerobes were studied.

RESULTS

A total of 19,739 blood cultures were collected, 2341 of which (11.9%) were positive. Anaerobic bottles were positive in 1528 (65.3%) of all positive BC but were positive alone (aerobic bottles negative) in 369 (15.8%). Overall 1081 episodes of bacteremia were identified, of which 209 (19.3%) had positive anaerobic bottles alone. The majority 126/209 (60.3%) were contaminants and 83 (39.7%) were BSI. BSI due to facultative anaerobes, obligate aerobes and obligate anaerobes were identified in 67 (80.7%), 3 (3.6%) and 13 (15.7%) of these 83 episodes, respectively. BSI due to obligate anaerobic bacteria were reported in 9 patients with gastro-intestinal disease, in 3 with febrile neutropenia and in 1 burned patient.

CONCLUSIONS

Anaerobic bottles contributed to the diagnosis of a significant number of episodes of bacteremia. Isolated bacteria were mostly contaminants and non-obligate anaerobic pathogens. Rare BSI due to obligate anaerobes were reported mainly in patients with gastro-intestinal disorders and during febrile neutropenia.

Does region of origin influence the timing and outcome of first-line antiretroviral therapy in France?

OBJECTIVES

The aim of the study was to assess whether the timing of combination antiretroviral therapy (cART) initiation, the choice of cART and virological response differ in migrants versus European natives in the north and east of Paris area, after dissemination of French recommendations for universal treatment.

METHODS

Antiretroviral therapy-naïve HIV-1-infected adults with at least two follow-up visits at one of 15 participating centres between 1 January 2014 and 31 March 2015 were included in the study. Factors associated with cART initiation before 31 March 2015, with protease inhibitor (PI)-containing cART among individuals initiating cART, and with 1-year virological success after cART initiation were assessed using multivariable logistic regression models. Sex, age, region of origin [Western Europe, sub-Saharan Africa (SSA) or other], HIV transmission group, baseline AIDS status, CD4 cell count and plasma viral load (VL), and hepatitis B and/or C virus infection were considered in the analyses.

RESULTS

Among 912 individuals, only 584 (64%) started cART during the study period. After adjustment, migrants from SSA were half as likely to initiate cART and to have a subsequent virological response compared with individuals from Western Europe [adjusted odds ratio (aOR) 0.54; 95% confidence interval (CI) 0.36-0.82; and aOR 0.52; 95% CI 0.28-0.98, respectively]. PI-containing cART was more frequently prescribed in migrants from SSA, in people with lower CD4 cell counts and in people with higher VL.

CONCLUSIONS

Even in the context of universal cART recommendations and of free access to care, migrants from SSA still have delayed access to cART and a lower virological response. Efforts are still necessary to provide immediate cART to all people living with HIV.

Cytomegalovirus reactivation in liver transplant recipients due to hepatitis C cirrhosis is associated with higher cardiovascular risk - an observational, retrospective study

The association between cytomegalovirus (CMV) reactivation and cardiovascular risk has been reported in solid organ transplant populations; however, it has yet to be assessed in liver transplantation (LT). We aim to evaluate whether CMV reactivation is associated with cardiovascular events (CVE) in HCV-LT patients. LT patients (2010 and 2014) due to HCV cirrhosis were included. Clinically significant CMV (CS-CMV) was defined as viral load (VL) >5000 copies/ml, need of therapy or CMV disease. Baseline variables and endpoint measures (CVE, survival, severe recurrent hepatitis C, de novo tumors, and diabetes) were collected. One hundred and forty patients were included. At LT, a history of AHT was present in 23%, diabetes 22%, tobacco use 45%, obesity 20%, and renal impairment (eGFR < 60 ml/min) in 26.5%. CS-CMV reactivation occurred in 25% of patients. Twenty-six patients (18.5%) developed a CVE. Cox regression analysis revealed two factors significantly associated with CVE: Pre-LT DM [HR = 4.6 95% CI (1.6, 13), P = 0.004] and CS-CMV [HR = 4.7 95% CI (1.8, 12.5), P = 0.002]. CS-CMV was not independently associated with the remaining endpoints except for survival (P = 0.03). In our series, CS-CMV reactivation was associated with a greater risk of developing CVE, thus confirming data from other solid organ transplant populations and emphasizing the need for adequate CMV control.

Efficacy, safety and patient-reported outcomes of ledipasvir/sofosbuvir in NS3/4A protease inhibitor-experienced individuals with hepatitis C virus genotype 1 and HIV coinfection with and without cirrhosis (ANRS HC31 SOFTRIH study)

OBJECTIVES

Studies evaluating the efficacy and safety of the fixed-dose combination ledipasvir (LDV)/sofosbuvir (SOF) in patients coinfected with HIV-1 and hepatitis C virus (HCV) have mainly included treatment-naïve patients without cirrhosis. We aimed to evaluate the efficacy and safety of this combination in treatment-experienced patients with and without cirrhosis.

