Morbidität und Mortalität der HIV-Infektion

Zusammenfassung: Morbidität und Mortalität von HIV-infizierten Menschen haben seit 1996 aufgrund der antiretroviralen Kombinationstherapie (cART) dramatisch abgenommen. Die HIV-Infektion wurde somit zu einer chronischen, ambulant behandelbaren und meist asymptomatischen Krankheit mit praktisch normaler Lebenserwartung. Ein Hauptgrund der verbleibenden Morbidität und Sterblichkeit ist, dass die HIV-Infektion in etwa 20% der Fälle spät diagnostiziert bzw. therapiert wird. Oft liegt zu diesem Zeitpunkt die CD4-Zellzahl bereits unter der Schwelle von 200Zellen/µl und/oder AIDS-definierende Krankheiten haben sich manifestiert. Weitere Gründe für die verbleibende Morbidität und Mortalität sind Komorbiditäten, insbesondere die Koinfektion mit einer viralen Hepatitis und Tumoren bei älteren Patienten. Durch die verbesserte Prognose nimmt das Alter HIV-infizierter Menschen zu. Dies bedeutet aufgrund von Komorbiditäten und sozioökonomischen Kosten eine erhebliche Herausforderung für die Zukunf

Secular Trend and Risk Factors for Antimicrobial Resistance in Escherichia coli Isolates in Switzerland 1997-2007

Abstract : Background: : Antibacterial resistance in Escherichia coli isolates of urinary infections, mainly to fluoroquinolones, is emerging. The aim of our study was to identify the secular trend of resistant E. coli isolates and to characterize the population at risk for colonization or infections with these organisms. Patients and Methods: : Retrospective analysis of 3,430 E.coli first isolates of urine specimens from patients admitted to the University Hospital Basel in 1997, 2000, 2003, and 2007. Results: : Resistance to ciprofloxacin, trimethoprim/sulfamethoxazole, and amoxicillin/clavulanate has increased over the 10-year study period (from 1.8% to 15.9%, 17.4% to 21.3%, and 9.5% to 14.5%, respectively). A detailed analysis of the 2007 data revealed that independent risk factors for ciprofloxacin resistance were age (5.3% 75 years; odds ratio [OR] 1.29 per 10 years, 95% confidence interval [CI] 1.15-1.45, p < 0.001) and male gender (OR 1.59, 95% CI 1.05-2.41, p = 0.04). In contrast, nosocomial E. coli isolates were associated with lower odds of ciprofloxacin resistance (OR 0.51, 95% CI 0.28-0.67, p < 0.001). The frequency of resistant isolate rates was not influenced by the clinical significance (i.e., colonization vs urinary tract infection, UTI) or by whether the urine was taken from a urinary catheter. Importantly, the increase in ciprofloxacin resistance paralleled the increase in ciprofloxacin consumption in Switzerland (Pearson's correlation test R2= 0.998, p = 0.002). Of note, resistance was less frequent in isolates sent in by general practitioners. However, after adjustment for age and gender, only resistance against amoxicillin/clavulanate was found to be less frequent (OR 0.34, 95% CI 0.16-0.92, p = 0.03). Conclusion: : Our study reveals that resistance rates have been increasing during the last decade. Published resistance rates may lack information due to important differences regarding age, gender, and probable origin of the isolates. Empirical therapy for UTI should be guided more on individual risk profile and local resistance data than on resistance data bank

