Management Of Opportunistic Infections Research Articles

Solid Organ Transplants in HIV-Infected Patients

There is a growing need for kidney and liver transplants in persons living with HIV. Fortunately, with the significant advances in antiretroviral therapy and management of opportunistic infections, HIV infection is no longer an absolute contraindication for solid organ transplantation. Data from several large prospective multi-center cohort studies have shown that solid organ transplantation in carefully selected HIV-infected individuals is safe. However, significant challenges have been identified including prevention of acute rejection, management of drug-drug interactions and treatment of recurrent viral hepatitis. This article reviews the selection criteria, outcomes, and special management considerations for HIV-infected patients undergoing liver or kidney transplantation.

P6.029 Antiretroviral Therapy (ART) Programme in Bangladesh: Increasing National Ownership

BackgroundThe first HIV positive case was detected back in 1989. From then 2,871 cases have been reported till December 2012. However, the estimated number of PLHIV in Bangladesh is 7,500....

PWE-165 Cervical Neoplasia in Low Risk Women with Inflammatory Bowel Disease on Combination of Infliximab and Thiopurines

IntroductionWomen with inflammatory bowel diseases (IBD) may have increased rates of pre-malignant lesions in the uterine cervix compared to age and sex matched controls (1.2). European guidelines recommend regular gynaecological...

Letter: mucosal PCR for cytomegalovirus in refractory ulcerative colitis – authors' reply

1. Chaparro M, Burgueno P, Iglesias E, et al. Infliximab salvage therapy after failure of ciclosporin in corticosteroid-refractory ulcerative colitis: a multicentre study. Aliment Pharmacol Ther 2012; 35: 275–83. 2. Yoshino T, Nakase H, Ueno S, et al. Usefulness of quantitative real-time PCR assay forearly detection of cytomegalovirus infection in patients with ulcerative colitis refractory to immunosuppressive therapies. Inflamm Bowel Dis 2007; 13: 1516–21. 3. Rahier JF, Ben-Horin S, Chowers Y, et al. European evidencebased Consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohns Colitis 2009; 3: 47–91. 4. Roblin X, Pillet S, Oussalah A, et al. Cytomegalovirus load in inflamed intestinal tissue is predictive of resistance to immunosuppressive therapy in ulcerative colitis. Am J Gastroenterol 2011; 106: 2001–8.

Risk of Infection and Prevention in Pediatric Patients With IBD

Combined immunosuppression by immunomodulators and biological therapy has become standard in the medical management of moderate-to-severe inflammatory bowel disease (IBD) because of clearly demonstrated efficacy. Clinical studies, registries, and case reports warn of the increased risk of infections, particularly opportunistic infections; however, already in the steroid monotherapy era, patients are at risk because it is accepted that a patient should be considered immunosuppressed when receiving a daily dose of 20 mg of prednisone for 2 weeks. Prescriptions increasingly involve azathioprine, methotrexate, and various biological agents. The TREAT registry evaluated safety in >6000 adult patients, half of them treated with infliximab (IFX) for about 1.9 years. IFX-treated patients had an increased risk of infections and this was associated with disease severity and concomitant prednisone use. The REACH study, evaluating the efficacy of IFX in children with moderate-to-severe Crohn disease, refractory to immunomodulatory treatment, reports serious infections as the major adverse events and their frequency is higher with shorter treatment intervals. The combination of immunosuppressive medications is a risk factor for opportunistic infections. Exhaustive guidelines on prophylaxis, diagnosis, and management of opportunistic infections in adult patients with IBD have been published by a European Crohn's and Colitis Organization working group, including clear evidence-based statements. We have reviewed the literature on infections in pediatric IBD as well as the European Crohn's and Colitis Organization guidelines to present a commentary on infection prophylaxis for the pediatric age group.