METHODS

We conducted a multicentre, open-label, double-arm, nonrandomized study in patients coinfected with HIV-1 and HCV genotype 1 with and without cirrhosis, who had good viral suppression on their antiretroviral regimens. All patients were pretreated with a first-generation NS3/4A protease inhibitor (PI) plus pegylated interferon/ribavirin. Patients received a fixed-dose combination of LDV/SOF for 12 weeks, or for 24 weeks if cirrhosis was present. The primary endpoint was a sustained virological response (SVR) 12 weeks after the end of therapy. Secondary endpoints included safety, pharmacokinetics and patient-reported outcomes.

RESULTS

Of the 68 patients enrolled, 39.7% had cirrhosis. Sixty-five patients [95.6%; 95% confidence interval (CI): 87.6-99.1%; P < 0.0001] achieved an SVR, with similar rates of SVR in those with and without cirrhosis. Tolerance was satisfactory, with mainly grade 1 or 2 adverse events. Among patient-reported outcomes, only fatigue significantly decreased at the end of treatment compared with baseline [odds ratio (OR): 0.36; 95% CI: 0.14-0.96; P = 0.04]. Mean tenofovir area under the plasma concentration-time curve (AUC) at week 4 was high, with mean ± SD AUC variation between baseline and week 4 higher in cirrhotic than in noncirrhotic patients (3261.57 ± 1920.47 ng/mL vs. 1576.15 ± 911.97 ng/mL, respectively; P = 0.03). Mild proteinuria (54.4%), hypophosphataemia (50.0%), blood bicarbonate decrease (29.4%) and hypokalaemia (13.2%) were reported. The serum creatinine level was not modified.

CONCLUSIONS

LDV/SOF provided a high SVR rate in PI-experienced subjects coinfected with HCV genotype 1 and HIV-1, including patients with cirrhosis.

Eimeria ninakohlyakimovae induces NADPH oxidase-dependent monocyte extracellular trap formation and upregulates IL-12 and TNF-α, IL-6 and CCL2 gene transcription

Extracellular trap (ET) formation has been demonstrated as novel effector mechanism against diverse pathogens in polymorphonuclear neutrophils (PMN), eosinophils, mast cells, macrophages and recently also in monocytes. In the current study, we show that E. ninakohlyakimovae triggers the deliverance of monocyte-derived ETs in vitro. Fluorescence illustrations as well as scanning electron microscopy (SEM) analyses showed that monocyte-derived ET formation was rapidly induced upon exposure to viable sporozoites, sporocysts and oocysts of E. ninakohlyakimovae. Classical features of monocyte-released ETs were confirmed by the co-localization of extracellular DNA adorned with myeloperoxidase (MPO) and histones (H3) in parasite-entrapping structures. The treatment of caprine monocyte ET structures with NADPH oxidase inhibitor diphenylene iodondium (DPI) significantly reduced ETosis confirming the essential role of reactive oxygen species (ROS) in monocyte mediated ETs formation. Additionally, co-culture of monocytes with viable sporozoites and soluble oocyst antigen (SOA) induced distinct levels of cytokine and chemokine gene transcription. Thus, the transcription of genes encoding for IL-12 and TNF-α was significantly upregulated after sporozoite encounter. In contrast IL-6 and CCL2 gene transcripts were rather weakly induced by parasites. Conversely, SOA only induced the up-regulation of IL-6 and CCL2 gene transcription, and failed to enhance transcripts of IL-12 and TNF-α in vitro. We here report on monocyte-triggered ETs as novel effector mechanism against E. ninakohlyakimovae. Our results strongly suggest that monocyte-mediated innate immune reactions might play an important role in early host immune reactions against E. ninakohlyakimovae in goats.

Targeting essential Eimeria ninakohlyakimovae sporozoite ligands for caprine host endothelial cell invasion with a phage display peptide library

Eimeria ninakohlyakimovae is an important coccidian parasite of goats which causes severe diarrhoea in young animals. Specific molecules that mediate E. ninakohlyakimovae host interactions and molecular mechanisms involved in the pathogenesis are still unknown. Although strong circumstantial evidence indicates that E. ninakohlyakimovae sporozoite interactions with caprine endothelial host cells (ECs) are specific, hardly any information is available about the interacting molecules that confer host cell specificity. In this study, we describe a novel method to identify surface proteins of caprine umbilical vein endothelial cells (CUVEC) using a phage display library. After several panning rounds, we identified a number of peptides that specifically bind to the surface of CUVEC. Importantly, caprine endothelial cell peptide 2 (PCEC2) and PCEC5 selectively reduced the infection rate by E. ninakohlyakimovae sporozoites. These preliminary data give new insight for the molecular identification of ligands involved in the interaction between E. ninakohlyakimovae sporozoites and host ECs. Further studies using this phage approach might be useful to identify new potential target molecules for the development of anti-coccidial drugs or even new vaccine strategies.

