Adriana Trajtman

Continuing performance feedback and use of the ultraviolet visible marker to assess cleaning compliance in the healthcare environment

BACKGROUND Environmental surfaces have long been suspected to be a reservoir that could contribute to the presence of micro-organisms in healthcare facilities. The objective of this study was to evaluate the effect of providing weekly feedback to the housekeeping staff in improving and sustaining cleaning compliance when using ultraviolet visible marker (UVM) as an audit tool. METHODS The housekeeping staff selected 90% as the cleaning compliance target. The UVM was applied to the toilet seat, sink, soap dispenser and door knob surfaces within the patients washrooms on consecutive weekdays. The study included three arms: staff in arm 1 received cleaning compliance feedback throughout the 24-week study period, arm 2 and arm 3 staff received feedback for weeks 13-24 and weeks 1-12, respectively. Feedback was also provided to housekeeping staff by posting graphs on the wards and in the housekeeping office. FINDINGS A pre-study audit showed 66.9%, 66.5% and 66.4% cleaning compliance for arms 1, 2 and 3 respectively. While receiving weekly feedback, all three arms demonstrated significantly improved cleaning compliance (86.7%, 80.4% and 73.7% for arms 1, 2 and 3, respectively). The use of casual staff may have contributed to difficulty in achieving better cleaning compliance as arms 1, 2 and 3 had 16.1%, 26% and 40.3% of shifts filled by casual staff, respectively. CONCLUSIONS The use of UVM as an audit tool combined with weekly feedback of results to housekeeping staff resulted in significant, sustained improvement in the overall level of cleaning compliance of housekeeping staff.

Atypical bacterial pneumonia in the HIV-infected population

Human immunodeficiency virus (HIV)-infected individuals are more susceptible to respiratory tract infections by other infectious agents (viruses, bacteria, parasites, and fungi) as their disease progresses to acquired immunodeficiency syndrome. Despite effective antiretroviral therapy, bacterial pneumonia (the most frequently occurring HIV-associated pulmonary illness) remains a common cause of morbidity and mortality in the HIV-infected population. Over the last few decades, studies have looked at the role of atypical bacterial pneumonia (i.e. pneumonia that causes an atypical clinical presentation or responds differently to typical therapeutics) in association with HIV infection. Due to the lack of available diagnostic strategies, the lack of consideration, and the declining immunity of the patient, HIV co-infections with atypical bacteria are currently believed to be underreported. Thus, following an extensive database search, this review aimed to highlight the current knowledge and gaps regarding atypical bacterial pneumonia in HIV. The authors discuss the prevalence of Chlamydophila pneumoniae, Mycoplasma pneumoniae, Coxiella burnetii, Legionella species and others in the HIV-infected population as well as their clinical presentation, methods of detection, and treatment. Further studies looking at the role of these microbes in association with HIV are required. Increased knowledge of these atypical bacteria will lead to a more rapid diagnosis of these infections, resulting in an improved quality of life for the HIV-infected population.

Systemic inflammation before and after antiretroviral therapy initiation as a predictor of immune response among HIV-infected individuals in Manitoba

INTRODUCTION Despite the life‐prolonging effects of Highly Active Antiretroviral Therapy (HAART), persons with HIV are still prone to higher rates of non‐AIDS related morbidity (such as heart, kidney, and liver disease) than the general public. This is likely due to chronic immune activation and inflammation that persists in HIV‐positive persons despite virological suppression. What remains undetermined, however, is whether a link exists between chronic inflammation/immune activation and suboptimal immune recovery on HAART. The hypothesis of the present study is that higher levels of systemic subclinical inflammation and immune activation are linked with suboptimal immune recovery on HAART. METHODS Fifteen eligible patients from the Manitoba HIV program were enrolled and followed for up to two years; blood samples were drawn at 4 timepoints each, and concentrations of 21 proinflammatory markers were measured. Patients were grouped according to CD4:CD8 recovery at viral suppression, and the inflammatory profiles of the two groups were compared. RESULTS AND CONCLUSIONS APRIL and BAFF are higher in those with poor recovery at the point of viral suppression, but were also higher in this group at the onset of therapy and through the three additional follow‐up visits. TNF‐R1, CD163, and Osteopontin, were also in higher concentrations at the outset of therapy and beyond. These five molecules could thus see potential use in the future as biomarkers of likely poor immune recovery. Future work should focus on replicating these findings with larger cohorts.

Unique cytokine and chemokine patterns in bronchoalveolar lavage are associated with specific causative pathogen among HIV infected patients with pneumonia, in Medellin, Colombia

We wanted to investigate the pro-inflammatory cytokine/chemokine profile associated with the etiological agents identified in HIV patients. Immunosuppressed patients admitted to two hospitals in Medellin, Colombia, with clinical and radiographic diagnosis of pneumonia were enrolled in the study. After consent, bronchoalveolar lavage (BAL) was collected for bacterial, mycobacterial and fungal diagnosis. All patients were followed for a year. A stored BAL sample was used for cytokine/chemokine detection and measurement using commercial, magnetic human cytokine bead-based 19-plex assays. Statistical analysis was performed by assigning cytokine/chemokine concentrations levels into <25 percentile (lower), 25-75 percentile (normal) and >75 percentile (higher). Principal component analysis (PCA) and Kruskal-Wallis analysis were conducted to identify the clustering of cytokines with the various infectious etiologies (fungi, Mycobacterium tuberculosis - MTB, and bacteria). Average age of patients was 35, of whom 77% were male, and the median CD4 count of 33cells/μl. Of the 57 HIV infected patients, in-hospital mortality was 12.3% and 33% died within a year of follow up. The PCA revealed increased IL-10, IL-12, IL-13, IL-17, Eotaxin, GCSF, MIP-1α, and MIP-1β concentrations to be associated with MTB infection. In patients with proven fungal infection, low concentrations of IL-1RA, IL-8, TNF-α and VEGF were identified. Bacterial infections displayed a distinct cytokine pattern and were not misclassified using the MTB or fungi cytokine patterns (p-value<0.0001). Our results indicate a unique pattern of pro-inflammatory cytokine/chemokine, allowing differentiation between bacterial and non-bacterial pathogens. Moreover, we found distinct, if imperfectly discriminatory, cytokine/chemokine patterns associated with MTB and fungal infections.

