First 15 Years of Assisted Reproductive Technology Using Washed Sperm in HIV-Positive Individuals Under Antiretroviral Therapy: Sweden's Nationwide Outcomes

Antiretroviral therapy has made HIV a chronic infectious disease. In Sweden, assisted reproductive technologies using sperm washing were implemented in 2004 for treatment of all HIV-positive males in serodiscordant couples at Karolinska Hospital in Stockholm. This study aimed to assess efficacy and safety of this approach and to investigate the effect of antiretroviral regimens on sperm quality of men treated for HIV. The study included all HIV-positive men (n = 53) adherent to antiretroviral treatment, including nucleoside/nucleotide analog reverse-transcriptase inhibitors (NRTIs) combined with non-nucleoside reverse-transcriptase inhibitors (NNRTIs) in 22 cases, or with other medication in 31 cases wishing fertility treatment. Sperm was washed using gradient centrifugation with a double tube system, frozen and thawed. Thereafter, single spermatozoa were injected in oocytes by intracytoplasmic sperm injection (ICSI). Treatment outcomes were compared to those of hepatitis B virus (HBV)-seropositive men in serodiscordant couples (n = 56), undergoing similar sperm washing protocols and ICSI at the center. In total, 82 fresh and 39 frozen/thawed embryo transfer (FET) cycles were performed in discordant HIV couples and 92 fresh and 36 FET cycles in HBV. Fertilization rates (69.2% vs. 64.6%, p = 0.310), clinical pregnancy rates (39.2% vs. 32.6%, p = 0.378), and live birth rates (35.8% vs. 31.5%, p = 0.565) were similar between the groups and the cumulative results yielded similar outcomes with a live birth rate of 52.8% and 51.8% (p = 0.913), respectively. No post-wash sperm sample was found positive for HIV viral particles. No partner seroconversion or offspring infection was reported. NNRTI-treated men had significantly lower motile sperm concentration than non-NNRTI-treated patients (54.48% vs. 36.41%, p < 0001). This study showed that in vitro fertilization/ICSI treatment with sperm washing was safe in individuals compliant to antiretroviral treatment and the reproductive outcome was similar to that of HBV-positive men. The observed moderate negative impact on sperm motility of NNRTI regimens may be overcome by using ICSI.

Multisystem inflammatory syndrome in adults with cardiac engagement: a case report and literature review

Background

Following infection with severe acute respiratory syndrome coronavirus, a post-infectious multisystem inflammatory syndrome in adults (MIS-A) has been identified. It affects multiple organ systems and can lead to multi-organic failure.

Case summary

This case report describes a patient with MIS-A with significant cardiac involvement including peri-myocarditis, pulmonary hypertension, right-sided heart failure, tricuspid regurgitation, and cardiogenic shock. After being diagnosed and treated correctly for MIS-A, the patient recovered completely, without any cardiac sequelae.

Discussion

The hyperinflammation in MIS-A can have cardiac engagement. Although more research is required to further clarify the underlying mechanisms, prompt diagnosis and anti-inflammatory treatment are crucial for better outcomes and cardiac recovery.

Cardiac Implantable Electronic Device Infections; Long-Term Outcome after Extraction and Antibiotic Treatment

Background: The aim of the study was to examine the treatment outcome for patients with cardiovascular implantable electronic device (CIED) infections after extraction. Methods: Patients who underwent CIED extractions due to an infection at Karolinska University Hospital 2006–2015 were analyzed. Results: In total, 165 patients were reviewed, 104 (63%) with pocket infection and 61 (37%) with systemic infection. Of the patients with systemic infection, 34 and 25 patients fulfilled the criteria for definite and possible endocarditis, respectively. Complications after extraction occurred only in one patient. Reimplantation was made after a mean of 9.5 days and performed in 81% of those with pocket infection and 44.3% in systemic infection. Infection with the new device occurred in 4.6%. The mean length of hospital stay for patients with pocket infection was 5.7 days, compared to 38.6 days in systemic infection. One-year mortality was 7.7% and 22.2% in pocket infection and systemic infection, respectively. Patients with Staphylococcus aureus infection had a higher mortality. Conclusions: In this study, the majority of the patients had a pocket CIED infection, with a short hospital stay. Patients with a systemic infection, and S. aureus etiology, had a prolonged hospital stay and a higher mortality.

Patients with infective endocarditis and history of injection drug use in a Swedish referral hospital during 10 years

Background

Patients with injection drug use (IDU) have increased risk of developing infective endocarditis (IE). Previous studies have reported recurrent IE, increased duration of hospital stay, poor adherence and compliance as well as higher mortality and worse outcomes after surgery in the IDU-IE patient group. Further studies are needed to provide a basis for optimized care and prevention of readmissions in this population. This study aims to describe the clinical characteristics and outcomes among patients with IDU-IE.

Methods

Data of adults with IDU-IE and non-IDU-IE, treated between 2008 and 2017 at the Karolinska University Hospital in Stockholm were obtained from the Swedish National Registry of Infective Endocarditis. Clinical characteristics, microbiological results, treatment durations, results from echocardiography and in-hospital mortality were compared between the groups.