Archived HIV-1 DNA resistance mutations to rilpivirine and etravirine in successfully treated HIV-1-infected individuals pre-exposed to efavirenz or nevirapine

OBJECTIVES

Efavirenz and nevirapine failure is associated with a rapid selection of resistance-associated mutations (RAMs), which may impact on etravirine or rilpivirine susceptibility. However, RAMs for rilpivirine and etravirine cannot be reported on previous resistance genotypes because these specific RAMs were not analyzed at that time. Therefore, our objective was to determine, in virologically suppressed HIV-1-infected individuals, the presence of RAMs to rilpivirine, etravirine and the combination of tenofovir/emtricitabine/rilpivirine in HIV-1 DNA from individuals previously exposed to efavirenz and/or nevirapine.

METHODS

The studied population included 169 treatment-experienced individuals enrolled in the ANRS 138-EASIER trial who previously failed on and/or were intolerant to efavirenz and/or nevirapine and who had plasma HIV-1 RNA<400 copies/mL. Resistance to rilpivirine, etravirine, tenofovir and emtricitabine by bulk sequencing was performed on extracted HIV-1 DNA from whole blood collected at the time of trial inclusion.

RESULTS

Reverse transcriptase gene amplification was successful in 128/169 (76%) individuals and 95% of HIV-1 were infected with subtype B. Rilpivirine RAMs were detected in 41 (32%) individuals, with highest frequency for the mutations Y181C/I/V (18%), K101E/P (7%) and E138A/G/K/Q/R/S (6%) and the association L100I+K103N/S (5%). Etravirine RAMs were detected in five (4%) individuals. Resistance to emtricitabine, tenofovir and at least one drug included in the combination of tenofovir/emtricitabine/rilpivirine were detected in 72 (56%), 12 (9%) and 88 (69%), respectively.

CONCLUSIONS

In individuals with suppressed viraemia under antiretroviral therapy (ART), but who had been previously exposed to an efavirenz and/or nevirapine-based regimen, rilpivirine RAMs are frequent and etravirine RAMs are rare. This finding suggests that the switch to a rilpivirine-based regimen should not be recommended.

Autochthonous falciparum malaria possibly transmitted by luggage-carried vector in Paris, France, February 2013

We report a case of autochthonous falciparum malaria in a patient in Paris, France, in February 2013 who reported no recent travel to malaria-endemic countries. The parasite, Plasmodium falciparum, was possibly transmitted by an infective Anopheles mosquito carried in baggage from a malaria-endemic area.

Isolation of an Eimeria ninakohlyakimovae field strain (Canary Islands) and analysis of its infection characteristics in goat kids

The current study was conducted to isolate a field strain of Eimeria ninakohlyakimovae, characterize its infectivity and the response to challenge under experimental conditions. The isolated strain (GC) induced a prepatent period of 14-15 days p.i., a patency of 7±2 days and a noticeable pathogenicity in infected goat kids. Challenge trials resulting in a decrease of oocysts per gram counts as well as a milder intensity of clinical signs in re-infected animals indicated the capacity of this strain to induce protective immune response. Altogether, the data reported in the present study suggest that the strain E. ninakohlyakimovae GC is a useful tool for the investigation of mechanisms of pathogenicity as well as host protective immune response in caprine coccidiosis, representing a valuable prerequisite for the development of future strategies in prophylaxis and control of this important parasitic disease in goat.

Effects of recombinant human interleukin 7 on T-cell recovery and thymic output in HIV-infected patients receiving antiretroviral therapy: results of a phase I/IIa randomized, placebo-controlled, multicenter study

BACKGROUND

The immune deficiency of human immunodeficiency virus (HIV) infection is not fully corrected with ARV therapy. Interleukin-7 (IL-7) can boost CD4 T-cell counts, but optimal dosing and mechanisms of cellular increases need to be defined.

METHODS

We performed a randomized placebo-controlled dose escalation (10, 20 and 30 µg/kg) trial of 3 weekly doses of recombinant human IL-7 (rhIL-7) in ARV-treated HIV-infected persons with CD4 T-cell counts between 101 and 400 cells/µL and plasma HIV levels <50 copies/mL. Toxicity, activity and the impact of rhIL-7 on immune reconstitution were monitored.