Causes of death in vertically infected paediatric HIV-seropositives- Karnataka experience

Results Ninety-seven deaths occurred between January-September 2011. 55% of the deceased were males. The mean duration of survival on antiretroviral therapy was 36 weeks. Median age at time of death was 10 years (range 1-19) median CD4 count was 210 cells/μl (7-2500); 57% had CD4 cell count <250 cells/μl. In all, 64 causes of death were reported. In 44% (28/64), the causes were WHO clinical stage IV AIDS-defining illness, 36% (23/ 64) and 2% (1/64) were stage III and stage II conditions, respectively. Adverse effects to anti retrovirals were noted in 6% (4/64) of patients. Multiple causes were also reported in 6% (4/64). Other immediate causes of death were cardio respiratory arrest (2), suicide (1) and intra-cerebral haemorrhage (1). Infections were noted in 22% (14/64) patients. 43% (23/64) patients had tuberculosis at the time of death. Patients dying from AIDSrelated events were more often men (17 out of 31). Conclusion Although antiretroviral therapy has substantially and dramatically decreased AIDS-related opportunistic infections (OIs) and deaths, prevention and management of OIs remain critical components of care for HIV-infected children.

Mobile Phone Communication and Health System Strengthening

I-TECH India established a warmline pilot in the year 2008 to provide mobile-based technical support on clinical management to doctors caring for HIV patients in antiretroviral therapy (ART) centers. Warmline was piloted from May to August 2008. Standardized call records were analyzed. Statistical analyses were performed using SPSS. The service was used by 38 doctors. The study demonstrated the frequency of calls and the nature of questions raised by them. Of the calls, 139 were new calls (90.3%) and 15 were follow-up calls. The average number of calls per day was 2.6 (SD 1.6). Of the total number, 81% of the calls were from high-volume centers. Most of the calls were related to ARV toxicities, ART initiation, and the management of opportunistic infections (OI). The South Indian warmline pilot demonstrated a potential model of ongoing technical assistance to ART doctors in times of need. AIDS-control organizations may consider expanding this model of expert distance-mentoring clinical support as a resource in India and other countries.

Introduction and evaluation of a ‘pre-ART care’ service in Swaziland: an operational research study

ObjectiveTo implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.DesignOperational research.SettingDistrict hospital in Southern Africa.Participants1171 patients with a previous diagnosis of HIV. A...

1 Introduction

1 Introduction

"I didn't know that ..." patient perceptions of print information, education, and communication related to HIV/AIDS treatment.

Improving health literacy is a necessary intervention for people with chronic health conditions to ensure adherence with long or life therapies and increase participation in self-care. While adherence is a multifactorial process, increasing health literacy among HIV-infected patients at all stages of living with HIV has been shown to improve treatment outcomes. In the era of rapid scale up of HIV care and treatment, little has been done to evaluate the utility of information, education, and communication (IEC) materials for increasing patient health literacy and how patients perceive such materials. Four patient-oriented print IEC brochures in Kiswahili were designed to be read at the clinic waiting areas and also carried home by patients to supplement the knowledge received from routine counselling during clinic visits. Brochures detail antiretroviral therapy and address common myths, side effects, types and management of opportunistic infections, and prevention of mother to child transmission of HIV. We conducted focus group discussions with HIV-infected patients to explore patient perceptions of IEC materials in the urban congested HIV care setting of Dar es Salaam, Tanzania. Groups of participants were recruited from eight public PEPFAR-supported HIV care and treatment centres in the city (N = 50). In this paper we present the results of those focus group discussions and introduce the print IEC materials as a pilot intervention in a Kiswahili-speaking setting where a need for additional health literacy exists. Further evaluation of these materials will follow as the data becomes available.

