Amanda J. Durante

Clinical predictors of Pneumocystis carinii pneumonia, bacterial pneumonia and tuberculosis in HIV-infected patients

Background:Clinicians are frequently faced with the differential diagnosis between Pneumocystis carinii pneumonia (PCP), bacterial pneumonia, and pulmonary tuberculosis in HIV-infected patients. Objectives:To identify features that could help differentiate these three pneumonia types at presentation by evaluating the clinical characteristics of the three diagnoses among patients at two urban teaching hospitals. Design:Retrospective chart review. Methods:Cases were HIV-infected patients with a verified hospital discharge diagnosis of PCP (n = 99), bacterial pneumonia (n = 94), or tuberculosis (n = 36). Admitting notes were reviewed in a standardized manner; univariate and multivariate analyses were used to determine clinical predictors of each diagnosis. Results:Combinations of variables with the highest sensitivity, specificity, and odds ratios (OR) were as follows: for PCP, exertional dyspnea plus interstitial infiltrate (sensitivity 58%, specificity 92%; OR, 16.3); for bacterial pneumonia, lobar infiltrate plus fever ≤ 7 days duration (sensitivity 48%, specificity 94%; OR, 14.6); and for tuberculosis, cough > 7 days plus night sweats (sensitivity 33%, specificity 86%; OR, 3.1). On regression analysis, independent predictors included interstitial infiltrate (OR, 10.2), exertional dyspnea (OR, 4.9), and oral thrush (OR, 2.9) for PCP; rhonchi on examination (OR, 12.4), a chart mention of ‘toxic’ appearance (OR, 9.1), fever ≤ 7 days (OR, 6.6), and lobar infiltrate (OR, 5.8) for bacterial pneumonia; and cavitary infiltrate (OR, 21.1), fever > 7 days (OR, 3.9), and weight loss (OR, 3.6) for tuberculosis. Conclusions:Simple clinical variables, all readily available at the time of hospital admission, can help to differentiate these common pneumonia syndromes in HIV-infected patients. These findings can help to inform clinical decision-making regarding choice of therapy, use of invasive diagnostic procedures, and need for respiratory isolation.

Peridomestic Lyme disease prevention: results of a population-based case-control study.

BACKGROUND Peridomestic Lyme disease-prevention initiatives promote personal protection, landscape modification, and chemical control. PURPOSE A 32-month prospective age- and neighborhood-matched case-control study was conducted in Connecticut to evaluate the effects of peridomestic prevention measures on risk of Lyme disease. METHODS The study was conducted in 24 disease-endemic Connecticut communities from 2005 to 2007. Subjects were interviewed by telephone using a questionnaire designed to elicit disease-prevention measures during the month prior to the case onset of erythema migrans. Data were analyzed in 2008 by conditional logistic regression. Potential confounders, such as occupational/recreational exposures, were examined. RESULTS Between April 2005 and November 2007, interviews were conducted with 364 participants with Lyme disease, and 349 (96%) were matched with a suitable control. Checking for ticks within 36 hours of spending time in the yard at home was protective against Lyme disease (OR=0.55; 95% CI=0.32, 0.94). Bathing within 2 hours after spending time in the yard was also protective (OR=0.42; 95% CI=0.23, 0.78). Fencing of any type or height in the yard, whether it was contiguous or not, was protective (OR=0.54; 95% CI=0.33, 0.90). No other landscape modifications or features were significantly protective against Lyme disease. CONCLUSIONS The results of this study suggest that practical activities such as checking for ticks and bathing after spending time in the yard may reduce the risk of Lyme disease in regions where peridomestic risk is high. Fencing did appear to protect against infection, but the mechanism of its protection is unclear.

Estimating the prevalence of syringe-borne and sexually transmitted diseases among injection drug users in St Petersburg Russia.

Injection drug users (IDUs) are the vanguard of the human immunodeficiency virus (HIV) epidemic in Russia. We sought a non-invasive method to estimate a point prevalence of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis and risk behaviours in IDUs attending the syringe exchange programme (SEP) in St Petersburg, Russia. One hundred and one IDUs returning syringes to the St Petersburg SEP were invited to complete a questionnaire requesting demographic, knowledge, and behavioural information, and to provide their syringes for antibody testing. The median age of IDUs was 23 years. Syringe prevalences were: 10.9% for HIV, 78.2% for HCV, 15.8% for HBV, and 6.9% for syphilis. All respondents recognized drug-related risk factors for getting AIDS. Only two-thirds of subjects recognized condoms to prevent sexually transmitted infections and half knew that oil-based lubricants are not appropriate for condoms. The IDU population studied was young and requires additional interventions to encourage safer sexual behaviours.