Results

Of the total 522 patients, 165 (32%) had IDU-IE. Patients with IDU-IE were younger than the patients with non-IDU-IE (mean age IDU-IE: 41.6 years, SD 11.9 years; non-IDU-IE: 64.3 years, SD 16.4 years; P <  0.01). No difference in distribution of gender was observed, 33% were females in both the IDU-IE and the non-IDU-IE group. History of previous IE (IDU-IE: n = 49, 30%; non-IDU-IE: n = 34, 10%; P <  0.01) and vascular phenomena (IDU-IE: n = 101, 61%; non-IDU-IE: n = 120, 34%; P <  0.01) were more common among patients with IDU-IE while prosthetic heart valves (IDU-IE: n = 12, 7%; non-IDU-IE: n = 83, 23%; P <  0.01) and known valvular disease (IDU-IE: n = 3, 2%; non-IDU-IE: n = 78, 22%; P <  0.01) were more common among patients with non-IDU-IE. Aetiology of Staphylococcus aureus (IDU-IE: n = 123, 75%; non-IDU-IE: n = 118, 33%; P <  0.01) as well as tricuspid (IDU-IE: n = 91, 55%; non-IDU-IE: n = 23, 6%; P <  0.01) or pulmonary valve vegetations (IDU-IE: n = 7, 4%; non-IDU-IE: n = 2, 1%; P <  0.01) were more common in the IDU-IE group. The overall incidence of IDU-IE decreased during the study period, while the incidence of definite IE increased (P <  0.01).

Conclusions

This study presents that patients with IDU-IE were younger, less frequently treated with surgery and had higher prevalence of vascular phenomena and history of previous IE, aspects that are important for improved management of this population.

Screening and treatment of tuberculosis among pregnant women in Stockholm, Sweden, 2016-2017

Swedish National tuberculosis (TB) guidelines recommend screening of active and latent TB (LTBI) among pregnant women (PW) from high-endemic countries or with previous exposure to possibly improve early detection and treatment.We evaluated cascade of care of a newly introduced TB screening programme of pregnant women in Stockholm county in 2016-2017. The algorithm included clinical data and Quantiferon (QFT) at the Maternal Health Care clinics and referral for specialist care upon positive test or TB symptoms.About 29 000 HIV-negative pregnant women were registered yearly, of whom 11% originated from high-endemic countries. In 2016, 72% of these were screened with QFT, of which 22% were QFT positive and 85% were referred for specialist care. In 2017, corresponding figures were 64%, 19% and 96%, respectively. The LTBI treatment rate among all QFT-positive pregnant women increased from 24% to 37% over time. Treatment completion with mainly rifampicin post-partum was 94%. Of the 69 registered HIV-positive pregnant women, 78% originated from high-endemic countries. Of these, 72% where screened with QFT and 15% were positive, but none was treated for LTBI. 9 HIV-negative active pulmonary TB cases were detected (incidence: 215/100 000). None had been screened for TB prior to pregnancy and only one had sought care due to symptoms.Systematic TB screening of pregnant women in Stockholm was feasible with a high yield of unknown LTBI and mostly asymptomatic active TB. Optimised routines improved referrals to specialist care. Treatment completion of LTBI was very high. Our findings justify TB screening of this risk group for early detection and treatment.

Associations between echocardiographic manifestations and bacterial species in patients with infective endocarditis: a cohort study

Background

The diagnosis of infective endocarditis (IE) is based on microbiological analyses and diagnostic imaging of cardiac manifestations. Echocardiography (ECHO) is preferred for visualization of IE-induced cardiac manifestations. We investigated associations between bacterial infections and IE manifestations diagnosed by ECHO.

Methods

In this cohort study, data from patients aged 18 years or above, with definite IE admitted at the Karolinska University Hospital between 2008 and 2017 were obtained from Swedish National Registry of Endocarditis. Bacteria registered as pathogen were primarily selected from positive blood culture and for patients with negative blood culture, bacteria found in culture or PCR from postoperative material was registered as pathogen. Patients with negative results from culture or PCR, and patients who did not undergo ECHO during hospital stay, were excluded. IE manifestations diagnosed by ECHO were obtained from the registry. Chi-squared test and two-sided Fisher’s exact test was used for comparisons between categorical variables, and student’s t test was used for continuous numerical variables. Multivariable analyses were performed using logistic regression. Secular trend analyses were performed using linear regression. Associations and the strength between the variables were estimated using odds ratios (ORs) with 95% confidence intervals (CIs). P < 0.05 was considered significant.

Results

The most common bacteria were Staphylococcus aureus (n = 239, 49%) and viridans group streptococci (n = 102, 21%). The most common manifestations were vegetation in the mitral (n = 195, 40%), aortic (n = 190, 39%), and tricuspid valves (n = 108, 22%). Associations were seen between aortic valve vegetations and Enterococcus faecalis among patients with native aortic valves, between mitral valve vegetations and streptococci of group B or viridans group, between tricuspid valve vegetations and S. aureus among patients with intravenous drug abuse, and between perivalvular abscesses as well as cardiovascular implantable electronic device (CIED)-associated IE and coagulase negative staphylococci (all P < 0.05).