RESULTS

Doses of rhIL-7 up to 20 µg/kg were well tolerated. CD4 increases of predominantly naive and central memory T cells were brisk (averaging 323 cells/µL at 12 weeks) and durable (up to 1 year). Increased cell cycling and transient increased bcl-2 expression were noted. Expanded cells did not have the characteristics of regulatory or activated T cells. Transient low-level HIV viremia was seen in 6 of 26 treated patients; modest increases in total levels of intracellular HIV DNA were proportional to CD4 T-cell expansions. IL-7 seemed to increase thymic output and tended to improve the T-cell receptor (TCR) repertoire in persons with low TCR diversity.

CONCLUSIONS

Three weekly doses of rhIL-7 at 20 µg/kg are well tolerated and lead to a dose-dependent CD4 T-cell increase and the broadening of TCR diversity in some subjects. These data suggest that this rhIL-7 dose could be advanced in future rhIL-7 clinical studies.

CLINICAL TRIALS REGISTRATION

NCT0047732.

Immunoprotective effect of cysteine proteinase fractions from two Haemonchus contortus strains adapted to sheep and goats

A preliminary analysis of the significance of genetic diversity in cysteine proteinase genes has been performed simultaneously in sheep and goats, with regard to the immunological control using these enzymes against haemonchosis. For this purpose, we have studied the cross-immunoprotective effect of cysteine protease-enriched protein fractions (CPFs) in adult worms of two Haemonchus contortus strains from North America and Spain that are adapted to sheep and goats, respectively. Previous genetic analysis of cysteine proteinase genes in both strains has shown that some of loci are polymorphic and these differences are translated into changes in the amino acid sequences. However, our results show that CPFs from H. contortus adult worms have a protective effect against the parasite in both sheep and goats. These results are similar regardless of whether they were obtained from sheep or goat-adapted H. contortus strains, which could be very important in case H. contortus CPFs were commercially used in different countries, as vaccines to prevent the negative effects of this parasite. Interestingly, this experimental inoculation of both species with a heterologous strain of H. contortus contributes to the idea shown in previous studies about how difficult is the interpretation and the comparison of vaccination where strains not adapted to a specific host are used. Therefore, the challenger of using heterologous strains could provide similar results to those observed in immunised animals. This study suggests the possibility of exploring the mechanisms involved in natural protection against non-adapted strains, in order to develop strategies to control haemonchosis.

Comparison of resistance mutation patterns in historical plasma HIV RNA genotypes with those in current proviral HIV DNA genotypes among extensively treated patients with suppressed replication

OBJECTIVES

Heavily treatment-experienced patients with good virological control could be at risk of virological failure on switching to a new regimen if pre-existing drug resistance is not taken into account. We examined whether genotyping based on cellular HIV-1 DNA during controlled viraemia identifies resistance mutations detected in plasma HIV-1 RNA during treatment with previous antiretroviral regimens.

PATIENTS AND METHODS

All 169 patients enrolled in the Agence Nationale de Recherche sur le SIDA (ANRS) 138-intEgrase inhibitor MK_0518 to Avoid Subcutaneous Injections of EnfuviRtide (EASIER) trial had already received three antiretroviral drug classes [nucleoside reverse transcriptase inhibitor (NRTI), nonnucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI)] and had plasma HIV-1 RNA<400 copies/ml at baseline. The results of previous resistance genotyping of plasma HIV-1 RNA in individual patients were compared with those of resistance genotyping of whole-blood HIV-1 DNA at randomization.

RESULTS

A median of 4 plasma RNA genotypes were available for the 169 patients. The median numbers of resistance mutations in HIV-1 RNA and DNA were, respectively, 5 and 4 for NRTIs, 2 and 1 for NNRTIs, and 10 and 8 for PIs. The difference was significant for all three drug classes (P=0.001). Resistance to at least one antiretroviral drug was detected exclusively in HIV-1 RNA or in DNA in 63% and 13% of patients for NRTI, 47% and 1% of patients for NNRTI, and 50% and 7% of patients for PI, respectively.

CONCLUSION

This study shows that, among highly treatment-experienced patients on effective highly active antiretroviral therapy, resistance genotyping of HIV-1 DNA detects fewer resistance mutations than previous analyses of HIV-1 RNA. These results have implications for patient management and for the design of switch studies.

Real-time PCR assay-based strategy for differentiation between active Pneumocystis jirovecii pneumonia and colonization in immunocompromised patients