Lessons from animal studies for the treatment of invasive human infections due to uncommon fungi

Clinical experience in the management of opportunistic infections, especially those caused by less common fungi, is, due to their rarity, very scarce; therefore, the most effective treatments remain unknown. The ever-increasing numbers of fungal infections due to opportunistic fungi have repeatedly proven the limitations of the antifungal armamentarium. Moreover, some of these fungi, such as Fusarium spp. or Scedosporium spp., are innately resistant to almost all the available antifungal drugs, which makes the development of new and effective therapies a high priority. Since it is difficult to conduct randomized clinical trials in these uncommon mycoses, the use of animal models is a good alternative for evaluating new therapies. This is an extensive review of the numerous studies that have used animal models for this purpose against a significant number of less common fungi. A table describing the different studies performed on the efficacy of the different drugs tested is included for each fungal species. In addition, there is a summary table showing the conclusions that can be derived from the analysis of the studies and listing the drugs that showed the best results. Considering the wide variability in the response to the antifungals that the different strains of a given species can show, the table highlights the drugs that showed positive results using at least two parameters for evaluating efficacy against at least two different strains without showing any negative results. These data can be very useful for guiding the treatment of rare infections when there is very little experience or when controversial results exist, or when treatment fails.

Combined liver–kidney transplantation in patients infected with human immunodeficiency virus

Although human immunodeficiency virus (HIV) infection has been a major global health problem for almost 3 decades, with the introduction of highly active antiretroviral therapy in 1996 and effective prophylaxis and management of opportunistic infections, mortality from acquired immunodeficiency syndrome has decreased markedly. In developed countries, this condition is now being treated as a chronic condition. As a result, rates of morbidity and mortality from other medical conditions leading to end-stage liver, kidney, and heart disease are steadily increasing in individuals with HIV. Because the definitive treatment for end-stage organ failure is transplantation, the demand for it has increased among HIV-infected patients. For these reasons, many transplant centers have eliminated HIV infection as a contraindication to transplantation, as a result of better patient management and demand.

Predictors of adherence to antiretroviral therapy among people living with HIV/AIDS in resource-limited setting of southwest ethiopia

BackgroundGood adherence to antiretroviral therapy is necessary to achieve the best virological response, lower the risk that drug resistance will develop, and reduce morbidity and mortality. Little is known about the rate and predictors of adherence in Ethiopia. Therefore this study determines the magnitude and predictors of adherence to antiretroviral therapy among people living with HIV/AIDS in Southwest Ethiopia.MethodsA cross sectional study was carried out from January 1, 2009 to March 3, 2009 among 319 adult PLWHA (≥ 18 years) attending ART clinic at Jimma university Specialized Hospital (JUSH). Multiple Logistic regression models were constructed with adherence and independent variables to identify the predictors.ResultsAbout 303(95%) of the study subjects were adherent based on self report of missed doses (dose adherence) in a one-week recall before the actual interview. The rate of self reported adherence in the study based on the combined indicator of the dose, time and food adherence measurement was 72.4%. Patients who got family support were 2 times [2.12(1.25-3.59)] more likely to adhere than those who didn't get family support as an independent predictor of overall adherence (dose, time and food). The reasons given for missing drugs were 9(27.3%) running out of medication/drug, 7(21.2%) being away from home and 7(21.2%) being busy with other things.ConclusionThe adherence rate found in this study is similar to other resource limited setting and higher than the developed country. This study highlights emphasis should be given for income generating activities and social supports that helps to remember the patients for medication taking and management of opportunistic infections during the course of treatment.

Structural characterization of a novel xylolipid biosurfactant from Lactococcus lactis and analysis of antibacterial activity against multi-drug resistant pathogens

Control of emerging multi-drug resistant bacteria is one of the major prerequisite in the management of opportunistic infections. Current research is focused towards the identification of effective control agents from biological origin without any alarming side effects. Lactococcus lactis, probiotic organisms was isolated and purified biosurfactant from the bacteria exhibited surface active and emulsification activities comparable to the standard biosurfactant producing bacteria Bacillus licheniformis MTCC 429. Co-culturing of the isolate with the standard organism increased the biosurfactant production and surfactant activity. Biosurfactant from the L. lactis was characterized as glycolipids which consist of Methyl-2-O-methyl-beta-d-xylopyranoside with octadecanoic acid with a cumulative molecular weight of approximately 476g/mol by GC-MS and NMR studies. Purified biosurfactants showed broad range of antibacterial activity and are safe to administrate orally and dermally. So it could be used as a therapeutic agent in pharmaceutical or as a preservative in food industries.