Conclusions

Associations were found between certain bacterial species and specific ECHO manifestations. Our study contributes to a better understanding of IE manifestations and their underlying bacterial etiology, which pathogens can cause severe infections and might require close follow-up and surgical treatment.

P3662Relationships between bacteria and echocardiographic manifestations in infective endocarditis - data from the Swedish endocarditis registry

Introduction

Echocardiography (ECHO) is a method of choice for direct visualization of infective endocarditis (IE) - induced cardiac manifestations.

Purpose

To investigate the correlations between certain bacteria causing the IE and specific IE manifestations diagnosed by ECHO in the population from the Swedish Endocarditis Registry.

Methods

A cohort study based on selected data from the Swedish Endocarditis Registry including patients aged 18 and above, admitted between 2008 and 2017 with positive culture result from blood or surgical material, in total 570 patients (mean age 58±18 years, 33% female, 67% male patients). For numeric variables, Student's t-test was used. Correlations between the variables were estimated using odds ratio (OR) and 95% confidence intervals (CI). P<0.05 was considered significant.

Results

Of 570 patients 165 (29%) had a history of drug abuse; 21 (4%) had a bicuspid aortic valve and 110 (19%) had prosthetic valves. Significant correlations were seen between patients with aortic valve IE and coagulase negative staphylococci (OR 2.88, p=0.01, CI 1.26–6.88) and enterococcus spp (OR 2.31, p<0.01, CI 1.30–4.16), specifically enterococcus faecalis (2.45, p<0.01, CI 1.34–4.54), mitral valve IE and streptococcus spp (OR 1.92, p<0.01, CI 1.31–2.83), specifically group B streptococci (OR 8.16, p<0.01, CI 1.71–77.03), tricuspid valve IE (OR 6.55, p<0.01, CI 3.93–11.23) and pulmonic valve IE (OR 7.53, p=0.03, CI 1.0–335.25), and staphylococcus spp, specifically staphylococcus aureus (tricuspid valve: OR 6.55, p<0.01, CI 3.93–11.23 and pulmonic valve: OR 9.26, p=0.01, CI 1.22–412.22), abscess and coagulase negative staphylococci (OR 4.13, p<0.01, CI 1.13–12.25), pacemaker or ICD-associated IE and HACEK (OR 7.60, p=0.01, CI 1.66–27.06).

Conclusions

Significant correlations were found between certain bacteria and specific IE manifestations detected by ECHO, i.e. on aortic valve, mitral valve, tricuspid valve or pulmonic valve, abscess and pacemaker or ICD-associated IE.

Sustainable treatment systems for removal of pharmaceutical residues and other priority persistent substances

Pharmaceutical residues and other emerging substances commonly summarised as micropollutants pass through wastewater treatment plants (WWTPs) and end up in the receiving waters and sludge. Many studies have investigated the removal efficiency of various techniques but a holistic evaluation of various relevant treatment alternatives regarding both the removal efficiency for various micropollutants, investment and operating costs, environmental impacts and future comprehensiveness is still lacking. This paper provides the results from a large 3-year project about the evaluation of sustainable treatment systems for removal of various micropollutants or disruptive effects at Swedish WWTPs and their environmental, economic and future sustainability. The presented results are based on our own pilot tests and related assessment and modelling efforts and provide a holistic view on advanced treatment of wastewater for removal of micropollutants.

Prophylaxis and treatment of HIV-1 infection in pregnancy - Swedish Recommendations 2017

Prophylaxis and treatment with antiretroviral drugs have resulted in a very low rate of mother-to-child transmission (MTCT) of HIV during recent years. Registration of new antiretroviral drugs, modification of clinical praxis, updated general treatment guidelines and increasing knowledge about MTCT have necessitated regular revisions of the recommendations for 'Prophylaxis and treatment of HIV-1 infection in pregnancy'. The Swedish Reference Group for Antiviral Therapy (RAV) has updated the recommendations from 2013 at an expert meeting 19 September 2017. In the new text, current treatment guidelines for non-pregnant are considered. The most important revisions are that: (1) Caesarean section and infant prophylaxis with three drugs are recommended when maternal HIV RNA >150 copies/mL (previously >50 copies/mL). The treatment target of undetectable HIV RNA remains unchanged <50 copies/mL; (2) Obstetric management and mode of delivery at premature rupture of the membranes and rupture of the membranes at full term follow the same procedures as in HIV negative women; (3) Vaginal delivery is recommended to a well-treated woman with HIV RNA <150 copies/mL regardless of gestational age, if no obstetric contraindications are present; (4) Treatment during pregnancy should begin as soon as possible and should continue after delivery; (5) Ongoing well-functioning HIV treatment at pregnancy start should usually be retained; (6) Recommended drugs and drug combinations have been updated.

Boosting Quality Registries with Clinical Decision Support Functionality*. User Acceptance of a Prototype Applied to HIV/TB Drug Therapy

BACKGROUND

The care of HIV-related tuberculosis (HIV/TB) is complex and challenging. Clinical decision support (CDS) systems can contribute to improve quality of care, but more knowledge is needed on factors determining user acceptance of CDS.