Sexual Functioning among HIV-Infected Women

The influence of HIV on sexual activity and functioning presents a unique set of issues. HIV transmissibility, partner disclosure, potential vertical transmission and, for some HIV-infected women, problems associated with illicit drug use, may affect sexuality. Few studies have examined HIV-infected womens sexuality and none have studied the relationship between HIV symptoms, HIV illness stage, quality of life, meaning of illness and sexual functioning. This descriptive study examines sexual activity, sexual functioning and safer sex behavior among 101 HIV-seropositive women. Results indicate that (1) the majority of women continue to be sexually active after testing HIV positive, (2) sexual functioning does not change as a result of HIV disease progression, and (3) few women report that HIV itself caused worsening of their sexual functioning. Those women with better mental health, more positive meaning attributed to life with HIV infection, better quality of life, fewer HIV-related symptoms and who never used injection drugs had higher levels of sexual functioning. Greater focus on sexual functioning as an integral part of clinical assessment is needed. Patterns of sexual behavior among HIV-infected women require continued study as we search for more effective means to prevent secondary HIV transmission.

Sexually Transmitted Infections, Sexual Risk Behaviors and the Risk of Heterosexual Spread of HIV among and beyond IDUs in St. Petersburg, Russia

Aims: This study investigates whether sexual transmitted behaviors and infections (STIs) among injection drug users (IDUs) may promote the spread of HIV among and beyond IDUs in Russia. Methods: We conducted a cross-sectional survey of behavior and tested for STIs in a convenience sample of 159 IDUs in St. Petersburg, Russia. Results: The median age was 27 and 57% were male. Almost all were sexually active, half had casual partners and 40% reported ≧2 sex partners in the previous 3 months. Of those who answered, 81% reported sex without condoms, 44% reported having sex with at least one partner who was not an IDU. Of 139 (87%) subjects who were actively injecting, 29% reported receptive syringe sharing. Twenty percent of subjects were seropositive for HIV-1 and 42% of HIV-1-negative subjects tested positive for an STI. Conclusions: The sample exhibited high levels of sexual risk behaviors and STIs, and a large proportion had sexual partners who were not IDUs. This population requires comprehensive interventions that ensures access to condoms and sterile injection supplies and that encourage safer sexual behaviors in an attempt to keep sexual transmission of HIV low.

Home-based study of anti-HIV drug regimen adherence among HIV-infected women: Feasibility and preliminary results

Collection of antiretroviral medication adherence data in the homes of HIV-infected people may have methodological advantages that can improve data quality. However, the feasibility of this approach has not been established. In addition, data on adherence, and its predictors, among HIV-infected women have been limited. Sixty-three HIV-positive women who were prescribed at least one antiretroviral drug in the last month were interviewed in their homes. A standard instrument was used to collect data on all antiretroviral medications prescribed and taken in the three days prior to the interview. Data were also collected on factors thought potentially to affect the ability to be adherent. The results of this study suggest that it is feasible to conduct home-based adherence research. Sixty-seven per cent reported taking all prescribed antiretroviral medication doses. One-third took a sub-optimal dose putting themselves at increased risk of treatment failure and the selection of resistant HIV strains. Unintentional reasons for missing doses were most commonly reported. An ability to describe the intended effect of antiretroviral therapy on HIV viral load was the best predictor of adherence. This finding is consistent with other research suggesting that adherence is associated with an understanding and belief in the effectiveness of antiretroviral therapy.

HIV infection in injecting drug users attending centres in England and Wales, 1990-1991

ObjectiveTo monitor trends in HIV infection and associated risk behaviours in injecting drug users (IDU) in England and Wales. DesignOngoing voluntary unlinked anonymous cross-sectional survey. MethodIDU attending centres in 1990 and 1991 were invited to complete a brief questionnaire requesting demographic and behavioural information, and to provide a saliva sample to be tested for antibodies to HIV and to the core antigen of hepatitis B virus (HBV). ResultsIn 1990, 1.2% (19 out of 1543) of samples from 33 centres, and in 1991 1.8% (25 out of 1417) of samples from 37 centres contained antibody to HIV. Antibody to HBV core-antigen was found in 33 and 31% of IDU in 1990 and 1991, respectively. The prevalence of HIV infection in IDU attending centres in London (4.2%) was higher than in those attending centres elsewhere (0.8%). The prevalence of HIV infection in 1991 varied between individual centres from 0 to 10.6%, and at many centres outside London no IDU were infected with HIV. In the same year the prevalence of past infection with HBV varied from 14 to 54%, and IDU who had evidence of HBV infection were found among attenders in nearly all centres. The prevalences of sharing injecting equipment and risky sexual behaviour were high at many centres. The prevalence of HIV infection was higher in IDU who had started to inject in 1985 or earlier, than in those who started injecting later. In each year, approximately half the IDU surveyed reported having had a voluntary confidential HIV-antibody test, and the prevalence of HIV infection was five times higher in those tested than in those who had not been tested. ConclusionHIV prevalence in IDU attending centres in England and Wales was low in 1990–1991. There is some indication that IDU have modified their injecting or sexual behaviour, but even at existing reduced levels of risk behaviour, transmission can occur if HIV is introduced into previously unexposed groups.

