Therapeutic Advances in Infectious Disease最新文献

Introduction: Despite escalating rates of sexually transmitted infections (STIs) in the United States (US), there has been progressive divestment of sexual health services leading to the reliance on emergency departments (EDs) for sexual healthcare, particularly among vulnerable populations. The Sexual Wellness Clinic (SWC), a novel care delivery model operating in collaboration with the ED, offers comprehensive sexual health services.

Objectives: This study aims to analyze the demographics, STI positivity, and HIV Pre-Exposure Prophylaxis (PrEP) uptake among patients accessing the SWC.

Design: This was a retrospective cohort study of patients attending the SWC between February 20, 2019, and September 30, 2022.

Methods: Sociodemographic characteristics, STI testing results, and PrEP initiation data were collected from the electronic health record (EHR). Two multivariable logistic regression models were employed to assess associations between patient factors and STI positivity or PrEP initiation.

Results: Among 651 individuals across 785 SWC visits, the majority were Black or African American (94.6%), 18-29 years of age (53.2%), and on Medicaid (65.8%). Of all visits, 27.3% resulted in a syphilis diagnosis, 16.1% tested positive for chlamydia test, and 15.0% tested positive for gonorrhea. Decreased STI positivity was associated with insertive vaginal sex (adjusted odds ratio (aOR): 0.34, p = 0.0079) while using condoms most of the time use was associated with increased STI positivity (aOR: 2.68, p = 0.0038). Eighty SWC patients started PrEP on the same day as their visit, most of which were non-Hispanic Black (96.26%), assigned female at birth (53.75%), and on Medicaid or Medicare (68.75%). Factors associated with PrEP initiation at the SWC included a previous STI (aOR: 3.78, p < 0.001), oral sex (aOR: 2.33, p = 0.008), receptive anal sex (aOR: 3.55, p = 0.010), having a partner with HIV (aOR: 8.95, p = 0.019), and participation in transactional sex (aOR: 29.46, p = 0.029).

Conclusion: Patients seen within the SWC were priority patient populations for sexual health services and PrEP linkage. The SWC was able to promote the initiation of same-day PrEP in Black cisgender women, a key population that continues to experience inequities in PrEP coverage. The SWC functions as a model for sexual healthcare delivery in populations with unmet sexual health needs.

Background: Molecular tests have contributed to reducing the mortality rate through early and accurate diagnosis of tuberculosis (TB). This is due to their low processing complexity and diagnostic accuracy superior to conventional methods.

Objective: To evaluate the diagnostic performance of Cobas MTB and Logix Smart MTB compared to Xpert MTB/RIF Ultra for pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB).

Design: A cross-sectional study of diagnostic tests was carried out in a clinical laboratory in Lima, Peru.

Methods: All pulmonary and extrapulmonary samples from patients with presumptive TB who had been subjected to smear microscopy, Xpert MTB/RIF Ultra, Cobas MTB, Logix Smart MTB, and mycobacteria culture were included to determine their diagnostic performance.

Results: A total of 175 samples were included, 102 (58.3%) of pulmonary origin and 73 (41.7%) of extrapulmonary origin. Among the total samples, 19 (10.9%) had positive cultures (all were pulmonary samples), 48 (27.4%) had positive Xpert MTB/RIF Ultra results, 45 (25.7%) had positive Cobas MTB results, and 36 (20.6%) had positive Logix Smart MTB results. The agreement between Cobas MTB and Logix Smart with the Xpert MTB/RIF Ultra was 97.1% and 93.8%, respectively. Compared to Xpert MTB/RIF Ultra, the area under the curve/receiver operating characteristic and sensitivity of the Cobas MTB and Logix Smart methods were 0.95 and 91.7%, and 0.90 and 81.0%, respectively.

Conclusion: Cobas MTB and Logix Smart presented adequate performance for diagnosing pulmonary and extrapulmonary tuberculosis comparable to the Xpert MTB/RIF Ultra.

Background: Key populations (KP) are highly vulnerable to HIV acquisition and account for 70% of new infections worldwide. To optimize HIV prevention among KP, the World Health Organization recommends the combination of emtricitabine plus tenofovir disoproxil fumarate for pre-exposure prophylaxis (PrEP). However, PrEP failure could be attributed to drug resistance mutations (DRMs) but this is unexplored in sub-Saharan Africa (SSA).

Objectives: We aim to conduct a systematic review that will provide evidence on the prevalence of HIV drug resistance (HIVDR) following PrEP failure among KP in SSA.

Design: This will be a systematic review and meta-analysis of studies conducted in sub-Saharan Africa.

Methods and analysis: This systematic review will include randomized and non-randomized trials, cohorts, case controls, cross-sectional studies, and case reports evaluating the prevalence of HIVDR following PrEP failure among KP (i.e., gay men and men who have sex with men, female sex workers, transgenders, people who inject drugs, prisoners, and detainees) in SSA. Results will be stratified according to various KP, age groups (adolescents and adults), and geographic locations. Primary outcomes will be "the prevalence of PrEP failure among KP" and "the prevalence of HIVDR after PrEP failure" in SSA. Secondary outcomes would be "the prevalence of DRMs and drug susceptibility" and "the level of adherence to PrEP." A random-effects model will be used to calculate pooled prevalence if data permit and we will explore potential sources of heterogeneity.