Risk Factor Analyses for Immune Reconstitution Inflammatory Syndrome in a Randomized Study of Early vs. Deferred ART during an Opportunistic Infection

BackgroundImmune reconstitution inflammatory syndrome (IRIS) is reported widely in patients initiating antiretroviral therapy (ART). However, few studies are prospective, and no study has evaluated the impact of the timing of ART when allocated randomly during an acute opportunistic infection (OI).Methodology/Principal FindingsA5164 randomized 282 subjects with AIDS-related OIs (tuberculosis excluded), to early or deferred ART. IRIS was identified prospectively using pre-defined criteria. We evaluated associations between IRIS and baseline variables in subjects with follow-up on ART using Wilcoxon and Fisher's exact tests, logistic regression, and Cox models with time-varying covariates. Twenty of 262 (7.6%) subjects developed IRIS after a median of 33 days on ART. Subjects with fungal infections (other than pneumocystis) developed IRIS somewhat more frequently (OR = 2.7; 95% CI: 1.02, 7.2; p-value = 0.06 (using Fisher's exact test)). In Cox models, lower baseline and higher on-treatment CD4+ T-cell counts and percentage were associated with IRIS. Additionally, higher baseline and lower on-treatment HIV RNA levels were associated with IRIS. Corticosteroids during OI management and the timing of ART were not associated with the development of IRIS.ImplicationsIn patients with advanced immunosuppression and non-tuberculous OIs, the presence of a fungal infection, lower CD4+ T-cell counts and higher HIV RNA levels at baseline, and higher CD4+ T-cell counts and lower HIV RNA levels on treatment are associated with IRIS. Early initiation of ART does not increase the incidence of IRIS, and concern about IRIS should not prompt deferral of ART.Trial RegistrationClinicalTrials.gov NCT00055120

Two cases of fatal Pneumocystis jirovecii pneumonia as a complication of tacrolimus therapy in ulcerative colitis — A need for prophylaxis

Here we report 2 cases of fatal Pneumocystis jirovecii pneumonia in patients with severe ulcerative colitis receiving combination immunosuppression including tacrolimus. We discuss the necessity of a P. jirovecii prophylaxis especially in elderly patients according to the European evidence-based consensus on the prevention and management of opportunistic infections in inflammatory bowel disease.

The prevalence of co-morbidities in patients on HAART referred for physiotherapy in three public hospitals in KwaZulu-Natal, South Africa: a short report

Introduction: The roll-out of Highly Active Antiretroviral Therapy (HAART) to patients infected with the Human Immuno-deficient Virus (HIV) is presenting with co-morbidities as a result of the side effects of the drugs or the prolonged lifespan of the HIV positive individual. This poses a challenge to physiotherapists for rehabilitation which has changed from prophylaxis and management of opportunistic infections to managing the co-morbidities. The aim of this preliminary study was to determine the number of patients on HAART with co-morbidities admitted to three public hospitals in KwaZulu-Natal and referred for physiotherapy.Method: This descriptive epidemiological study used a cross-sectional design to determine the prevalence of co-morbidities associated with HAART. Baseline data of patients and their demographics, AIDS status and clinical co-morbidities were recorded. The sample consisted of 78 patients with an average CD4 count of 338 cells/mm³ and a viral load of 133 copies/mL. Patients were categorised according to their HIV stages: 13 (17%) asymptomatic, 44 (56%) ‘AIDS-related complex’ and 21 (27%) had full blown AIDS.Results: Patients referred for physiotherapy presented with peripheral neuropathy 36 (46%), pulmonary tuberculosis 29 (37%), musculo-skeletal pain 17(22%), myopathies 9 (12%), pneumonia 8 (10%), enthesopathies 4 (5%), cerebral vascular accidents 2 (3%) and abdominal pain 1(1%). Conclusion: To rehabilitate the HIV infected individual successfully physiotherapists should note the side effects and co-morbidities associated with HAART.