Diagnosis of pneumocystosis usually relies on microscopic demonstration of Pneumocystis jirovecii in respiratory samples. Conventional PCR can detect low levels of P. jirovecii DNA but cannot differentiate active pneumonia from colonization. In this study, we used a new real-time quantitative PCR (qPCR) assay to identify and discriminate these entities. One hundred and sixty-three bronchoalveolar lavage fluids and 115 induced sputa were prospectively obtained from 238 consecutive immunocompromised patients presenting signs of pneumonia. Each patient was classified as having a high or a low probability of P. jirovecii pneumonia according to clinical and radiological presentation. Samples were processed by microscopy and by a qPCR assay amplifying the P. jirovecii mitochondrial large-subunit rRNA gene; qPCR results were expressed as trophic form equivalents (TFEq)/mL by reference to a standard curve obtained from numbered suspensions of trophic forms. From 21 samples obtained from 16 patients with a high probability of P. jirovecii pneumonia, 21 were positive by qPCR whereas only 16 were positive by microscopy. Fungal load ranged from 134 to 1.73 × 10(6)  TFEq/mL. Among 257 specimens sampled from 222 patients with a low probability of P. jirovecii pneumonia, 222 were negative by both techniques but 35 were positive by qPCR (0.1-1840 TFEq/mL), suggesting P. jirovecii colonization. Two cut-off values of 120 and 1900 TFEq/mL were proposed to discriminate active pneumonia from colonization, with a grey zone between them. In conclusion, this qPCR assay discriminates active pneumonia from colonization. This is particularly relevant for patient management, especially in non-human immunodeficiency virus (HIV)-infected immunocompromised patients, who often present low-burden P. jirovecii infections that are not diagnosed microscopically.

Debris and 1/f noise in sliding friction dynamics under wear conditions

Friction force time series showing irregular fluctuations have been since long considered one of the possible stick-slip regimes in sliding friction. However, it has not been until recently that a 1/f power spectrum in friction force time series derived from sliding friction experiments under wear conditions has been identified. A variety of models, mostly inspired in the field of earthquakes, has been explored, without reaching a fully satisfactory explanation of that behavior. Recently, the present authors have reported results of sliding friction experiments on steel with alumina pins, carried out with and without debris blowing, that proved the role of loose debris in determining the 1/f character of the friction force. A damped-forced harmonic oscillator with two friction terms was proposed to describe the dynamics of friction under wear conditions: one purely random, which accounts for surface roughness, and another inversely proportional to the amount of loose debris that was calculated by means of a modified sand-pile model. This paper presents a full discussion of the experiments that allowed to reach that conclusion and of the model proposed to rationalize the results. In addition, the results of experiments devised to understand the transition from friction with debris to friction without debris (experiment initiated without blowing and after some time switching on blowing) and vice versa are reported. The results of further studies of the wear track are presented, namely, the variation in the track width with sliding distance and results of chemical analyses and surface roughness measurements of the track, for both with or without debris blowing experiments. These additional data give further support to the crucial role of debris in the 1/f character of the friction force.

Results of laparoscopic cholecystectomy in a third-level university hospital after 17 years of experience

OBJECTIVE

The aim of the study is to determine the results obtained with laparoscopic cholecystectomy at Ramón y Cajal Hospital after 17 years of experience, comparing current results with those at the beginning of the experience.

MATERIAL AND METHODS

Between 1991 and December 2007, 3,933 laparoscopic cholecystectomies were performed at the "Ramón y Cajal Hospital"; 1,849 patients were operated on between 1991 and 2000, and 2,084 between 2001 and 2007. Patients studied included 69.8% of women and 30.2% of men, with a mean age of 56.95 years (range 9-94 years). In all, 54.68% of patients had a concomitant disease before surgery (hypertension, diabetes, ischemic heart disease, respiratory disease). Surgery was performed by a staff surgeon for 58.04% of cases, and by a resident in the remaining 41.96%. Surgical indications were cholelithiasis in 75.5%, pancreatitis in 13.3%, cholecystitis in 6.3%, choledocholithiasis in 3.05%, and others in 1.2% of cases.

RESULTS

Mean hospital stay was 3.06 days. Conversion to open surgery was required for 8.3% of cases (331 patients). The major surgical complication rate was 2.34%, with the most frequent being hemoperitoneum (1%). Common bile duct injury occurred in thirteen cases (0.3%), 51 patients (1.3%) were soon re-operated, and 5 patients died (0.13%). When the results of both decades (1991-2000 vs. 2001-2007) were compared, we observed differences in the number of procedures performed by residents (31.7 vs. 51.1%, p = 0.00001), number of laparoscopic cholecystectomies for cholecystitis (4.9 vs. 7.53%, p = 0.001), conversion rate (5.46 vs. 11%, p = 0.000001), and mean hospital stay (2.43 vs. 3.7 days, p = 0.001).

CONCLUSION

These results should be interpreted with caution as this is a retrospective study with multiple uncontrolled variables (high number of surgeons and continuous learning curve). The lower conversion rate and mean hospital stay in the first decade of the learning curve are amazing, although this could be related to better patient selection and a lower number of cholecystites operated using a laparoscopic approach in the initial series. In general, these results are acceptable and concur with the rest of the literature.