HIV-Infektion : Update 2009 für Hausärzte. Teil 1

Quintessenz: In der Schweiz werden jährlich >750 HIV-Infektionen neu diagnostiziert. Die Ansteckung geschieht via Blut oder Sex, und nicht bei alltäglichen sozialen Kontakten. Die CD4-Lymphozytenzahl ist bestens etabliert zur Messung der Immunsuppression. Die grösste Gefahr opportunistischer Infekte droht bei CD4-Werten <200/μl. Dank antiretroviraler Therapie (ART) sollten viele HIV-infizierte Patienten in der Schweiz eine quasi normale Lebenserwartung haben. Momentan ist eine ART bei CD4-Werten <350/μl indiziert. Die HIV-Diagnose wird auch in der Schweiz häufig zu spät gestellt. Hausärzte spielen bei der frühzeitigen Diagnosestellung (grosszügiges Anbieten von HIV-Tests) und bei der Prävention von Immundefizienz und opportunistischen Komplikationen eine entscheidende Rolle. P Bei HIV-Neudiagnose soll der Patient einem HIV-Spezialisten zugewiesen werden, um weitere Abklärungen durchzuführen und die Indikation zum ART-Beginn zu stellen

Effect of SLCO1B1 c.521T>C polymorphism on the lipid response to statins in people living with HIV on a boosted protease inhibitor-containing regimen

AIMS: We previously observed that some individuals on HIV boosted protease inhibitor-containing regimen do not achieve their lipid targets despite elevated statin concentrations. This study evaluated whether the common single polymorphism c.521T>C in SLCO1B1, associated with reduced statin uptake in the liver, could explain this observation. METHODS: People living with HIV in the Swiss HIV Cohort Study were eligible if they were on a boosted protease inhibitor concomitantly with a statin for at least 6 months and if their SLCO1B1 genotype was available. Furthermore, their lipids had to be documented before and after the introduction of the statin. The statin efficacy was defined as % change in total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol and triglycerides levels after statin initiation compared to pretreatment levels. Lipid response was adjusted for differences in potency and dose between statins. RESULTS: In total, 88 people living with HIV were included, of whom 58, 28 and 2 carried the SLCO1B1 TT, TC and CC genotypes, respectively. The change in lipid levels after statin initiation tended to be lower in carriers of the polymorphism although the difference was not statistically significant (TT vs. TC/CC: total cholesterol: -11.7 vs. -4.8%; low-density lipoprotein- cholesterol: -20.6 vs. -7.4%; high-density lipoprotein-cholesterol: 1.6 vs. 0%; triglycerides: -11.5 vs. -7.9%). In the multiple linear regression, change in total cholesterol was inversely correlated with the total cholesterol level prestatin treatment (coefficient -6.60, 95% confidence interval: -9.63 to -3.56, P < .001). CONCLUSION: The lipid-lowering effect of statins tended to be attenuated by SLCO1B1 polymorphism and progressively declined as total cholesterol under the boosted protease inhibitor treatment decreased

Evaluation of treatment outcomes for Stenotrophomonas maltophilia bacteraemia

Objective: The goal of this study was to retrospectively collect data about treatment outcomes in patients diagnosed with Stenotrophomonas maltophilia bacteraemia over a period of 20years and evaluate these data with respect to the efficacy of treatment options. Methods: The setting was a 700-bed tertiary care hospital in a large urban area. Hospital databases and medical records provided information about episodes of S. maltophilia, patient characteristics and treatment outcomes. Patients with at least one positive blood culture for S. maltophilia were included in the study. Data were analysed with respect to clinical improvement and mortality ≤30days after the onset of infection. We compared patient characteristics, laboratory values and treatments by using the Chi-square or Fisher's exact tests and the Mann-Whitney test. Results: We investigated 27 patients with S. maltophilia bacteraemia. The focus of infection was a central venous catheter in 18 (67%) cases. The 30-day mortality rate was 11%. All patients who were treated with an antibiotic that was effective in vitro against the pathogen recovered clinically and survived ≥30days after the onset of infection. The most frequently used antibiotic was trimethoprim-sulfamethoxazole administered alone or in combination with a fluoroquinolone. Conclusions: Despite the fact that S. maltophilia is resistant to multiple antibiotics, the prognosis for patients with S. maltophilia bacteraemia is good when they are treated with antibiotics that are effective against this pathogen in vitro