OBJECTIVES

To analyze physicians' and nurses' acceptance of a CDS prototype for evidence-based drug therapy recommendations for HIV/TB treatment.

METHODS

Physicians and nurses were involved in designing a CDS prototype intended for future integration with the Swedish national HIV quality registry. Focus group evaluation was performed with ten nurses and four physicians, respectively. The Unified Theory of Acceptance and Use of Technology (UTAUT) was used to analyze acceptance.

RESULTS

We identified several potential benefits with the CDS prototype as well as some concerns that could be addressed by redesign. There was also concern about dependence on physician attitudes, as well as technical, organizational, and legal issues.

CONCLUSIONS

Acceptance evaluation at a prototype stage provided rich data to improve the future design of a CDS prototype. Apart from design and development efforts, substantial organizational efforts are needed to enable the implementation and maintenance of a future CDS system.

Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy

IMPORTANCE

A key factor in assessing the effectiveness and cost-effectiveness of antiretroviral therapy (ART) as a prevention strategy is the absolute risk of HIV transmission through condomless sex with suppressed HIV-1 RNA viral load for both anal and vaginal sex.

OBJECTIVE

To evaluate the rate of within-couple HIV transmission (heterosexual and men who have sex with men [MSM]) during periods of sex without condoms and when the HIV-positive partner had HIV-1 RNA load less than 200 copies/mL.

DESIGN, SETTING, AND PARTICIPANTS

The prospective, observational PARTNER (Partners of People on ART-A New Evaluation of the Risks) study was conducted at 75 clinical sites in 14 European countries and enrolled 1166 HIV serodifferent couples (HIV-positive partner taking suppressive ART) who reported condomless sex (September 2010 to May 2014). Eligibility criteria for inclusion of couple-years of follow-up were condomless sex and HIV-1 RNA load less than 200 copies/mL. Anonymized phylogenetic analysis compared couples' HIV-1 polymerase and envelope sequences if an HIV-negative partner became infected to determine phylogenetically linked transmissions.

EXPOSURES

Condomless sexual activity with an HIV-positive partner taking virally suppressive ART.

MAIN OUTCOMES AND MEASURES

Risk of within-couple HIV transmission to the HIV-negative partner.

RESULTS

Among 1166 enrolled couples, 888 (mean age, 42 years [IQR, 35-48]; 548 heterosexual [61.7%] and 340 MSM [38.3%]) provided 1238 eligible couple-years of follow-up (median follow-up, 1.3 years [IQR, 0.8-2.0]). At baseline, couples reported condomless sex for a median of 2 years (IQR, 0.5-6.3). Condomless sex with other partners was reported by 108 HIV-negative MSM (33%) and 21 heterosexuals (4%). During follow-up, couples reported condomless sex a median of 37 times per year (IQR, 15-71), with MSM couples reporting approximately 22,000 condomless sex acts and heterosexuals approximately 36,000. Although 11 HIV-negative partners became HIV-positive (10 MSM; 1 heterosexual; 8 reported condomless sex with other partners), no phylogenetically linked transmissions occurred over eligible couple-years of follow-up, giving a rate of within-couple HIV transmission of zero, with an upper 95% confidence limit of 0.30/100 couple-years of follow-up. The upper 95% confidence limit for condomless anal sex was 0.71 per 100 couple-years of follow-up.

CONCLUSIONS AND RELEVANCE

Among serodifferent heterosexual and MSM couples in which the HIV-positive partner was using suppressive ART and who reported condomless sex, during median follow-up of 1.3 years per couple, there were no documented cases of within-couple HIV transmission (upper 95% confidence limit, 0.30/100 couple-years of follow-up). Additional longer-term follow-up is necessary to provide more precise estimates of risk.

Impact of immunosuppression and region of birth on risk of cervical intraepithelial neoplasia among migrants living with HIV in Sweden

Little is known about the incidence and risk of cervical intraepithelial neoplasia (CIN) grade 3, adenocarcinoma in situ and invasive cervical cancer (CIN3+) among migrants living with HIV in a European setting. We assessed the cumulative incidence (CuI) and hazard ratio (HR) of CIN2+ and CIN3+ in a cohort of women living with HIV (WLWH) (n = 893) identified from the Swedish national HIV register and HIV-negative women (n = 205,842) identified from the Swedish Population Register, matched on region of birth and age. Data was collected between 1993 and 2011 by linking our cohort with the Swedish National Cervical Screening Registry, collecting all cytological and histological results since 1993. The CuI of CIN3+ was 13.1% [95% confidence interval (CI) 8.9-17.2] for WLWH and 2.1% (95% CI 2.0-2.2) for HIV-negative after 18 years of follow-up. WLWH had more than eight times higher, age and region of birth matched, risk of CIN3+ than HIV-negative (HR 8.8: 95% CI 6.9-11.3). WLWH born in the East region, dominated by Thai women, had a two times higher risk of CIN3+ compared with WLWH born in Sweden (HR 2.47: 95% CI 1.2-5.0), which remained after adjusting for immunosuppression. Our results showed a substantially increased risk of CIN3+ among WLWH, which differed depending on birth region. Early HIV diagnosis and attendance to cervical cancer screening, with focus on migrants, is of crucial importance to minimize the incidence of cervical intraepithelial neoplasia.

