Caroline Solas

Chronic hepatitis E resolution in a human immunodeficiency virus (HIV)-infected patient treated with ribavirin

both with the intrinsic colistin resistance of the species and the acquired fluoroquinolone resistance of this specific isolate. The ESBL-carrying plasmid was successfully transferred by transformation to rifampicin-resistant E. coli K-12 J53, along with the streptomycin resistance. However, conjugation could not be achieved despite several attempts. PCR and sequencing of the whole coding sequence of the resistance determinant in the transformant proved the presence of a blaCTX-M-55/57 gene preceded by an ISEcpI element. The blaCTX-M-55/57 gene was carried on a 70-kb F2:A-:BIncFII plasmid, as determined by replicon sequence typing and by Southern blot with blaCTX-M and IncF probes on S1 nuclease pulsed-field gel electrophoresis (S1-PFGE) gels (data not shown). The CTX-M-55/57 enzyme, which was almost concomitantly described in the recent past in Salmonella enterica, E. coli and Klebsiella pneumoniae isolates issuing from Asian countries, only differs from CTX-M-15 by an A80V substitution [3]. This CTX-M-1 group enzyme has been abundantly reported in Thailand, Hong Kong and China, not only in humans but also in a broad range of animal species, including food-producing animals and pets [3,4]. In Europe on the contrary, this enzyme has only been detected in humans who had contact with Asian countries. Only one veterinary case has recently been described in a dairy farm in England that had apparently no link with Asia. Altogether, it is thus reasonable to hypothesise that this CTX-M-55/57-producing P. mirabilis isolate most probably originated from Vietnam and was acquired by the primate before its transportation to France. Interestingly enough, as shown by restriction fragment length polymorphism (RFLP) analysis using PstI and EcoRI restriction enzymes, this plasmid was also indistinguishable from an F2:A:Bplasmid carrying the blaCTX-M-14 gene and harboured by a ST45 K. pneumoniae isolate #26971 recovered from a cow mastitis sample in 2011 in France (Fig. 1) [5]. F2:A-:Bplasmids were reported as vehicles of ESBL genes in food-producing animals and pets, in which they were carrying the blaCTX-M-14, blaCTX-M-3 or blaCTX-M-65 genes. They are also one of the most frequently reported IncFII plasmids carrying ESBL genes in Enterobacteriaceae in humans, where they were particularly found in association with the blaCTX-M-15 gene. Once again, this highlights the fact that the F2:A-:Bplasmid backbone has widely disseminated both in humans and animals worldwide. In conclusion and to the best of our knowledge, this case report is the first characterisation of an ESBL-producing P. mirabilis isolate in animals. This study further indicates that F2:A-:Bplasmids are also carrying ESBL genes in P. mirabilis in animals, as already reported in K. pneumoniae and E. coli.

Relapse of hepatitis C virus after 14 months of sustained virological response following pegylated-interferon alpha plus ribavirin therapy in a human immunodeficiency virus type 1 infected patient

It has been demonstrated that sustained virological response (SVR) in patients with chronic hepatitis C indicates resolution of infection. We describe a late hepatitis C virus (HCV) relapse with nearly identical HCV genotype 1a RNA, 14 months after a SVR achievement following a 12-month pegylated-interferon plus ribavirin treatment in a human immunodeficiency virus (HIV) infected patient. This virological relapse occurred concomitantly with interruption of highly active antiretroviral therapy and subsequent increased immunosuppression. HCV retreatment was successful and HCV RNA was undetectable at 50 months of follow-up. This case suggests that late relapse of HCV infection in HIV-positive patients with SVR is possible in case of increased immunodeficiency related to highly active antiretroviral therapy interruption. In such circumstances, a close monitoring of HCV viremia and aminotransferases should be performed.