1/f Noise in sliding friction under wear conditions: the role of debris

It has been shown that the friction force time series in sliding friction under wear conditions is self-similar and has a 1/f power spectrum. Albeit a variety of models, mostly inspired in the field of earthquakes, has been explored, an important factor was overlooked: the role of debris. This Letter describes sliding friction experiments on steel with alumina pins, carried out with and without debris blowing, that prove the role of loose debris in determining the 1/f character of the friction force. A damped-forced harmonic oscillator with two friction terms, one purely random and another inversely proportional to the amount of loose debris, calculated by means of a modified sandpile model, is proposed to describe the dynamics of friction under wear conditions.

[Epidemiology of genotypic resistance of HIV-1 in Valencia. A 4-year study]

HIV resistance to antiretroviral drugs was studied in 348 samples taken from patients at the Molecular Biology Unit of the Microbiology Department of the Hospital La Fe, from January 2003 to July 2007. Once the viral load in plasma was determined, resistance was detected using complete gene sequencing for protease up to position 3464 of the HIV-1 reverse transcriptase gene. The results were analyzed using the Omiga 1.2 (Oxford Molecular Group) and HIV db Genotypic Resistance Interpretation Algorithm Version 4.3.0 (Stanford University) programs. The drugs least affected by the presence of mutations leading to resistance were the protease inhibitors darunavir, tripanavir and lopinavir (sensitivity >80%), the nucleoside reverse transcriptase inhibitors tenofovir and lamivudine (sensitivity >90%) and the non-nucleoside reverse transcriptase inhibitor TMC125 (sensitivity >80%).

IGM and IGG response to 29-35-kDa Toxoplasma gondii protein fractions in experimentally infected goats

The evolution of the humoral responses of IgG and IgM against 29-35-kDa Toxoplasma gondii fractions from experimentally infected goats were studied and compared by ELISA with the use of whole T. gondii soluble extracts and 29-35-kDa electroeluted proteins as antigens. The IgM response to electroeluted proteins was detected from wk 1 to wk 3 postinfection, showing a similar evolution to that observed when T. gondii crude extracts were used as antigens. These results suggest that this group of proteins could be used for a more specific detection of anti-T. gondii IgM. In the same way, the IgG response was equivalent in both cases, although when 29-35-kDa T. gondii fractions were used as antigens, the level of specific IgGs reached a peak 2 wk before than when T. gondii crude extract was used. The detection by ELISA of anti-T. gondii IgM in goats does not seem to be affected by the presence of specific IgG in serum samples when 29-35-kDa protein fractions were used as antigens.

Influence of climatic and management factors on Eimeria infections in goats from semi-arid zones

A survey of Eimeria infections was performed in dairy goats and kids (<6 months old) of six farms from a dry desert area of Gran Canaria Island (Spain). The number of oocysts per gram of faeces (OPG) was determined by a modified McMaster technique over a total of 2,616 individual faecal samples taken from the rectum in monthly intervals. Eimeria oocysts were found in 96.1% of the samples with OPG ranging from 1 x 10(2) to 1.4 x 10(6). Kid goats had significantly (P < 0.001) higher OPG counts (46,496 +/- 5,228) than dairy females (2,225 +/- 287). Eight Eimeria species were identified, with Eimeria ninakohlyakimovae (30.0%), Eimeria arloingi (28.6%) and Eimeria alijevi (20.5%) being the most frequent species followed by Eimeria caprina (9.1%), Eimeria christenseni (4.5%), Eimeria jolchijevi (3.4%), Eimeria caprovina (3.2%) and Eimeria hirci (0.7%). Although significant differences were observed among goat groups and herds, the eight species were present in the six farms in both dairy goats and kids. The intensity of oocysts shedding was related to some factors such as the size of the herd and was further influenced by the prevailing climatic conditions of the area. The highest OPG counts were recorded during the hot season in dairy goats and close to weaning time in kids reared in small farms having no prophylactic treatments against eimeriosis.

Pneumocystose chez les patients d’onco-hématologie : est-ce inévitable ?

INTRODUCTION

Although the use of prophylactic medication has reduced the incidence of Pneumocystis jiroveci pneumonia (PCP), it still occurs in cancer patients and is associated with a high morbidity and mortality.

STATE OF THE ART

Patients with haematological malignancies are at high risk for PCP because of chemotherapy and steroid-induced immunosuppression. Despite highly active prophylactic regimens, most cases occur in patients who are not receiving any prophylactic treatment even though the risk factors are well described. PCR techniques have been used for PCP diagnosis but these highly sensitive methods may not be able to discriminate between airway colonisation and infection.

PERSPECTIVES

Prophylaxis should be widely recommended for patients receiving prolonged steroid therapy or other immunosuppressive drugs. A low CD4+-T cell count (less than 200/microl) may be a useful marker to identify high risk patients who should not discontinue prophylaxis.

