Brian Wispelwey

Candida prosthetic arthritis: report of a case treated with fluconazole and review of the literature

Prosthetic arthritis due to Candida species is uncommon, with only 15 cases reported in the literature. We recently cared for a human immunodeficiency virus-infected patient who developed Candida parapsilosis prosthetic arthritis unresponsive to resection arthroplasty, intravenous amphotericin B, and suppressive ketoconazole therapy. Treatment with fluconazole led to mycologic cure and symptom improvement, although he subsequently underwent above-the-knee amputation due to continued joint instability. Fluconazole may be useful follow-up therapy after a course of amphotericin B combined with resection arthroplasty or when removal of the prosthesis cannot be accomplished.

Clinical Implications of Pharmacokinetics and Pharmacodynamics of Fluoroquinolones

This review summarizes key data illustrating the clinical importance of pharmacodynamics, particularly among the fluoroquinolone family of antibacterials. Antibacterials are often divided into 2 groups--either time-dependent or concentration-dependent agents--on the basis of their mechanism of killing. Fluoroquinolones are concentration-dependent agents, and the parameter that correlates most closely with clinical and/or bacteriological success is the ratio of the area under plasma concentration curve (AUC) to the minimum inhibitory concentration (MIC). The AUC : MIC threshold may vary by organism. For example, a ratio of at least 30 is often cited as optimal to achieve success against Streptococcus pneumoniae, whereas higher ratios (>100) are considered to be optimal for the treatment of infections due to gram-negative bacilli. Data are cited to suggest that the minimum ratio necessary to prevent the selection of resistant mutants may, in fact, be somewhat higher. Maximizing the AUC : MIC through the use of potent therapy may offer an opportunity to limit the development of resistance to fluoroquinolones.

Adrenal suppression due to an interaction between ritonavir and injected triamcinolone: a case report

Two HIV-1 infected patients developed signs and symptoms consistent with adrenal suppression after being exposed to intra-articular triamcinolone acetate while also receiving ritonavir as part of their highly active antiretroviral therapy. Laboratory evaluation confirmed secondary adrenal suppression in both cases. Both patients recovered without the need for chronic replacement steroids. Adrenal suppression has been described as an adverse outcome in patients treated with fluticasone and concomitant ritonavir. In the reported cases, the adrenal suppression likely developed as a result of increased systemic concentrations of triamcinolone due to an inhibition of cytochrome p450 3A4 metabolism. Practitioners of HIV medicine should be aware of the potential negative interaction of injected triamcinolone and ritonavir.

Infected Physicians and Invasive Procedures: Safe Practice Management

There is currently no public policy that provides guidance concerning whether and when physicians infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or human immunodeficiency virus (HIV) can safely perform invasive procedures. A committee of experts in the fields of medicine, law, and biomedical ethics and 1 community member, aided by an advisory board, was established to produce recommendations for policy reform. An extensive literature review was conducted for these 3 infectious diseases, medicine, surgery, epidemiology, law, and bioethics to gather all relevant data. Special recommendations are made regarding the management of physicians who are infected with HIV, HBV, and/or HCV. This policy proposal includes a list of exposure-prone procedures and a decision chart that indicates under what conditions infected physicians can practice beyond the need for disclosure of their serological status.

Case Report: Venous Thromboembolism in AIDS

Recently, the authors managed three patients with AIDS and venous thromboembolism. All three were active, ambulatory, and without known risk factors for pulmonary embolism or deep venous thrombosis. One patient had a low titer for IgG anticardiolipin antibody (1:13). Two had low normal values for free protein S, and the third patient had a very low value (5%). Clinicians caring for AIDS patients should be alert to the possibility that venous thromboembolism may complicate HIV infection.

Pentamidine: a review.

With the advent of the acquired immunodeficiency syndrome (AIDS), the therapeutic importance of pentamidine isethionate has increased greatly. This review summarizes the pharmacology, clinical experience in the treatment of Pneumocystis carinii pneumonia, and toxicity of pentamidine. Data are conflicting as to whether pentamidine is more or less effective than trimethoprim-sulfamethoxazole (TMP-SX) for the treatment of P carinii pneumonia in individuals with AIDS, but due to its toxicity and expense, it is considered as second-line therapy for P carinii pneumonia by many authorities. Hypoglycemia has been encountered in up to 27%, and nephrotoxicity in 25%, of treatment courses with pentamidine. In an attempt to circumvent the toxicities associated with parenteral administration, aerosolized delivery has been evaluated for both therapy and prevention of P carinii pneumonia. Aerosolized pentamidine, on the basis of early clinical results, convenience, and low toxicity, is being used extensively to prevent P carinii pneumonia in individuals at high risk. Relapses occur, however, and pneumothorax may be more common in those using this form of prophylaxis. Aerosolized pentamidine should not be used as sole therapy for acute P carinii pneumonia.

