Open Forum Infectious Diseases最新文献

Background: Social precariousness hinders access to the cascade of care in people with HIV (PHIV). Its impact on the clinical presentation and outcome of critical illnesses in this patient population is unknown.

Methods: We included all PHIV admitted over the 2015 to 2020 period in 12 university-affiliated intensive care units in France. Precarious patients encompassed undocumented migrants, homeless, and individuals facing other forms of socioeconomic deprivation. Precarious and nonprecarious PHIV were compared for baseline characteristics and reasons for admission. The effect of precariousness on in-hospital mortality (primary endpoint) and 1-year mortality (secondary endpoint) was measured through logistic regression.

Results: Among the 939 included PHIV, 136 (14.5%) were classified as precarious (migrants, 5.7%; others, 8.7%). Compared to nonprecarious patients, (1) migrants were younger, had fewer comorbidities, and were more often admitted with previously unknown HIV and/or for AIDS-defining opportunistic infections; and (2) precarious patients other than migrants presented with lower rates of viral suppression (despite similar access to combination antiretroviral therapies) and were more often admitted for bacterial sepsis. Overall in-hospital and 1-year mortality rates were 17.8% and 24.2%, respectively. Precariousness was not independently associated with in-hospital mortality (adjusted odds ratio, 1.04; 95% confidence interval, .98-1.10) or 1-year mortality (adjusted odds ratio, .89; 95% confidence interval, .54-1.48), including when analyzing migrants separately.

Conclusions: Precarious PHIV requiring intensive care unit admission have particular clinical features that likely reflect chronic inequities in access to HIV care. However, precariousness is probably not linked with a higher hazard of death during the index hospital stay or at 1 year.

Background: Human adenovirus (HAdV) is a common cause of pediatric acute respiratory illness (ARI), contributing to 5-13% of cases worldwide. Clinical manifestations vary by HAdV species and type; therefore, delineating type-specific disease presentations and understanding severity of specific HAdV types' disease may help develop targeted interventions.

Methods: We conducted a multicenter, prospective study within the New Vaccine Surveillance Network to characterize HAdV types. Children <18 years old with ARI were enrolled in the emergency department or inpatient setting at 7 US children's hospitals from 1 December 2016 to 30 November 2019. Respiratory specimens were collected and tested for HAdV and other viruses. Subsequently, typing was conducted on HAdV specimens using single-plex real-time PCR assays targeting sequences in the hexon gene. Comparisons between HAdV types were performed to determine differences in characteristics and outcomes. Generalized linear mixed effects models were used to evaluate severity.

Results: Among the 1843 HAdV-positive cases, 1402 specimens (76%) were typed. The most common types detected were HAdV-C1 (n = 439), HAdV-C2 (n = 393), and HAdV-B3 (n = 221). Children with HAdV-B7 (n = 78) had higher odds of severe outcomes compared to those with other HAdV types (aOR = 2.05; 95% CI: 1.24, 3.40). Symptom presentation varied across types within species B, C, and E; while all species had high frequency of upper respiratory symptoms, species B cases presented with a higher frequency of non-respiratory manifestations.

Conclusions: Among children with HAdV-positive ARI, those with HAdV-B7 had higher odds of severe outcomes. These findings suggest heterogeneity in clinical presentation and severity among HAdV types, emphasizing the importance of HAdV type in future prevention and treatment strategies.

Background: Mortality associated with Pseudomonas aeruginosa bloodstream infection (PABSI) remains high despite advances in clinical care and therapeutics. In a recent study using a mouse model of PABSI, the gallbladder was identified as a reservoir for bacterial expansion. Furthermore, bile exposure has been linked to increased antimicrobial resistance. Therefore, we asked whether patients with retained gallbladders might experience more antimicrobial-resistant PABSIs, extended culture positivity, and worsened clinical outcomes.

Methods: We conducted a retrospective cohort study of adults hospitalized over a 5-year period with PABSI. PABSI cases were defined as patients with ≥1 positive P. aeruginosa bacterial culture from the blood. Patients were categorized as those retaining a gallbladder (no cholecystectomy) or not (cholecystectomy). Cholecystectomy was defined as a history of cholecystectomy ≥1 year prior to the index episode of PABSI. Inferential statistics were used to identify associations between remote cholecystectomy and antimicrobial resistance profile, length of blood culture positivity, and in-hospital and 90-day mortality.

Results: The overall study population included 336 patients: 262 (78%) with a retained gallbladder and 74 (22%) without. Using the entire study population and a matched cohort, we observed no difference in length of culture positivity, 90-day mortality, or in-hospital mortality between groups based on the presence of a gallbladder. Overall, composite 90-day mortality was 30.1%, which was similar to a prior investigation of PABSI outcomes at our institution. While the presence of a gallbladder did not affect the outcome, patients with PABSI and liver disease had significantly higher 90-day mortality than those without liver disease. Furthermore, no robust differences were observed in the antimicrobial resistance profile of P. aeruginosa isolates from the group with or without a gallbladder.