Improved Virological Outcome in White Patients Infected With HIV-1 Non-B Subtypes Compared to Subtype B

Patients infected with HIV type 1 non-B subtypes had a decreased probability for a virological failure while receiving combination antiretroviral therapy compared with individuals infected with subtype B. Subtypes A and CRF02_AG, in particular, revealed improved outcome

Ageing with HIV: medication use and risk for potential drug-drug interactions

Objectives To compare the use of co-medication, the potential drug-drug interactions (PDDIs) and the effect on antiretroviral therapy (ART) tolerability and efficacy in HIV-infected individuals according to age, ≥50 years or <50 years. Methods All ART-treated participants were prospectively included once during a follow-up visit of the Swiss HIV Cohort Study. Information on any current medication was obtained by participant self-report and medical prescription history. The complete treatment was subsequently screened for PDDIs using a customized version of the Liverpool drug interaction database. Results Drug prescriptions were analysed for 1497 HIV-infected individuals: 477 age ≥50 and 1020 age <50. Older patients were more likely to receive one or more co-medications compared with younger patients (82% versus 61%; P < 0.001) and thus had more frequent PDDIs (51% versus 35%; P < 0.001). Furthermore, older patients tended to use a higher number of co-medications and certain therapeutic drug classes more often, such as cardiovascular drugs (53% versus 19%; P < 0.001), gastrointestinal medications (10% versus 6%; P = 0.004) and hormonal agents (6% versus 3%; P = 0.04). PDDIs with ART occurred mainly with cardiovascular drugs (27%), CNS agents (22%) and methadone (6%) in older patients and with CNS agents (27%), methadone (15%) and cardiovascular drugs (11%) in younger patients. The response to ART did not differ between the two groups. Conclusions The risk for PDDIs with ART increased in older patients who take more drugs than their younger HIV-infected counterparts. However, medication use in older and younger patients did not differ in terms of effect on antiretroviral tolerability and respons

Tuberculosis in HIV-Negative and HIV-Infected Patients in a Low-Incidence Country: Clinical Characteristics and Treatment Outcomes

BACKGROUND: In Switzerland and other developed countries, the number of tuberculosis (TB) cases has been decreasing for decades, but HIV-infected patients and migrants remain risk groups. The aim of this study was to compare characteristics of TB in HIV-negative and HIV-infected patients diagnosed in Switzerland, and between coinfected patients enrolled and not enrolled in the national Swiss HIV Cohort Study (SHCS). METHODS AND FINDINGS: All patients diagnosed with culture-confirmed TB in the SHCS and a random sample of culture-confirmed cases reported to the national TB registry 2000-2008 were included. Outcomes were assessed in HIV-infected patients and considered successful in case of cure or treatment completion. Ninety-three SHCS patients and 288 patients selected randomly from 4221 registered patients were analyzed. The registry sample included 10 (3.5%) coinfected patients not enrolled in the SHCS: the estimated number of HIV-infected patients not enrolled in the SHCS but reported to the registry 2000-2008 was 146 (95% CI 122-173). Coinfected patients were more likely to be from sub-Saharan Africa (51.5% versus 15.8%, P<0.0001) and to present disseminated disease (23.9% vs. 3.4%, P<0.0001) than HIV-negative patients. Coinfected patients not enrolled in the SHCS were asylum seekers or migrant workers, with lower CD4 cell counts at TB diagnosis (median CD4 count 79 cells/µL compared to 149 cells/µL among SHCS patients, P = 0.07). There were 6 patients (60.0%) with successful outcomes compared to 82 (88.2%) patients in the SHCS (P = 0.023). CONCLUSIONS: The clinical presentation of coinfected patients differed from HIV-negative TB patients. The number of HIV-infected patients diagnosed with TB outside the SHCS is similar to the number diagnosed within the cohort but outcomes are poorer in patients not followed up in the national cohort. Special efforts are required to address the needs of this vulnerable population