Transition of HIV-infected youths from paediatric to adult care, a Swedish single-centre experience

BACKGROUND

Transition of HIV-infected adolescents from paediatric care to adult care is vulnerable and entails a risk of treatment failure. Therefore, a Transitional Outpatient Clinic for HIV-infected adolescents and young adults was started in 2008. The aims were to describe the transition process and treatment results in a Swedish cohort of adolescents with HIV.

MATERIALS AND METHODS

A cross-sectional study of the adolescent and young adults with HIV at the clinic was performed in October 2013 and a 2-year follow-up at the end of 2015.

RESULTS

The 34 patients in care in October 2013 were a median of 19 years, 50% were female. Thirty-one out of 34 (91%) were perinatally infected. In 2013, 88% were on antiretroviral treatment (ART), for a median duration of 9 years, 74% were on a protease inhibitor-based regimen. Twenty-nine patients were followed-up at the end of 2015. Twenty-three were transferred to the Infectious Disease Clinic and the median age for transition was 19 years. At the end of 2015, 90% were treated with ART and 61% had an integrase inhibitor-based treatment. Of those treated with ART for more than 6 months, 90% (2013) and 96% (2015) had a viral load < 50 HIV RNA copies/mL, despite resistance problems and complicating social factors. These figures were higher than reported in other studies and similar to the treatment results in the adult HIV population in Sweden.

CONCLUSIONS

The present study showed that it is possible to achieve good treatment results in adolescents with HIV.

Tuberculosis among HIV-infected patients in Stockholm, Sweden, 1987-2010: treatment outcomes and adverse reactions

BACKGROUND

The treatment of patients co-infected with human immunodeficiency virus (HIV) and tuberculosis (TB) is challenging. The aim of this study was to compare socio-demographic and clinical characteristics among HIV-infected patients before and after the introduction of combined antiretroviral therapy (cART) in a Swedish cohort, and to identify factors associated with anti-TB treatment success as well as adverse reactions.

METHODS

This was a retrospective observational study of HIV/TB co-infected patients in Stockholm County from 1987 to 2010. The study population was stratified into an early and a late cohort (before and after the introduction of cART in 1996). Data were analyzed using descriptive statistics and multiple logistic regression analysis.

RESULTS

The study population comprised 127 patients; the majority were foreign-born (87%). The proportion of female patients more than doubled from the early to the late cohort, and anti-TB treatment success increased from 65% to 91%. The median duration of successful treatment was 8 months in both cohorts. Predictors of treatment success in the late cohort were cART (odds ratio (OR) 13.3, 95% confidence interval (CI) 1.5-114.8) and a CD4 cell count at TB diagnosis > 200 cells/μl (OR 17.2, 95% CI 1.2-236.6). Severe adverse reactions in the late cohort occurred in 23% and were associated with the initiation of cART after TB diagnosis (OR 13.3, 95% CI 1.6-112.4).

CONCLUSION

The introduction of cART was favourable for the treatment outcome of HIV-infected patients with concomitant TB. However, adverse reactions increased in patients who initiated cART during anti-TB treatment and these patients require careful attention.

HIV and tuberculosis coinfection: a qualitative study of treatment challenges faced by care providers

SETTING

Infectious Diseases Department, Karolinska University Hospital, Stockholm, Sweden.

OBJECTIVE

To understand the challenges faced by nurses and physicians in the treatment of patients co-infected with the human immunodeficiency virus (HIV) and tuberculosis (TB), with special focus on opportunities for information and communication technology.

DESIGN

Using a qualitative study design, on-site observations and informal discussions were carried out to become acquainted with the clinical context. Seven nurses and six physicians were purposefully selected to participate in one-to-one in-depth interviews inspired by cognitive task analysis. Interviews were audio recorded and transcribed verbatim, and analysed using inductive thematic analysis.

RESULTS

Care providers faced challenges related to 1) the complexities inherent to TB-HIV co-treatment, 2) clinical knowledge and task standardisation, 3) care coordination and collaboration, 4) information management, and 5) engaging patients in their treatment.

CONCLUSION

Support is needed on several levels to address the emerging burden of TB-HIV coinfection in Sweden. Educational material and tools need to be further developed to support care providers in making decisions about adequate care, and to support collaborative activities and communication among patients and care providers. Information and communication technology based solutions may provide an opportunity to address some of these challenges.

A nationwide cohort study of mortality risk and long-term prognosis in infective endocarditis in Sweden

OBJECTIVES

Infective endocarditis (IE) remains a serious disease with substantial mortality. In this study we investigated the incidence of IE, as well as its associated short and long term mortality rates.

METHODS

The IE cases were identified in the Swedish national inpatient register using ICD-10 codes, and then linked to the population register in order to identify deaths in the cohort. Crude mortality rates among IE patients were obtained for different time intervals. These rates were directly standardized using sex- and age-matched mortality in the general population.