Renal transplantation in patients with HIV

HIV infection has been a major global health problem for almost three decades. With the introduction of highly active antiretroviral therapy in 1996, and the advent of effective prophylaxis and management of opportunistic infections, AIDS mortality has decreased markedly. In developed countries, this once fatal infection is now being treated as a chronic condition. As a result, rates of morbidity and mortality from other medical conditions leading to end-stage liver, kidney and heart disease are steadily increasing in individuals with HIV. Presence of HIV infection used to be viewed as a contraindication to transplantation for multiple reasons: concerns for exacerbation of an already immunocompromised state by administration of additional immunosuppressants; the use of a limited supply of donor organs with unknown long-term outcomes; and, the risk of viral transmission to the surgical and medical staff. This Review examines open questions on kidney transplantation in patients infected with HIV-1 and clinical strategies that have resulted in good outcomes. It also describes the clinical concerns associated with the treatment of renal transplant recipients with HIV.

Training health care workers to promote HIV services for patients with tuberculosis in the Democratic Republic of Congo.

BackgroundHIV counseling and testing, HIV prevention and provision of HIV care and support are essential activities to reduce the burden of HIV among patients with TB, and should be integrated into routine TB care.MethodsThe development of training materials to promote HIV services for TB patients involved the definition of target health care workers (HCWs); identification of required tasks, skills and knowledge; review of international guidelines; and adaptation of existing training materials for voluntary counseling and testing, prevention of mother-to-child transmission of HIV, and management of opportunistic infections (OIs). Training effectiveness was assessed by means of questionnaires administered pre- and post-training, by correlating post-training results of HCWs with the centre's HIV testing acceptance rates, and through participatory observations at the time of on-site supervisory visits and monthly meetings.ResultsPre-training assessment identified gaps in basic knowledge of HIV epidemiology, the link between TB and HIV, interpretation of CD4 counts, prevention and management of OIs, and occupational post-exposure prophylaxis (PEP). Opinions on patients' rights and confidentiality varied. Mean test results increased from 72% pre-training to 87% post-training (p < 0.001). Important issues regarding HIV epidemiology and PEP remained poorly understood post-training. Mean post-training scores of clinic's HCWs were significantly correlated with the centre's HIV testing acceptance rates (p = 0.01). On-site supervisory visits and monthly meetings promoted staff motivation, participatory problem solving and continuing education. Training was also used as an opportunity to improve patient-centred care and HCWs' communication skills.ConclusionMany HCWs did not possess the knowledge or skills necessary to integrate HIV activities into routine care for patients with TB. A participatory approach resulted in training materials that fulfilled local needs.

55-jährige Patientin mit Thymom und Hypogammaglobulinämie (Good-Syndrom), Colitis ulcerosa sowie CMV-Infektion

The authors report on a 55-year-old female patient after R1 resection of a malignant thymoma with spindle type epithelial cells (WHO type A, Masaoka stage III) referred for further therapy of an ulcerative colitis. At that time, both adjuvant radiation and cytostatic therapy were not applicable due to severe activity of the ulcerative colitis. Under immunosuppressive treatment with azathioprine and steroids, the patient developed cytomegalovirus (CMV) enteritis which was triggered by therapy-induced leukopenia. After a switch from azathioprine to mycophenolatmofetil (MMF) treatment and administration of cidofovir because of nonresponse to ganciclovir and incompatibility of foscarnet sodium (Foscavir), the patient clinically improved. In addition, the patient was treated with immunoglobulins every 3-4 weeks because of antibody deficiency. At present, 3.5 years after R1 resection, the patient still has no clues of a remaining tumor mass under current immunosuppressive therapy. Ulcerative colitis is also in complete remission stage. This case indicates the very rare features of a syndrome with thymoma and antibody deficiency which was first described by Robert Good. Furthermore, the impact of immunosuppressive therapy and management of opportunistic infections on the course of this disease is obvious.