First Real Life Evidence of New Direct-acting Antivirals (DAA) in Co-infected HIV HCV Patients: Better than Ever

TO THE EDITOR—Direct-acting antiviral (DAA)-based anti-hepatitis C virus (HCV) therapies currently provide amazing opportunities to cure almost all HCVpositive patients. However, these results were obtained in clinical trials. We read the points raised by Shafran with interest [1], proposing that all future phase 3 antiHCV clinical trial programmes should include human immunodeficiency virus (HIV)-coinfected participants with HCVmonoinfected patients, because HIV coinfection does not affect sustained

HIV Protease Inhibitors Do Not Cause the Accumulation of Prelamin A in PBMCs from Patients Receiving First Line Therapy: The ANRS EP45 “Aging” Study

Background The ANRS EP45 “Aging” study investigates the cellular mechanisms involved in the accelerated aging of HIV-1 infected and treated patients. The present report focuses on lamin A processing, a pathway known to be altered in systemic genetic progeroid syndromes. Methods 35 HIV-1 infected patients being treated with first line antiretroviral therapy (ART, mean duration at inclusion: 2.7±1.3 years) containing boosted protease inhibitors (PI/r) (comprising lopinavir/ritonavir in 65% of patients) were recruited together with 49 seronegative age- and sex-matched control subjects (http://clinicaltrials.gov/, NCT01038999). In more than 88% of patients, the viral load was <40 copies/ml and the CD4+ cell count was >500/mm3. Prelamin A processing in peripheral blood mononuclear cells (PBMCs) from patients and controls was analysed by western blotting at inclusion. PBMCs from patients were also investigated at 12 and 24 months after enrolment in the study. PBMCs from healthy controls were also incubated with boosted lopinavir in culture medium containing various concentrations of proteins (4 to 80 g/L). Results Lamin A precursor was not observed in cohort patient PBMC regardless of the PI/r used, the dose and the plasma concentration. Prelamin A was detected in PBMC incubated in culture medium containing a low protein concentration (4 g/L) but not in plasma (60–80 g/L) or in medium supplemented with BSA (40 g/L), both of which contain a high protein concentration. Conclusions Prelamin A processing abnormalities were not observed in PBMCs from patients under the PI/r first line regimen. Therefore, PI/r do not appear to contribute to lamin A-related aging in PBMCs. In cultured PBMCs from healthy donors, prelamin A processing abnormalities were only observed when the protein concentration in the culture medium was low, thus increasing the amount of PI available to enter cells. ClinicalTrials.gov NCT01038999 http://clinicaltrials.gov/ct2/show/NCT01038999.

HIV-1 Infection and First Line ART Induced Differential Responses in Mitochondria from Blood Lymphocytes and Monocytes: The ANRS EP45 “Aging” Study

Background The ANRS EP45 “Aging” study investigates the cellular mechanisms involved in the accelerated aging of HIV-1 infected and treated patients. The data reported focus on mitochondria, organelles known to be involved in cell senescence. Methods 49 HIV-1 infected patients untreated with antiretroviral therapy, together with 49 seronegative age- and sex-matched control subjects and 81 HIV-1 infected and treated patients, were recruited by 3 AIDS centres (Marseille, Montpellier, Nice; France; http://clinicaltrials.gov/, NCT01038999). In more than 88% of treated patients, the viral load was <40 copies/ml and the CD4+ cell count was >500/mm3. ROS (reactive oxygen species) production and ΔΨm (inner membrane potential) were measured by flow cytometry in blood lymphocytes and monocytes (functional parameters). Three mitochondrial network quantitative morphological parameters were computed using confocal microscopy and image analysis. Three PBMC mitochondrial proteins (porin and subunits 2 and 4 of cytochrome C oxidase encoded by mtDNA or nuclear DNA, respectively) were analysed by western blotting. Results Quantitative changes in PBMC mitochondrial proteins were not induced by either HIV-1 infection or ART. Discriminant analysis integrating functional (ROS production and ΔΨm) or morphological (network volume density, fragmentation and branching) parameters revealed HIV-1 infection and ART differential effects according to cell type. First line ART tended to rescue lymphocyte mitochondrial parameters altered by viral infection, but induced slight changes in monocytes. No statistical difference was found between the effects of three ART regimens on mitochondrial parameters. Correlations between functional parameters and viral load confirmed the damaging effects of HIV-1 in lymphocyte mitochondria. Conclusions In patients considered to be clinically stable, mitochondria exhibited functional and morphological modifications in PBMCs resulting from either direct or indirect effects of HIV-1 infection (lymphocytes), or from first line ART (monocytes). Together with other tissue impairments, these changes may contribute to global aging. Trial Registration ClinicalTrials.gov NCT01038999 NCT01038999