RESULTS

The cohort consisted of 7603 individuals and 7817 episodes of IE during 1997-2007. The 30 days all-cause crude mortality rate was 10.4% and the standardized mortality ratio (SMR) was 33.7 (95% confidence interval [CI]: 31.0-36.6). Excluding the first year of follow-up, the long term mortality (1-5 years) showed an increased SMR of 2.2 (95% CI: 2.0-2.3) compared to the general population. Significantly higher SMR was found for cases of IE younger than 65 years of age with a 1-5 year SMR of 6.3, and intravenous drug-users with a SMR of 19.1. Native valve IE cases, in which surgery was performed had lower crude mortality rates and Mantel-Haenzel odds ratios of less than one compared to those with medical therapy alone during 30-day and 5-years follow-up.

CONCLUSIONS

The 30-days crude mortality rate for IE was 10.4% and long-term relative mortality risk remains increased even up to 5 years of follow-up, therefore a close monitoring of these patients would be of value.

Long-term survival after operations for native and prosthetic valve endocarditis

BACKGROUND

The objective was to compare long-term survival after operations for active infective endocarditis (IE) in native or prosthetic valves. We also investigated differences in early death and postoperative complications.

METHODS

We conducted a population-based cohort study including all patients who underwent operations for IE between January 2002 and July 2012. The SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry and patients records were used to acquire information about patient characteristics, preoperative comorbidities, and postoperative complications. Date of death was ascertained by using the Swedish personal identity number and the Total Population Register at Statistics Sweden. We used multivariable Cox regression to analyze the association between prosthetic valve IE and survival.

RESULTS

Of the 252 included patients, 22% underwent operations for prosthetic valve IE. There was no significant difference in unadjusted 5-year survival between patients who underwent operations for prosthetic valve IE compared with native valve IE (75% vs 65%; p = 0.34). We found no significant association between operations for prosthetic valve IE and death (multivariable adjusted hazard ratio, 0.83; 95% confidence interval, 0.46 to 1.49) compared with native valve IE. There was no significant difference in 30-day mortality between prosthetic and native valve IE (14% vs 12%; p = 0.61), with a multivariable adjusted odds ratio of 0.62 (95% confidence interval, 0.24 to 1.64).

CONCLUSIONS

We found no significant difference in long-term survival between patients who underwent operations for prosthetic valve IE compared with native valve IE. Early death and morbidity were also similar between the groups. These results are promising because an increasing amount of patients with IE have prosthetic valve infections.

Rapid decline in HIV viral load when introducing raltegravir-containing antiretroviral treatment late in pregnancy

Antenatal screening program for HIV has been in use in Sweden since 1987 with a 95-98% acceptance rate. Screening is performed during gestational week 10-12 and antiretroviral treatment (ART) to prevent mother-to-child transmission (MTCT) is initiated at gestational week 14-18. However, some women present with HIV in late pregnancy and additional treatment are wanted to achieve viral suppression before delivery. The integrase inhibitor raltegravir has a favorable pharmacokinetic profile and a capacity to rapidly decrease the viral load (VL). We describe four women presenting as HIV positive late in pregnancy, their ART, and outcome for the mother and child. Four women were discovered as HIV positive late in pregnancy, of 7 discovered in the antenatal screening programme in Stockholm County Council during 2011. Raltegravir was added to standard ART. The mean VL at presentation was 217,000 copies per milliliter (range, 65,000-637,000). A rapid decline of HIV RNA was observed in all cases, one woman treated with ART for only 8 days prior to delivery. The mean VL decline per week was 1.12 log (range, 0.94-1.22), which is estimated to occur (based on literature) after 1-2 months with standard ART. No side effects due to raltegravir were observed in mothers or infants. Caesarean section was performed in all cases, and the women did not breastfeed. No infant was infected. This report suggests that raltegravir added to standard antiretroviral treatment would be an option for women presenting with HIV in late pregnancy.

Toxoplasmosis not transmitted by cat bite, but high prevalence of antibodies to Toxoplasma gondii in patients bitten by their own cat

The aims of the study were to investigate the prevalence of antibodies to Toxoplasma gondii in a group of patients bitten by cats, and also to determine if toxoplasmosis can be transferred by cat bite. Seventy-two patients who attended the emergency wards at 3 hospitals in Stockholm, Sweden, due to infection by cat bite, were investigated for specific IgM and IgG antibodies to T. gondii in the acute phase, as well as in the convalescent phase about 2 weeks later. Specific IgG antibodies to T. gondii (> or =8 IU/ml) were found in 17/72 patients (24%) in the acute phase. No case of seroconversion occurred. Patients who were bitten by their own cat had positive antibody titres to T. gondii significantly more often than those bitten by a foreign cat; 30% and 5%, respectively (p = 0.02). This suggests that regular contact with cats may contribute to the transmission of the parasite.