Conclusions: In our study, neither PABSI antimicrobial resistance pattern nor clinical outcomes were affected by remote cholecystectomy. However, we do demonstrate that mortality for patients with PABSI in the modern era remains high despite advances in antipseudomonal therapeutics.

Hepatitis C continues to pose a significant global health burden, particularly in low- and middle-income countries, where access to diagnosis and treatment remains limited. This perspective explores how integrated care models, featuring decentralization, task-shifting, and simplified protocols, can accelerate hepatitis C elimination. Drawing on case studies from Egypt, Rwanda, Cambodia, Malaysia, and Nigeria, we highlight key enablers such as political commitment, infrastructure integration, and public engagement. These examples demonstrate that scalable, cost-effective strategies can achieve high treatment uptake and cure rates, even in resource-constrained settings. The paper underscores the importance of adapting successful models to local contexts and calls for broader adoption of World Health Organization-aligned policies to meet 2030 elimination targets.

Background: Cases of coccidioidomycosis are increasing dramatically in the United States. The utility of intrathecal (IT) amphotericin in treating coccidioidal meningitis (CM) in the era of azole therapy is unknown. We sought to understand how IT therapy is associated with mortality.

Methods: We conducted a retrospective chart review of adult patients with laboratory-proven CM seen at Stanford Healthcare by an infectious diseases physician from 2008 to 2023.

Results: Fifty-seven patients met inclusion criteria. All patients received azole therapy. Twenty-seven of those patients (47.4%) additionally received IT amphotericin. Patients receiving IT therapy had a higher median initial cerebrospinal fluid white blood cell count at diagnosis (462.5 vs 188 cells/μL, P = .05), higher rates of intravenous liposomal amphotericin use (88.9% vs 56.7%, P = .02) and corticosteroid use (51.9% vs 26.7%, P = .09), and higher median therapeutic switches per year (0.84 vs 0.44, P = .01). An unadjusted Kaplan-Meier curve demonstrated a 5-year mortality rate of 26.7% in the IT amphotericin group, compared to 6.7% in the nonreceiver group (P = .28). A Cox regression revealed that older age at diagnosis (hazard ratio [HR], 1.07 [95% confidence interval {CI}, 1.03-1.11]), receipt of IT amphotericin (HR, 13.9 [95% CI, 1.92-100.48]), and corticosteroid use (HR, 8.3 [95% CI, 1.92-35.4]) were significantly associated with mortality, with a significant interaction between IT amphotericin and corticosteroids (interaction HR, 0.14 [95% CI, .02-.97]).

Conclusions: Patients who received IT amphotericin had higher mortality rates than those who did not, likely reflecting disease refractory to treatment. More therapies are needed for those who have disease progression on azole therapy.

Background: People with HIV (PWH) have a higher incidence of heart failure (HF) and acute myocardial infarction (AMI) than people without HIV (PWoH). While hospital readmission is a common quality-of-care indicator, readmission risk for HF or AMI by HIV status is not well defined.

Methods: We included adults hospitalized for HF or AMI from the 2016-2022 Nationwide Readmissions Database. The outcome was 30-day all-cause unplanned readmission. We examined trends in readmission risk between 2016 and 2022, and subgroup-specific readmission risk in 2022, by HIV status. Crude and age-and sex-adjusted risk ratios (aRR) were calculated using marginal estimates from mixed-effects logistic regressions.

Results: From 2016 to 2022, 30-day readmission risk significantly declined among PWH hospitalized for HF (39.5%-to-33.0%), PWoH hospitalized for HF (22.9%-to-21.6%), and PWH hospitalized for AMI (19.3%-to-16.8%). In 2022, we included 1 062 309 weighted index hospitalizations for HF and 470 369 for AMI. PWH had significantly higher readmission risk than PWoH for both HF (aRR = 1.46; 95%CI = 1.39-1.53) and AMI (aRR = 1.59; 95%CI = 1.39-1.80). For HF, the most common readmission diagnosis for both PWH and PWoH was hypertensive heart and stages 1-4 chronic kidney disease with HF. For AMI, recurrent unspecified AMI was the most common readmission diagnosis among both PWH and PWoH. In age- and sex-stratified analyses, PWH consistently had higher readmission risk than PWoH for both HF and AMI, with the largest disparities in younger males and older females.

Conclusions: PWH had a significantly higher 30-day readmission risk after HF and AMI hospitalization. Targeted interventions, such as early follow-up and multidisciplinary care, are needed to reduce readmission risks.

Background: HIV pre-exposure prophylaxis (PrEP) use has been linked with increases in sexually transmitted infection (STI) incidence. Despite efforts to expand PrEP uptake among young Black and Hispanic men who have sex with men (YBHMSM), little research has been done to understand the impact of PrEP on STI incidence within these communities. We examine the effect of PrEP use on gonorrhea and chlamydia (NG/CT) incidence, condom use, and external STI testing (ie, outside of study visits).

Methods: In a longitudinal cohort of HIV-negative YBHMSM (ages 16-24 years), we modeled the effect of PrEP use on study-external STI testing and number of condomless sex partners during the following 6 months using mixed-effects generalized linear models. We modeled the effect of PrEP use on NG/CT incidence using time-updated proportional hazard regression.