CONCLUSION

Because PCP is very severe in cancer patients, higher risk patients must be identified and long-term prophylaxis should be maintained as long as immunosuppression persists.

Benign rectovaginal fistulas: management and results of a personal series

BACKGROUND

Treatment of benign rectovaginal fistula has a high failure rate and entails difficult decisions. The purpose of this retrospective study was to clarify the concepts which may improve its management.

METHODS

Between 1983 and 2004, 46 consecutive women of median age 41 years were treated by the same surgeon. Etiology of simple fistulas was iatrogenic (n=6), obstetric (n=4) and septic (n=3). Complex fistulas were due to inflammatory bowel diseases (IBD) (n=18, 11 pouchvaginal) or were iatrogenic (n=9), actinic (n=5) or septic (n=1). Surgical techniques included endorectal or vaginal advancement flaps, fistulectomy and sphincteroplasty, vaginal/rectal closure and epiploplasty, restorative proctectomy and restorative proctocolectomy. In 20 patients, a diverting stoma was performed as a single procedure or concomitant to the curative attempt.

RESULTS

Overall, 33 of the 39 fistulas (85%) treated for cure healed, including all simple fistulas and 20 complex fistulas (8 iatrogenic, 3 actinic, 2 ulcerative colitis without restorative proctocolectomy; 5 pouch vaginal; 1 septic; 1 Crohn's disease) (p=0.009). The first operation for the fistula was curative in 20 of 39 fistulas, including 10 of 13 simple and 10 of 26 complex fistulas (p=0.023). There was no significant age difference between cured and not-cured patients.

CONCLUSIONS

Simple versus complex fistulas is the most determinant factor for healing. In IBD fistulas, ulcerative colitis shows better prognosis than Crohn's disease. For complex fistulas, a temporary diverting stoma seems necessary.

Five-Year Follow up of Once-Daily Therapy with Emtricitabine, Didanosine and Efavirenz (Montana ANRS 091 Trial)

Background

Once-daily combination therapy with emtricitabine, didanosine and efavirenz has been highly effective in clinical trials but its long-term efficacy and safety has not been previously reported.

Methods

This multicentre, single-arm, open-label trial enrolled 40 antiretroviral-naive HIV-1-infected patients who received a once-daily regimen of emtricitabine, didanosine and efavirenz. The objective was to assess the long-term effects of this combination on plasma HIV RNA levels, CD4+ T-cell counts, safety and tolerability.

Results

After 5 years, 73% and 68% of patients had plasma HIV RNA levels <400 and <50 copies/ml, respectively, in an intent-to-treat, missing-equals-failure analysis. Genotypic resistance on treatment emerged in six patients. There was a significant increase in CD4+ T-cell count of 294x106 cells/l. Only six patients discontinued study treatment, because of non-severe adverse events. Lipodystrophy was infrequent, and lipid and glucose profiles were favourable with a significant increase in high-density lipoprotein cholesterol.

Conclusions

A convenient once-daily regimen of emtricitabine, didanosine and efavirenz provided durable antiretroviral response and was well tolerated through 5 years of therapy.

Borreliosis: a rare and alternative diagnosis in travellers' febrile illness

We report a case of borreliosis mimicking uncomplicated malaria in a patient returning from Mali. Identification of spirochetes through examination of a thick blood smear completed by an acridine-orange quantitative buffy coat allowed the diagnosis of borreliosis. All symptoms rapidly resolved following tetracycline therapy. Epidemiological and clinical features of borreliosis, diagnostic tools and management are discussed.

Occurrence of Pneumocystis jiroveci pneumonia after allogeneic stem cell transplantation: a 6-year retrospective study

Pneumocystis jiroveci pneumonia (PCP) has become a rare opportunistic infection due to the efficacy of prophylactic regimens. We conducted a 6-year retrospective study at our institution. A total of 13 cases of PCP were diagnosed among 519 patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) (2.5%). In three patients, PCP occurred within the first 5 months following HSCT. These severely immunocompromised patients were receiving prophylaxis and had concomitant aspergillosis that caused rapid death in two of them. In 10 other patients, PCP occurred a median of 14.5 months after HSCT. In all these patients, PCP prophylaxis had been discontinued, mainly because of the suspected bone-marrow toxicity of the prophylactic regimen. Median CD4+ T cell count was 131/microl at diagnosis. Seven of these 10 patients were receiving immunosuppressive therapy for chronic graft versus host disease and three had a relapse of their hematological malignancy. One patient died from PCP despite high doses of cotrimoxazole. We conclude that PCP is still occurring after allogeneic HSCT, mainly as a late complication in patients in whom PCP prophylaxis had been prematurely discontinued. Long-term PCP prophylaxis should be maintained in patients receiving immunosuppressive drugs, and in those with low CD4+ T cell counts or a relapse of their hematological malignancy.