Prophylaxis and treatment of HIV-1 infection in pregnancy: Swedish Recommendations 2007

Prophylaxis and treatment with antiretroviral drugs, a consequent low viral load, and the use of elective Caesarean section, are factors that radically decrease the risk of HIV transmission from mother to child during pregnancy and delivery. The availability of new antiretroviral drugs, updated general treatment guidelines and increasing knowledge of the importance of drug resistance, have necessitated recurrent revisions of the recommendations for 'Prophylaxis and treatment of HIV-1 infection in pregnancy'. For these reasons, The Swedish Reference Group for Antiviral Therapy (RAV) has, at an expert meeting on May 4, 2007, once more updated the treatment recommendations of 1999, 2002 and 2005, which were defined in cooperation with the Swedish Medical Products Agency (Läkemedelsverket). This new text takes the recently updated general HIV treatment recommendations into account. Furthermore, the very low risk of HIV transmission when the mother is treated with combination antiretroviral therapy, has undetectable levels of viraemia and no obstetric risk factors, has been considered in the recommendations concerning the mode of delivery. Finally, the recommendations for monitoring of infants born to HIV-infected mothers have been modified. The recommendations are evidence graded in accordance with the Oxford Centre for Evidence Based Medicine, 2001 (see http://www.cebm.net/levels_of_evidence.asp#levels).

Swedish guidelines for diagnosis and treatment of infective endocarditis

Swedish guidelines for diagnosis and treatment of infective endocarditis (IE) by consensus of experts are based on clinical experience and reports from the literature. Recommendations are evidence based. For diagnosis 3 blood cultures should be drawn; chest X-ray, electrocardiogram, and echocardiography preferably transoesophageal should be carried out. Blood cultures should be kept for 5 d and precede intravenous antibiotic therapy. In patients with native valves and suspicion of staphylococcal aetiology, cloxacillin and gentamicin should be given as empirical treatment. If non-staphylococcal etiology is most probable, penicillin G and gentamicin treatment should be started. In patients with prosthetic valves treatment with vancomycin, gentamicin and rifampicin is recommended. Patients with blood culture negative IE are recommended penicillin G (changed to cefuroxime in treatment failure) and gentamicin for native valve IE and vancomycin, gentamicin and rifampicin for prosthetic valve IE, respectively. Isolates of viridans group streptococci and enterococci should be subtyped and MIC should be determined for penicillin G and aminoglycosides. Antibiotic treatment should be chosen according to sensitivity pattern given 2-6 weeks intravenously. Cardiac valve surgery should be considered early, especially in patients with left-sided IE and/or prosthetic heart valves. Absolute indications for surgery are severe heart failure, paravalvular abscess, lack of response to antibiotic therapy, unstable prosthesis and multiple embolies. Follow-up echocardiography should be performed on clinical indications.

Identification of species of viridans group streptococci in clinical blood culture isolates by sequence analysis of the RNase P RNA gene, rnpB

OBJECTIVES

Viridans group streptococci (VGS) cause severe diseases such as infective endocarditis and septicaemia. Genetically, VGS species are very close to each other and it is difficult to identify them to species level with conventional methods. The aims of the present study were to use sequence analysis of the RNase P RNA gene (rnpB) to identify VGS species in clinical blood culture isolates, and to compare the results with the API 20 Strep system that is based on phenotypical characteristics.

METHODS

Strains from patients with septicaemia or endocarditis were analysed with PCR amplification and sequence analysis of the rnpB gene. Clinical data were registered as well.

RESULTS

One hundred and thirty two VGS clinical blood culture isolates from patients with septicaemia (n=95) or infective endocarditis (n=36) were analysed; all but one were identified by rnpB. Streptococcus oralis, Streptococcus sanguinis and Streptococcus gordonii strains were most common in the patients with infective endocarditis. In the isolates from patients with haematological diseases, Streptococcus mitis and S. oralis dominated. In addition in 76 of the isolates it was possible to compare the results from rnpB analysis and the API 20 Strep system. In 39/76 (51%) of the isolates the results were concordant to species level; in 55 isolates there were no results from API 20 Strep.

CONCLUSION

Sequence analysis of the RNase P RNA gene (rnpB) showed that almost all isolates could be identified. This could be of importance for evaluation of the portal of entry in patients with septicaemia or infective endocarditis.

In-hospital and long-term mortality in infective endocarditis in injecting drug users compared to non-drug users: a retrospective study of 192 episodes

In a retrospective study, in-hospital and long-term mortality for patients with infective endocarditis (IE) was analysed. The study was conducted at a department of infectious diseases in Stockholm, Sweden. Mortality was compared between injecting drug users (IDUs) and patients without drug abuse (non-IDUs). 192 episodes of IE from 1995 to 2000 were analysed, 60 in IDUs and 135 in non-IDUs, median follow-up 4.4 y. Episodes were classified using the Duke criteria: 145 definite and 47 possible. Of 53 definite episodes in IDUs, 55% were right-sided IE and 43% left-sided IE (including combined left- and right-sided). Surgical treatment was used in 34/145 definite episodes, all being left-sided IE. The in-hospital mortality was 14/145 (9.6%). There was no difference in in-hospital mortality between patient groups with left-sided IE. The IDU patients with left-sided IE had a higher long-term mortality with the increased mortality rate explained by late deaths in the surgically treated IDUs. Treatment results for IDUs with right-sided IE were good with no in-hospital mortality, no relapses and no increase in long-term mortality. This difference in prognosis between left-sided and right-sided IE in IDUs makes high quality echocardiography important to identify patients with left-sided IE and worse prognosis.