Hepatitis C virus NS3 protease genotyping and drug concentration determination during triple therapy with telaprevir or boceprevir for chronic infection with genotype 1 viruses, southeastern France

Telaprevir and boceprevir, the two first hepatitis C virus (HCV) NS3 protease inhibitors (PIs), considerably increase rates of sustained virologic response in association with pegylated interferon and ribavirin in chronic HCV genotype 1 infections. The 30 first patients treated by telaprevir or boceprevir including anti‐HCV therapies since 2011 in Marseille University hospitals, France, were monitored. HCV loads and plasmatic concentrations of telaprevir and boceprevir were determined on sequential blood samples. HCV NS3 protease gene population sequencing was performed at baseline of treatment and in case of treatment failure. Fifteen patients (including 7 co‐infected with HIV) received telaprevir and the other 15 patients (including 4 co‐infected with HIV) received boceprevir. At baseline, HCV NS3 protease from six patients harbored amino acid substitutions associated with PI‐resistance. Treatment failure occurred at week 12 for 7 patients. Amino acid substitutions associated with PI‐resistance were observed in six of these cases. HCV NS3 R155K and T54A/S mutants, all of genotype 1a, were found from four patients. Median (interquartile range) plasma concentrations were 3,092 ng/ml (2,320–3,525) for telaprevir and 486 ng/ml (265–619) for boceprevir. For HIV–HCV co‐infected patients, median concentrations were 3,162 ng/ml (2,270–4,232) for telaprevir and 374 ng/ml (229–519) for boceprevir. Plasma drug concentration monitoring revealed undetectable concentrations for two patients at week 4, and probable non‐adherence to therapy for another patient. These findings indicate that routine HCV NS3 protease sequencing and plasma PI concentration monitoring might be helpful to characterize cases of therapy failure, at a cost dramatically low compared to that of anti‐HCV therapy. J. Med. Virol. 86:1868–1876, 2014.

Addition of boceprevir to PEG-interferon/ribavirin in HIV-HCV-Genotype-1-coinfected, treatment-experienced patients: efficacy, safety, and pharmacokinetics data from the ANRS HC27 study.

Background: Scarce data exist on the efficacy and safety of the PEGylated-interferon/ribavirin/boceprevir regimen in HIV/HCV-coinfected patients who failed to respond to PEGylated-interferon/ribavirin treatment. Objectives: To evaluate the efficacy and safety of this drug regimen and the impact of the addition of boceprevir(BOC) on atazanavir (ATV) or raltegravir (RAL) pharmacokinetic parameters in a subgroup of patients. Methods: In this single-arm phase 2 trial, HIV-1/HCV-genotype-1-coinfected patients received PEGylated-interferonα2b (1.5 μg/kg/week)+ ribavirin (800–1400 mg/day) alone until W4 and with BOC(800 mgTID) until W48. Based on virologic response at W8, the three drugs were stopped or PEGylated-interferon/ribavirin was continued alone until W72. The primary endpoint was SVR at W24 off-therapy (SVR24). Results: 64 patients were included. SVR24 was achieved in 53% of patients (CI90%: 43–63%) and in 90% of previous relapsers. In univariate analysis, SVR24 was associated with response to previous HCV treatment, HCV-1b subtype, HCV-RNA decline, ribavirin-Ctrough at W4, and HCV-RNA at W8 but not to fibrosis score, IL28B genotype, or boceprevir-Ctrough at W8. In multivariate analysis, SVR24 remained associated with response to previous HCV treatment [non-responders versus null responders: OR = 5.0(1.3–20.0); relapsers vs. null responders: OR = 28.8(4.9–169.5)]. HCV treatment was discontinued for adverse events in 17% of patients. A 51% decrease in ATV/r-AUC0–8 h (p < 0.01) and a 57% increase in RAL-AUC0–8 h (p < 0.01) were observed, although atazanavir/r or raltegravir did not affect BOC-AUC0–8 h significantly. The ATV mean Cthrough fell from 763.8 ng/mL (CI 95%: 230.3–1297.3) without BOC to 507.7 ng/mL (CI 95%: 164–851.4) with BOC. Conclusions: Boceprevir-based regimen demonstrated a high SVR24 rate in treatment-experienced HIV-HCV genotype-1-coinfected relapsers.