Discussion: Our findings will provide estimates of HIVDR following PrEP failure among KP in SSA. In addition, determinants of PrEP failure and driving factors of the emergence of DRMs will also be investigated. Evidence will help in selecting effective antiretrovirals for use in PrEP among KP in SSA.

Registration: PROSPERO: CRD42023463862.

Background: Tuberculosis (TB) is the leading cause of death from a single infectious agent globally. The stigma associated with TB, encompassing self, anticipated, and public stigma, has significant negative effects on treatment adherence. In Uganda, limited data exist on the prevalence of stigma and its relationship with sex among patients with TB.

Objectives: We aimed to evaluate the prevalence of three types of stigma and their relationship with the sex of patients undergoing TB treatment.

Design: Cross-sectional study.

Methods: This cross-sectional study was conducted among patients living with TB attending selected TB clinics in Kampala, Uganda, between July 2020 and March 2021. We collected data on sociodemographics and used 13 items to capture the self, anticipated, and public stigma from which we composed the dependent variables. We employed multivariable logistic regression analysis to evaluate the association between sex and the three stigma types. Additionally, we considered potential confounders such as age, HIV, and employment status. Statistical significance was defined as p < 0.05.

Results: In this study, we enrolled 144 participants with a mean age of 35.8 years (standard deviation = 12). Half of the participants were female, 44.4% had a secondary education, 37.5% were unemployed, and 32.6% were living with both HIV and TB. The prevalence of self-stigma was 71.1%, anticipated stigma was 75.7%, and public stigma was 41.7%. Significant factors associated with self-stigma were female sex (adjusted odds ratio (AOR): 2.35, 95% confidence interval (CI): 1.02-5.74) and unemployment (AOR: 2.95, 95% CI: 1.16-8.58). Living with HIV was significantly associated with anticipated stigma (AOR: 3.58, 95% CI: 1.38-11.23). However, none of the evaluated variables showed a significant association with public stigma.

Conclusion: Our study showed a relatively high prevalence of self, anticipated, and public stigma among TB patients. Notably, females and unemployed individuals were at a higher risk of self-stigma, while those with HIV/AIDS and TB were more likely to report anticipated stigma. To combat stigma effectively, interventions should be tailored to cater to sex-specific needs and persons living with HIV. Future research should delve further into determinants of TB-related stigma in high-burden settings.

Background: Asymptomatic bacteriuria (ASB) is the presence of bacteria in the urine of patients without symptoms of a urinary tract infection. Generally, treating ASB is not beneficial.

Objective: We aimed to reduce overtreatment of ASB in the emergency department (ED) through a multifaceted de-implementation strategy.

Design: A stepped-wedge cluster randomised trial.

Methods: We performed our study in five EDs in the Netherlands from December 2020 to December 2021. Adult patients with urine cultures obtained during ED presentation were screened for inclusion and we excluded patients with indications for antibiotic therapy. The de-implementation strategy included education, reminders and competitive feedback on baseline results. The primary endpoint was patients with ASB treated with antibiotics. Secondary endpoints included the treatment duration and the number of urine tests ordered (urinalyses and urine cultures) in the ED per 1000 adult patients.

Results: In total, 6837 urine cultures were screened. ASB was present in 224/3289 (7%) and 201/3548 (6%) patients, from whom 65/224 (29%) and 46/201 (23%) were inappropriately treated with antibiotics in the baseline and intervention period, respectively (adjusted odds ratio 1.20, 95% CI 0.56-2.62, p = 0.65). The number of urinalyses ordered decreased from 182 to 153 per 1000 patients (incidence rate difference -29.10, 95% CI -46.36 to -11.78, p < 0.001). Further, the treatment duration was shortened for patients with ASB in the intervention period (baseline period: 7.98 days (standard deviation (SD) 4.31) vs 5.79 days (SD 3.33), p = 0.006).

Conclusion: Diagnostic stewardship by our de-implementation strategy reduced the number of urinalyses ordered and treatment duration in the ED, but we found no significant reduction in overtreatment of ASB.

Trial registration: The trial was registered at https://onderzoekmetmensen.nl/en/trial/25918, on 17-12-2019, registration number NL8242. The first participants were enrolled on 01-12-2020.

Background: A predictive scoring system used in patients with acute respiratory distress syndrome (ARDS) known as Age, PaO₂/FiO₂, Plateau Pressure Score (APPS) has been externally validated to predict mortality in Asian and Caucasian populations. Its performance in Latin American and COVID-19 patients still needs to be done.

Objective: To assess the association between APPS and mortality, as well as APPS performance in predicting mortality within 28 days of intensive care unit (ICU) admission in patients with ARDS due to COVID-19.