Viridans group streptococci in blood culture isolates in a Swedish university hospital: antibiotic susceptibility and identification of erythromycin resistance genes

One hundred and twenty-nine isolates of viridans group streptococci in blood cultures from patients with septicaemia or endocarditis isolated between 1998 and 2003 were tested for antibiotic susceptibility to penicillin, ciprofloxacin, clindamycin, dalbavancin, daptomycin, erythromycin, linezolid, tigecycline, trimethoprim/sulphamethoxazole and vancomycin. Reduced susceptibility to penicillin (minimum inhibitory concentration (MIC) > or =0.25 microg/mL) was found in 18% of the isolates, and 4% of the strains were resistant to penicillin (MIC> or =4.0 microg/mL). Nineteen percent of the isolates had reduced susceptibility to erythromycin (MIC> or =0.5 microg/mL), among which ermB and mefA were found in 40% and 80%, respectively. Strains sequenced as Streptococcus mitis by rnpB had a high degree of non-susceptibility to erythromycin (32%) and penicillin (21%). The level of penicillin resistance in this Swedish study was lower compared with studies from other countries where the antibiotic pressure might be higher than in Sweden. Susceptibility to newer antibiotics was high; all strains were susceptible to dalbavancin, daptomycin, linezolid and vancomycin.

Candida albicans tricuspid valve endocarditis in an intravenous drug addict: successful treatment with fluconazole

An addicted, intravenous drug user was treated for Candida albicans tricuspid valve endocarditis with high dose fluconazole for 8 months, without relapse after 30 months.

Reduced susceptibility to penicillin of viridans group streptococci in the oral cavity of patients with haematological disease

The occurrence of oral penicillin-resistant viridans group streptococci (VGS) was studied in 50 patients with either newly diagnosed acute leukaemia or autologous peripheral stem cell transplants. One patient was excluded because of Staphylococcus aureus growth in the stem cell harvest. VGS were isolated from the oral cavity of 48 of the remaining 49 patients. Of these 48 patients, 12 (25%) yielded VGS resistant (MIC > 2 mg/L) to penicillin. These 12 patients had a higher frequency of septicaemia (p 0.04) and more days of treatment with trimethoprim-sulphamethoxazole (p 0.04) than patients who harboured susceptible or intermediately resistant VGS (MIC 2 mg/L). There were no other statistically significant differences between the two groups. It is important to be aware of the high level of penicillin resistance in oral VGS in patients with haematological disease, and this parameter should be considered when selecting antibiotic therapy for cases of septicaemia caused by VGS in immunocompromised patients.

Tricuspid valve endocarditis caused by a new species of actinomyces: Actinomyces funkei

We present a case of tricuspid valve endocarditis in a 40-y-old woman with a history of heroin abuse. Blood cultures yielded a Gram-positive rod, preliminarily identified as "Actinomyces turicensis-like", but subsequently formally described as Actinomyces funkei sp. nov. The patient was cured by prolonged treatment with 10 weeks of i.v. antibiotics followed by oral antibiotic treatment for 12 weeks.

Streptococcus viridans septicaemia: a comparison study in patients admitted to the departments of infectious diseases and haematology in a university hospital

Infective endocarditis caused by viridans streptococci is a well-described disease. Streptococcus viridans is also an important etiologic agent causing septicaemia in neutropenic patients with haematological diseases. In this study we retrospectively reviewed charts from 111 patients with 121 episodes of viridans streptococci septicaemia during the period 1992-97 for clinical data, presence of endocarditis, subtype and outcome. Forty-seven episodes of S. viridans septicaemia were documented in 45 non-neutropenic patients treated at the Department of Infectious Diseases (Group A). Thirty of these episodes were defined as definite and 9 as possible infective endocarditis, using Duke's critera. Seventy-four episodes of S. viridans septicaemia were identified in 66 patients treated at the Department of Haematology (Group B), only 1 of which fulfilled the criteria for possible infective endocarditis. S. sanguis was the most common subtype (18/47; 38%) in Group A and S. mitis was the major subtype (51/74; 69%) in Group B.

Myocarditis associated with Campylobacter infection

We describe the case of a young man with fever, chest pain and enteric symptoms. He developed myocarditis and Campylobacter was isolated in faeces.

Actinomyces funkei sp. nov., isolated from human clinical specimens

Three strains of a previously undescribed Actinomyces-like bacterium were isolated from human clinical specimens. Phenotypic studies indicated that the strains were members of the genus Actinomyces and were presumptively identified as Actinomyces turicensis. Comparative 16S rRNA gene sequencing studies showed that although the bacterium is phylogenetically closely related to Actinomyces turicensis, it nevertheless constitutes a new sub-line within the genus Actinomyces. Based on phenotypic and molecular chemical and molecular genetic evidence, it is proposed that the unknown Actinomyces-like bacterium from human clinical specimens be classified as Actinomyces funkei sp. nov. The type strain of Actinomyces funkei is CCUG 42773T (= CIP 106713T).