HIV-1 envelope glycoprotein stimulates viral transcription and increases the infectivity of the progeny virus through the manipulation of cellular machinery

During HIV infection, large amounts of progeny viral particles, including infectious virus and a large proportion of defective viral particles, are produced. Despite of the critical role of the infectious viruses in infection and pathogenesis in vivo, whether and how those defective viral particles, especially the virus-associated envelope glycoprotein (vEnv), would impact viral infection remains elusive. In this study, we investigated the effect of vEnv on HIV-infected T cells and demonstrated that the vEnv was able to stimulate HIV transcription in HIV-infected cells, including peripheral blood mononuclear cells (PBMCs) isolated from HIV patients. This vEnv-mediated HIV transcription activation is mediated primarily through the interaction between vEnv and CD4/coreceptors (CCR5 or CXCR4). Through transcriptome analysis, we found that numerous cellular gene products involved in various signaling pathways were modulated by vEnv. Among them, we have further identified a cellular microRNA miR181A2, which is downregulated upon vEnv treatment, resulting in increased HIV LTR histone H3 acetylation and HIV transcription. Furthermore, we also found a vEnv-modulated cellular histone deacetylase, HDAC10, whose downregulation is associated with the increased infectivity of progeny viruses. Altogether, these findings provide evidence of the important role vEnv plays in modulating cellular environments and facilitating HIV expression and infection.

The Prevalence of Legionella Species as a Co-pathogen in HIV-Associated Community-Acquired Pneumonia

Abstract Background Due to the lack of clinical suspicion, poor diagnostic performance, increased patient immunosuppression, and the increased chance of co-infection, HIV-associated Legionella community-acquired pneumonia (CAP) is currently under-reported. Thus, this study aimed to determine the frequency of Legionella in CAP-infected HIV patients. Methods Following initial diagnosis, DNA extracted from bronchoalveolar lavage (BAL) from CAP-infected HIV patients hospitalized at Hospital San Vicente Fundación in Medellin, Colombia were assayed for the presence of Legionella species (PAN Legionella, L. Anisa, L. bozemanii, L. micdadei, L. pneumophila and L. pneumophila serogroup 1) using singleplex real-time PCR (qPCR). Results were validated with agarose gel electrophoresis and reconfirmed using pre-amplification qPCR. Results Of the 59 HIV-infected individuals in the study, majority were non-smokers (64.4%), male (77.9%), and highly immunosuppressed (CD4 cell count <200 cells/μL). Initial CAP diagnoses were M. tuberculosis (37.3%), P. jiroveci (32.2%) and others (30.5%). Initial screening of pooled BAL samples indicated that majority of positive PAN Legionella were associated with M. tuberculosis and P. jiroveci. Of the 14 individual M. tuberculosis-infected patient BAL assayed, 10 were positive for PAN Legionella. Likewise, 6/9 P. jiroveci-infected BAL were also positive. Of all of the detected Legionellaceae infections, 31.3% were L. Anisa, 25.0% L. bozemanii, 18.8% L. pneumophila, and 12.5% L. micdadei, and 37.5% uncharacterized. Interestingly, none of the L. pneumophila infections were due to serogroup 1. Of note, all L. bozemanii and L. micdadei infections were associated with P. jiroveci, while all L. pneumophila infections were associated with M. tuberculosis. Legionella-infected patients had more complications and higher mortality rates compared with un-infected patients. Conclusion Results indicate that Legionella are prevalent in the BAL of HIV co-infected patients. Clinicians should be aware of the possibility of the presence of Legionella—and not just L. pneumophila—in HIV-associated CAP. The role Legionella plays in clinical presentation, disease severity and inflammation remains to be determined. If further investigation supports these findings, this could change the way that CAP is managed in HIV-infected individuals. Disclosures All authors: No reported disclosures.

Evaluation of the Utility of Point-of-Care HIV Testing on a Canadian Internal Medicine Inpatient Unit

Point-of-care (POC) HIV testing has been shown to be an acceptable method for increasing HIV testing uptake. To date, no studies have examined the use of POC testing for routine HIV screening on the medicine inpatient unit. A prospective cross-sectional study was conducted over a three-month period in July, August, and October 2016 to evaluate the prevalence of undiagnosed HIV and the attitudes towards routine POC HIV testing. Patients admitted directly to medicine inpatient teaching units at a tertiary hospital in Winnipeg, Canada, were approached for participation. The POC HIV test was administered at the bedside. Reactive and indeterminate tests were confirmed with standard serological HIV testing. Participants were given a questionnaire regarding their attitudes towards POC testing on the unit. Although no cases of previously undiagnosed HIV were identified during the study period, only 35% of participants were found to have ever had HIV testing previously. The majority of participants were satisfied with the POC testing experience and would choose to have the POC testing again. Overall, the low rate of outpatient testing highlights the need for routine HIV testing on an inpatient basis.