Design: Analytical observational retrospective cohort study.

Methods: We conducted a retrospective cohort study in patients diagnosed with ARDS according to the Berlin criteria who were admitted to the ICU. We evaluated the prognostic performance of APPS using the area under the receiver operating characteristic curve (AUC-ROC), and association with mortality was measured using the Cox proportional hazards regression models.

Results: A total of 271 patients were analyzed. The AUC for 28-day mortality was 0.78 (95% CI: 0.73-0.84). In the Cox proportional hazards model, after adjusting for sex and categorized Charlson Comorbidity Index, it was found that grade 2 APPS (aHR: 3.67, 95% CI: 2.14-6.30, p < 0.001) and grade 3 APPS (aHR: 7.95, 95% CI: 3.72-17.02, p < 0.001) were associated with a higher hazard of 28-day mortality.

Conclusion: The APPS scoring system has a good prognostic performance for mortality in patients diagnosed with COVID-19-induced ARDS.

Introduction: The blood culture positivity rate in the emergency department (ED) is <20%; however, the mortality associated with Community-acquired bacteraemia (CAB) is as high as 37.8%. For this reason, several models have been developed to predict blood culture positivity for the diagnosis of CAB.

Objective: To validate two bacteraemia prediction models in a high-complexity hospital in Colombia.

Design: External validation study of the ID-BactER and Shapiro scores based on a consecutive cohort of patients who underwent blood culture within 48 h of ED admission.

Methods: Scale calibration was assessed by comparing expected and observed events (calibration belt). Discriminatory ability was assessed by area under the ROC curve (AUC-ROC).

Results: We included 1347 patients, of whom 18.85% were diagnosed with CAB. The most common focus of infection was the respiratory tract (36.23%), and the most common microorganism was Escherichia coli (52.15%). The Shapiro score underestimated the risk in all categories and its discriminatory ability was poor (AUC 0.68 CI 95% 0.64-0.73). In contrast, the ID-BactER score showed an adequate observed/expected event ratio of 1.07 (CI 0.85-1.36; p = 0.018) and adequate calibration when expected events were greater than 20%, in addition to good discriminatory ability (AUC 0.74 95% CI 0.70-0.78).

Conclusion: The Shapiro score is not calibrated, and its discriminatory ability is poor. ID-BactER has an adequate calibration when the expected events are higher than 20%. Limiting blood culture collection to patients with an ID-BactER score ⩾4 could reduce unnecessary blood culture collection and thus health care costs.

Great disparities and inequities in the delivery and acceptance of human immunodeficiency virus (HIV) prevention exist globally among women. Various barriers, such as societal stigma, low perceived risk, relationship dynamics, and lack of education on routes of HIV transmission can cause low utilization in HIV preexposure prophylaxis (PrEP) adoption and use. In addition, socioeconomic and structural factors, such as financial burden, lack of provider knowledge and willingness to prescribe, absence of insurance coverage, and limited access to healthcare services are additional barriers to PrEP use among cisgender women. The goal of this review is to highlight current and prospective PrEP options, attitudes, and views of PrEP use among cisgender women and healthcare providers, and the role of PrEP in special populations of cisgender women.

Background: Young people's sexual health decision-making, including decisions to access and adhere to HIV prevention strategies such as Pre-Exposure Prophylaxis (PrEP), are influenced by a range of internal and external factors. Synthesizing these factors is essential to guide the development of youth-focused PrEP health promotion strategies to contribute to international goals of ending HIV transmission.

Objective: To understand the individual, interpersonal, sociocultural and systemic barriers and facilitators to PrEP access, uptake and use experienced by young people 24 years and younger.

Design: A systematic review that adhered to the Preferred Reporting Items of Systematic Review and Meta-Analysis Protocols.

Data sources and methods: Eight databases (PubMed, Scopus, Cochrane, Medline, CINAHL, JBI, EMBASE, Web of Science) were systematically searched using terms related to young people, HIV and PrEP use. A narrative synthesis approach was used to delineate key barriers and facilitators to PrEP access, uptake and use.

Results: Of 11,273 returned articles, 32 met the eligibility criteria for inclusion: 18 from the United States, 10 from African nations and two from Brazil. Barriers and facilitators to PrEP access, uptake and use experienced by young people were identified across intrapersonal, interpersonal, community and systems levels. These factors are described under four overarching themes that relate to knowledge, side effects and perceptions of risk; attitudes and perceptions of family and partners; community attitudes and stigma; and negative healthcare provider experiences and difficulties navigating complex costly healthcare systems.

Conclusion: Findings suggest individual-level factors need consideration alongside the impacts of healthcare systems and broader systemic sociocultural structures within young people's relationships when developing PrEP health promotion strategies and services. Without considering these wider external implications to access, uptake and use of PrEP, global targets towards the elimination of HIV transmission will likely remain out of reach.

Registration: This review was registered with Prospero (CRD42022296550).