Results: While on PrEP compared with periods not on PrEP, participants reported on average 2.51 (adjusted beta; 95% CI, 1.51-3.51; P < .001) more condomless sex partners and were 2.28 (adjusted OR; 95% CI, 1.48-3.52; P < .001) times as likely to report study-external STI testing during the following 6 months. NG/CT incidence did not increase (adjusted HR, 0.75; 95% CI, 0.45-1.27; P = .286) while on PrEP compared with not on PrEP.

Conclusions: Condomless sex increased with PrEP use; however, its potential to elevate STI acquisition or prolonged duration of infection may be mitigated by PrEP-associated routine testing. Efforts to expand PrEP uptake among YBHMSM appear unlikely to exacerbate the STI epidemic.

Advocacy has long been at the core of the infectious diseases (ID) field, with clinicians and researchers advocating to ensure patients can access the care they need on an individual and global scale. The Infectious Diseases Society of America Training Program Directors' (PD) Committee met in 2024 and discussed ways that advocacy is and should be incorporated into fellowship training, as well as highlighted the role PDs play in advocating for their trainees. Policies with a negative impact on ID clinical care, public health, and research underscore the importance of mobilizing the field of ID to advocate for the patients and communities we serve, as well as for ourselves. This paper presents ideas generated at this meeting and is meant to serve as a reference for ID PDs, as well as the wider ID community, as a call to action for teaching and participating in advocacy work.

Background: Despite successful ART, people with HIV are at increased risk of non-AIDS-related comorbidities, including cardiovascular and metabolic disease. Adults with perinatally acquired HIV (PaHIV) may face additional risks due to lifelong HIV-related inflammation and ART exposure. We explored cardiovascular and metabolic risk factors in a cohort of adults with PaHIV.

Methods: Case-note review of adults with PaHIV ≥18 years attending a UK specialist service. Hypertension was defined by World Health Organisation (WHO; ≥ 140/90 mmHg) and American Heart Association (AHA; ≥ 130/80 mmHg) guidelines. Standard lipid and blood pressure thresholds defined metabolic syndrome [triglycerides ≥1.7 mmol/L, high-density lipoprotein <1.04 mmol/L (men) and <1.29 mmol/L (women), BP ≥130/85 mmHg]. CVD risk was assessed using modifiable factors and Pathobiological Determinants of Atherosclerosis in Youth (PDAY) scores for coronary arteries (CAs) and abdominal aorta (AA).

Results: The cohort included 225 adults with PaHIV; median age 27 (IQR 23, 30) years, 55% female, and 86% Black ethnicity. Median CD4 count 634 (IQR 438, 815) cells/μL and ART duration 19 (IQR 13, 22) years. About 83% had HIV-1 RNA <50 copies/mL. Hypertension was identified in 9% and 21% of participants by WHO and AHA criteria, respectively. Metabolic syndrome was present in 3%. Elevated PDAY scores ≥1 were observed in 57% for CA and 51% for AA.

Conclusions: Despite viral suppression, over half the cohort had elevated PDAY scores, predictive of increased cardiovascular risk. WHO-defined hypertension rates were similar to an age-matched UK population; however, 1 in 5 were hypertensive by AHA criteria. Statin initiation guidelines may need adaptation for this population.

Background: Ongoing high-risk behaviors continue to fuel HCV transmission among men who have sex with men (MSM), challenging elimination efforts. We studied HCV epidemiology in MSM with HIV (MSM-WH) and without HIV in the region of Madrid.

Methods: This prospective study (2022-2024) enrolled MSM-WH from 10 centers and MSM on PrEP from an STI clinic. Visits were scheduled at baseline, 3, 6, 9, and 12 months (PrEP group), or baseline, 6, and 12 months (HIV group). Assessments included liver enzymes, HCV serology, HCV-RNA, and STI screening (syphilis, chlamydia, and gonorrhea by PCR).

Results: A total of 1372 MSM (733 with HIV; 639 on PrEP) were enrolled. Baseline HCV prevalence was 1.68%, significantly higher in those with prior HCV exposure (5.60% vs 0.72%; prevalence ratio: 7.72, 95% CI: 3.31-18.03). Over 1240.4 person-years (PY) of follow-up, overall HCV incidence was 1.45/100 PY. Primary infection incidence was 0.79/100 PY: 0.94 in PrEP users versus 0.65 in MSM-WH (IRR: 1.44, 95% CI: .24-9.80). Reinfection incidence was 4.32/100 PY overall: 12.90 in PrEP users and 4.05 in MSM-WH (IRR: 3.21, 95% CI: .07-22.53). Two participants experienced within study reinfection (8.7/100 PY, 95% CI: 1.05-31.4). Slamsex and condomless receptive anal intercourse with ≥4 partners were independently associated with HCV infection and reinfection.

Conclusions: MSM with prior HCV exposure had markedly higher HCV prevalence and incidence, regardless of HIV status. Risky sexual behaviors remain key drivers of HCV transmission. Behavior-informed prevention strategies are critical to sustain elimination efforts in MSM populations.