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

Significance of Staphylococcus lugdunensis Bacteremia: Report of 28 Cases and Review of the Literature

Abstract : Background: : Staphylococcus lugdunensis endocarditis has been associated with an aggressive course. The aim of this study was to determine factors associated with the development of endocarditis in patients with S. lugdunensis bacteremia. Methods: : A retrospective analysis of all patients with S. lugdunensis bacteremia in three tertiary care centers in Switzerland was performed. Data regarding medical history, symptoms, and susceptibility of S. lugdunensis isolates were collected. Our results were reviewed in the context of the current literature. Results: : A total of 28 patients with S. lugdunensis bacteremia were identified. Of the 13 patients with endocarditis, all were community acquired. Cardiac surgery was performed in 85% of these patients; mortality was 23%, reflecting the aggressive course of this disease. In contrast, in the 15 patients without endocarditis, no complications associated with S. lugdunensis bacteremia were observed. In 73%, a probable source was identified in the form of a venous catheter or other foreign device. Only three of these episodes were community acquired. No difference was observed in susceptibility of the S. lugdunensis isolates to penicillin, which was 77% in endocarditis isolates, and 87% in isolates of bacteremia without endocarditis, respectively. Conclusion: : S. lugdunensis bacteremia is associated with endocarditis in up to 50% of patients. Every patient with community-acquired S. lugdunensis bacteremia should be carefully examined for signs of endocarditis. Once S. lugdunensis endocarditis is diagnosed, close monitoring is essential and surgical treatment should be considered early. In the nosocomial setting, endocarditis is far less frequent, and S. lugdunensis bacteremia is usually associated with a catheter or other foreign material

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

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

Pregnancy and delivery outcomes of HIV infected women in Switzerland 2003-2008

Objective: Rates of vertical HIV transmission between mother and child are low, allowing many HIV positive women to have children with near impunity. In this study, data from the Swiss Mother and Child HIV Cohort Study were used to describe maternal characteristics and their association with pregnancy outcomes in HIV positive women. Study design: HIV positive women were followed prospectively during their pregnancies and deliveries by anonymous questionnaires between January 2003 and October 2008. Adverse pregnancy outcomes included preterm delivery, preeclampsia and gestational diabetes mellitus. Results: This study included 266 HIV positive women, of which 67 (25.2%) were first diagnosed with HIV during pregnancy. Thirty percent (n=80) of the women had pregnancy complications after 24weeks of gestation. Preterm delivery was noted in 72 (27%) patients. Other complications included preeclampsia (n=7; 2.6%) and gestational diabetes (n=7; 2.6%). Older maternal age was the only risk factor associated with adverse pregnancy outcomes (adjusted odds ratio: 1.06, 95% confidence interval 1.01-1.12, P=0.02). Conclusions: HIV positive women, especially with advanced maternal age, have high-risk pregnancies and should be monitored as in an interdisciplinary setting. The preponderance of initial HIV diagnosis during pregnancy confirms the importance of HIV screening in pregnant wome

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

Height and timing of growth spurt during puberty in young people living with vertically acquired HIV in Europe and Thailand.

OBJECTIVE: The aim of this study was to describe growth during puberty in young people with vertically acquired HIV. DESIGN: Pooled data from 12 paediatric HIV cohorts in Europe and Thailand. METHODS: One thousand and ninety-four children initiating a nonnucleoside reverse transcriptase inhibitor or boosted protease inhibitor based regimen aged 1-10 years were included. Super Imposition by Translation And Rotation (SITAR) models described growth from age 8 years using three parameters (average height, timing and shape of the growth spurt), dependent on age and height-for-age z-score (HAZ) (WHO references) at antiretroviral therapy (ART) initiation. Multivariate regression explored characteristics associated with these three parameters. RESULTS: At ART initiation, median age and HAZ was 6.4 [interquartile range (IQR): 2.8, 9.0] years and -1.2 (IQR: -2.3 to -0.2), respectively. Median follow-up was 9.1 (IQR: 6.9, 11.4) years. In girls, older age and lower HAZ at ART initiation were independently associated with a growth spurt which occurred 0.41 (95% confidence interval 0.20-0.62) years later in children starting ART age 6 to 10 years compared with 1 to 2 years and 1.50 (1.21-1.78) years later in those starting with HAZ less than -3 compared with HAZ at least -1. Later growth spurts in girls resulted in continued height growth into later adolescence. In boys starting ART with HAZ less than -1, growth spurts were later in children starting ART in the oldest age group, but for HAZ at least -1, there was no association with age. Girls and boys who initiated ART with HAZ at least -1 maintained a similar height to the WHO reference mean. CONCLUSION: Stunting at ART initiation was associated with later growth spurts in girls. Children with HAZ at least -1 at ART initiation grew in height at the level expected in HIV negative children of a comparable age