Fluoroquinolones in the management of community-acquired pneumonia in primary care.

A literature search was conducted to evaluate the pharmacokinetic and pharmacodynamic profile of the respiratory fluoroquinolones (gemifloxacin, levofloxacin and moxifloxacin) and their efficacy and safety in the management of community-acquired pneumonia (CAP). Data show that CAP is a common presentation in primary care practice, and is associated with high rates of morbidity and mortality, particularly in the elderly. Although the causative pathogens differ depending on treatment setting and patient factors, Streptococcus pneumoniae is the primary pathogen in all treatment settings. As a class, the respiratory fluoroquinolones have a very favorable pharmacokinetic and pharmacodynamic profile. Pharmacodynamic criteria suggest that moxifloxacin and gemifloxacin are more potent against S. pneumoniae, which may have the added benefit of reducing resistance selection and enhancing bacterial eradication. The respiratory fluoroquinolones are also generally well tolerated, and are first-line options for outpatient treatment of CAP in patients with comorbidities or previous antibiotic use.

Pretransplant cryptococcosis and outcome after liver transplantation

The posttransplant outcomes and optimal management of patients with end‐stage liver disease who develop cryptococcosis prior to transplantation have not been defined. We discuss these issues in the context of successful liver transplantation and pretransplant cryptococcal disease. Our report suggests that liver transplantation may be cautiously considered under the umbrella of fluconazole therapy in patients with end‐stage liver disease and pretransplant cryptococcosis, provided that disease control is achieved with adequate treatment before transplantation. Liver Transpl , 2010.

Urbs in Rure Redux: Changing Risk Factors for Rural HIV Infection

The purpose was to ascertain risk factors for HIV infection in a predominantly rural population using descriptive epidemiologic studies performed at a university health sciences center. Participants included adult patients with HIV infection or AIDS who were cared for between January 1982 and January 1993. The relative frequency of cases in minority and female heterosexual patients increased significantly. The male to female ratio among blacks with HIV infection declined to 1.1:1 during the final 3 years of the study. Patients who believed they had acquired infection in Virginia were more likely to cite a rural area of acquisition and to have had multiple heterosexual partners but were less likely to have had male homosexual contact than patients who believed they had been infected in other states. HIV continued to spread into rural areas of Virginia, and the gender ratio among blacks with HIV declined throughout the study. Having multiple heterosexual partners, the main risk factor for HIV transmission worldwide, may now result in HIV infection in rural Virginia.

Increase in CD4 Lymphocyte Counts After Splenectomy in HIV-infected Patients

The records were reviewed of five human immunodeficiency virus (HIV) type 1-infected patients who underwent splenectomy, four for HIV-associated thrombocytopenia and one for gastric compression secondary to splenomegaly. After splenectomy, the four adult patients all had marked, sustained increases in their absolute CD4 lymphocyte counts; greater increases were observed in CD8 lymphocyte counts, accounting for decreases in the CD4:CD8 ratios. In patients 5 (one of triplets, all of whom were infected with HIV after a blood transfusion), absolute CD4 lymphocyte counts were stabilized after splenectomy; the other siblings manifested a decline in CD4 counts, which was associated with a delay in physical development and recurrent episodes of varicella. Immunohistochemical staining of spleen sections demonstrated significantly higher numbers of CD4 cells in splenic tissue from HIV-infected patients than from patients splenectomized secondary to trauma (2,070 +/- 284 vs. 962 +/- 296; p = 0.025). In addition, the HIV-infected patients had significantly higher percentages of CD4 lymphocytes in splenic tissue than in peripheral blood (49.3 +/- 11.0 vs. 20.3 +/- 7.9; p = 0.005), suggesting that CD4 cells were sequestered in the spleens of these patients. These findings have implications for the management of splenectomized HIV-infected patients with regard to optimal timing of initiation of zidovudine therapy and for prophylaxis of Pneumocystis carinii pneumonia.