Measurement of serum D-arabinitol/creatinine ratios for initial diagnosis and for predicting outcome in an unselected, population-based sample of patients with Candida fungemia.

ABSTRACT d-Arabinitol (DA) is a useful diagnostic marker for candidiasis in patients with neutropenia and other high-risk groups, but its use in unselected patients with a broad range of underlying diseases and conditions has not been studied. We used an automated enzymatic fluorometric assay to measure serum DA/creatinine ratios (DA/crs) in 30 healthy adults, 100 hospitalized controls without Candida fungemia, and 83 patients from a study of all Candida fungemias in Connecticut between October 1998 and September 1999. Sixty-three of 83 (76%) fungemic patients and 11 of 100 (11%) nonfungemic controls had serum DA/crs ≥3.9 μM/mg/dl (mean + 3 standard deviations for 30 healthy adults). High serum DA/crs were less frequent in patients with cancer or fungemia caused by the DA nonproducer Candida glabrata than in patients with cancer or fungemia caused by a DA producer, C. albicans, C. tropicalis, or C. parapsilosis. The serum DA/cr was first ≥3.9 μM/mg/dl before, on the same day as, or after the first positive blood culture was drawn for 30 (36%), 22 (27%), and 11 (13%) fungemia patients, respectively. Mortality did not differ significantly among the patients with high or normal initial or peak serum DA/crs, but mortality was higher if any serum DA/cr value was ≥3.9 μM/mg/dl 3 or more days after the onset of fungemia (18/27 versus 4/24 patients, respectively; P < 0.001). We conclude that serum DA/crs are useful both for the initial diagnosis of Candida fungemia and for prognostic purposes for unselected patients with a broad range of underlying diseases and conditions.

Connecticut Competency-Based Point of Dispensing Worker Training Needs Assessment

OBJECTIVES In April 2006, Connecticut conducted an exercise that tested its ability to receive and dispense antibiotics from the Strategic National Stockpile. In conjunction with the exercise, a competency-based assessment was performed to determine the training needs of point of dispensing (POD) workers. METHODS POD core competencies were developed by adapting existing preparedness materials. They were used to assess the training needs of more than 250 people who staffed a POD during the exercise. The assessment measured their confidence in their ability to perform 17 competency-based tasks. RESULTS The vast majority needed training on 5 or fewer tasks, suggesting that they were fairly well trained. Pharmacists were particularly likely to need training on at least 5 tasks. Given their role in a POD operation, they should be a focus of further training. Almost one third of participants needed additional training on at least 1 of the 3 basic POD Incident Command System tasks. Additional training is also needed on competencies concerning POD safety and security, liability protections, and family preparedness. POD workers who are concerned about these matters may be less willing or able to staff a POD. People who participated in training both before and on the day of the exercise were best prepared to staff the POD, indicating that both types of training have value. CONCLUSIONS When compared with the competencies, POD workers possessed many of the necessary skills to staff a POD; however, training with emphasis on areas of weakness revealed by the assessment could improve willingness to report for duty and performance.

An Evaluation of the National Malaria Surveillance System of Bhutan, 2006–2012 as It Approaches the Goal of Malaria Elimination

Introduction Bhutan is progressing toward malaria elimination. The purpose of this evaluation was to assess the ability of the surveillance system from 2006 to 2012 to meet the objectives of the Bhutan Vector-borne Disease Control Program (VDCP) and to highlight priorities requiring attention as the nation transitions to elimination. Methods The evaluation was conducted using the Center for Disease Control guidelines for evaluating public health surveillance systems. Data sources included a search of publically available literature, VDCP program data, and interviews with malaria surveillance personnel. Blood slide quality assurance and control through formal assessment of slide preparation and measures of between-reader correlation were performed. Results Total malaria cases declined from 2006 to 2012. The average slide positivity rate decreased from 3.4% in 2006 to 0.2% in 2012. The proportion of non-residents in all cases increased to its highest value of 22.6% in 2012, and significant clustering in the border regions of India was noted, with Sarpang accounting for more cases than any other district from 2009 onward. Case detection was almost exclusively passive, but flexibility and sensitivity was demonstrated by the later addition of active case detection and specification of imported and locally acquired cases. Spatial data were limited to the village level, not allowing identification of transmission hotspots. For blood smears, statistical measures of between-reader agreement and predictive value were not computed. Blood smear quality was suboptimal by at least one criterion in over half of evaluated smears. Timeliness in reporting of cases was on a weekly to monthly basis, and did not meet the WHO goal of immediate notification. Conclusion As of 2012, the national malaria surveillance system demonstrated flexibility, representativeness, simplicity, and stability. The full potential for data analysis was not yet realized. Attaining the goal of malaria elimination will require system function enhancement through increased and more accurate case detection and rapid investigation, improved health worker training and accountability, focally targeted response measures, and, in particular, the challenge of finding re-introductions of infections from India. Many such measure have been undertaken or planned as part of the next phase of the Bhutan’s National Strategic Plan.