Comparison of Quantitative PCR and Antigenemia in Cytomegalovirus Infection in Renal Transplant Recipients

Cytomegalovirus infection is a common complication of renal transplantation. Antigen pp65 levels serve as indicators of viral load, although the technique is difficult to perform and interpret. We sought to determine whether quantitative PCR had a higher sensitivity and predictive value in CMV infection.

METHODS

The study included 100 renal transplant recipients who were screened for IgM and IgG at the time of admission. On days 7, 15, 30, 45, 60, 75, 90, 120, 180, and 360, antigenemia tests were performed on blood (pp65) and urine, and a quantitative PCR on blood. Among 59 patients recruited between November 2003 and August 2004 the mean age was 54.5 +/- 12.9 years. Two patients did not reach 90 days follow-up (3%); four patients have not surpassed 90 days (7%); 22, 120 days (37%); and 31, 180 days (53%). Ninety-three percent of patients showed anti-IgG CMV-positive titers with all being IgM CMV-negative at baseline. The patients at risk for infection were given valgancyclovir as prophylaxis throughout the study.

RESULTS

At 474 visits, 8 samples (2.4%) were positive with urine; 5 (1.4%) with pp65, and 15 (4.7%) with PCR. Among the 15 positive samples, two (>100,000 and 3250 copies) revealed agreement of positive IgM and shellvial test on urine; two (15,100 and 5670 copies), antigen pp65 1+; one (17,400 copies) with pp65 2+ and shellvial urine; two (99,400 and 28,300 copies) with pp65 1+ and shellvial urine; and eight remaining determinations, 749, 2250, 686, 928, 2250, 26600, 777, and 2790 copies. The rest of the tests were negative.

CONCLUSION

The preliminary results of this study demonstrated that quantitative PCR was a useful rapid tool for diagnosing and monitoring CMV infections.

[Cytomegalovirus viral load and antigenemia in the monitorization of prophylactic treatment with valganciclovir in renal transplant recipients]

Cytomegalovirus (CMV) disease is one of the most relevant infectious complications in solid organ transplant, and we must perform an appropriate prophylactic intervention. The goal of this study was to evaluate the effectiveness of prophylactic treatment with valganciclovir in renal transplant recipients in the first three months post transplantation by shell vial urine culture assay, and by measuring antigenemia (pp65) and CMV viral load, the latter by PCR. The population of the study included 100 renal transplant recipients. We analyzed the results of 36 patients recruited between November 2003 and July 2004 who were receiving a prophylactic oral treatment with valganciclovir, and who had finished the follow-up period of 90 days. The three tests mentioned above were performed on days 7, 15, 30, 45, 60, 75 and 90. No positive antigenemia was detected, the virus was cultured in a urine specimen and, in one patient, three measurements of viral load in serum were positive. Preliminary results of the study suggest that universal chemoprophylaxis with valganciclovir is effective for the prevention of CMV infection in renal transplant recipients and that, although all three tests used were useful, the measurement of CMV viral load seems to be the most appropriate method for monitoring these patients.

Impact of Newly Available Drugs on Clinical Progression in Patients with Virological Failure after Exposure to Three Classes of Antiretrovirals

Objective

To study the prognosis of HIV-infected patients with virological failure after exposure to three classes of antiretroviral drugs (ARVs).

Design

Cohort study. Setting: French Hospital Database on HIV.

Patients

Patients previously exposed to at least two nucleoside reverse transcriptase inhibitors (NRTIs), two protease inhibitors and one non-NRTI, with viral load (VL) values of >5000 copies/ml after the exposure criteria were met and a new treatment initiated between 1998 and 2001 with VL >5000 copies/ml.

Main outcome measures

Risk of new AIDS-defining-events (ADEs) or death from first introduction of a drug never used before occurring between 1998 and 2001 defined as baseline.

Results

The main baseline characteristics of the 1092 patients were: previous ADE in 49% of cases, median CD4 cell count 181 μl, median VL 4.9 log10 copies/ml, median duration of ARV therapy 5.0 years and previous exposure to a median of nine ARVs. The crude progression rates were 20.1/100 patient-years among patients included in 1998, 15.1 in 1999, 11.1 in 2000 and 8.6 in 2001. After adjustment for baseline characteristics, the calendar year of inclusion was associated with the risk of clinical progression ( P<0.001). When the types of newly available drugs used at baseline or during follow-up were introduced into the model, year of inclusion was no longer associated with the risk of clinical progression ( P=0.42), while exposure to amprenavir/r, lopinavir/r, abacavir or tenofovir was associated with a lower risk.

Conclusions

The clinical prognosis of heavily pretreated patients experiencing virological failure improved between 1998 and 2001, mainly thanks to the use of newly available drugs with more favourable resistance profiles.