Lack of benefit of 3-month intensification with enfuvirtide plus optimized background regimen (OBR) versus OBR alone in patients with multiple therapeutic failures: the INNOVE study.

The objective of the present study was to evaluate the virological efficacy of a 3‐month short‐course intensification with enfuvirtide (ENF) associated with an optimized background regimen (OBR) in treatment‐experienced patients infected with HIV‐1 with multiple therapeutic failures. This was a prospective, randomized, open‐label multicenter trial including patients infected with HIV‐1 and harboring a multi‐resistant virus that was still susceptible to at least 2 active compounds. Patients were randomized (1:1) to receive OBR + ENF or OBR alone. ENF was discontinued at Week 12. The primary endpoint was the proportion of patients with plasma viral load <50 copies/ml at Week 24. Fifteen patients were randomized into the OBR group and 14 into the OBR + ENF group with a median viral load of 4.1 log10 copies/ml and a median CD4+ cell count of 346 cells/mm3. The primary endpoint was achieved in 93% (14/15) and 79% (11/14) of patients, respectively. Eighty‐seven percent (13/15) of patients had a viral load <50 copies/ml as soon as Week 12 in the OBR group and 79% (11/14) in the OBR + ENF group. At Week 12, the median CD4+ cell count was 327 in the OBR and 437 in the OBR + ENF groups and at Week 24 they were comparable. Intensification with ENF had no significant impact on PBMCs HIV‐DNA levels. A 3‐month short‐course intensified treatment with ENF did not improve Week‐24 virological response in treatment‐experienced patients infected with HIV‐1 harboring resistant viruses that were still susceptible to two antiretroviral drugs. J. Med. Virol. 84:1710–1718, 2012.

Ebola viral dynamics in nonhuman primates provides insights into virus immuno-pathogenesis and antiviral strategies

Despite several clinical trials implemented, no antiviral drug could demonstrate efficacy against Ebola virus. In non-human primates, early initiation of polymerase inhibitors favipiravir and remdesivir improves survival, but whether they could be effective in patients is unknown. Here we analyze the impact of antiviral therapy by using a mathematical model that integrates virological and immunological data of 44 cynomolgus macaques, left untreated or treated with favipiravir. We estimate that favipiravir has a ~50% efficacy in blocking viral production, which results in reducing virus growth and cytokine storm while IFNα reduces cell susceptibility to infection. Simulating the effect of delayed initiations of treatment, our model predicts survival rates of 60% for favipiravir and 100% for remdesivir when treatment is initiated within 3 and 4 days post infection, respectively. These results improve the understanding of Ebola immuno-pathogenesis and can help optimize antiviral evaluation in future outbreaks.Optimization of antiviral therapy can be crucial in the management of Ebola virus outbreaks. Here, Madelain et al. use an integrative mathematical model to correlate the dose and the time of treatment initiation with survival rate, enhanced immune response and viral clearance.

Drug-Drug Interactions Potential of Direct Acting Antivirals for the treatment of Chronic Hepatitis C infection

The advent of direct-acting antiviral agents (DAAs) has transformed the hepatitis C virus (HCV) therapeutic landscape in terms of efficacy and safety, with a cure rate of more than 90%. However, an important potential for drug-drug interactions (DDIs) is expected with these combinations, particularly in patients with other comorbidities (e.g. HIV co-infection, cardiovascular diseases). Each DAA can be a substrate, an inhibitor and/or an inducer of metabolic enzymes and drug efflux transporters. DAAs can act as both victims and perpetrators of DDIs and can sometimes increase the risk and/or intensity of side effects or limit the efficacy of treatment. Therefore, knowledge and management of DDIs with DAAs should be considered a key issue of HCV therapy. This review describes the pharmacokinetic profile of currently used and recommended DAA regimens and summarizes available data regarding DDIs to optimize HCV treatment in clinical practice.