R.B.S. Laing

Trends in missed presentations and late HIV diagnosis in a UK teaching hospital: a retrospective comparative cohort study

BackgroundLate diagnosis is an important cause of HIV-related morbidity, mortality and healthcare costs in the UK and undiagnosed infection limits efforts to reduce transmission. National guidelines provide recommendations to increase HIV testing in all healthcare settings. We evaluated progress towards these recommendations by comparing missed opportunities for HIV testing and late diagnosis in two six year cohorts from North East Scotland.MethodsWe reviewed diagnostic pathways of all patients newly diagnosed with HIV referred to infectious diseases and genito-urinary medicine services between 1995 and 2000 (n = 48) and 2004 to 2009 (n = 117). Missed presentations (failure to diagnose ≤ 1 month of a clinical or non-clinical indicator for testing), late diagnosis (CD4 < 350 cells/mm3), and time to diagnosis (months from first presentation to diagnosis) were compared between cohorts using χ2 and log-rank tests. Determinants of missed presentation were explored by multivariate logistic regression. Breslow-Day tests assessed change in diagnostic performance by patient subgroup.ResultsThere were significant decreases in missed presentations (33% to 17%; P = 0.02) and time to diagnosis (mean 17 months to 4 months; P = 0.005) but not in late diagnosis (56% vs. 60%; P = 0.57) between earlier and later cohorts. In the later cohort patients were significantly more likely to have acquired HIV abroad and presented with early HIV disease, and testing was more likely to be indicated by transmission risk or contact with GUM services than by clinical presentation. Missed presentation remained significantly less likely in the later cohort (OR = 0.28, 95% CI 0.11 to 0.72; P = 0.008) after adjustment for age, transmission risks and number of clinical indicators. Reductions in missed presentation were greater in patients < 40 years, of non-UK origin, living in least deprived neighbourhoods and with early disease at presentation (P < 0.05). 27% of missed presentations occurred in primary care and 46% in general secondary care.ConclusionsWhile early diagnosis has improved in epidemiological risk groups, clinical indications for HIV testing continue to be missed, particularly in patients who are older, of UK origin and from more deprived communities. Increasing testing in non-specialist services is a priority.

Parenteral ganciclovir treatment of acute CMV infection in the immunocompetent host

SummaryThe treatment with ganciclovir of two non-compromised patients who required hospitalisation with acute cytomegalovirus (CMV) infection is described. Ganciclovir has rarely been used in such circumstances but, in four previously reported patients and in the patients described here, a rapid response to therapy was seen. In contrast to previous reports, relatively short courses of treatment (3–5 days) were given to our patients. The drug was well tolerated in each case and may have a role to play in the treatment of severe acute CMV infection in the normal host.

Epidemiology and outcome of HIV infection in North-East Scotland (1985–1997)

OBJECTIVE to assess the epidemiology of HIV infection in North-East Scotland. METHODS retrospective casenote review of all HIV-infected patients who have had contact with the Infection Unit in Aberdeen. RESULTS one hundred and forty-two HIV-infected patients were treated between April 1985 and December 1997. The risk behaviour related to the acquisition of the HIV infection was: 56 (39%) homosexually infected, 45 (32%) heterosexually-infected, 34 (24%) injecting drug users (IDUs), and seven (5%) blood products or not known. Sixteen of the 45 (36%) heterosexually-infected patients were native to Africa and 16 of the 34 (31%) IDUs were prisoners in Peterhead prison at the time of referral. Fifty-two (37%) of the cohort continue to attend the Infection Unit, 41 (29%) have relocated, 40 (28%) have died and nine (6%) have been lost to follow-up. The ratio of heterosexual:homosexual men:IDUs changed significantly between the first 7 years (12:21:25) and the second 6 years (33:35:9) of the review, with significantly more patients being infected through heterosexual contact and fewer infected by IDU in the second period-P<0.001. The median AIDS survival was 17 months. Survival was significantly longer in those patients who took anti-retroviral therapy (median = 20 months) than in the patients who opted not to take anti-retroviral therapy (median = 11 months)-P<0.01. CONCLUSIONS Although homosexual contact represents the commonest risk group for HIV infection in this region, the number of heterosexually-infected patients has increased significantly in the last 5 years. Temporary residents account for one-third of the HIV-infected population cared for in NE Scotland. Almost half of those lost to follow-up have returned to Africa or been released from prison. The introduction of anti-retroviral therapy has resulted in a dramatic improvement in AIDS survival in our cohort as it has done elsewhere.

Listeria monocytogenes and Staphylococcus aureus coinfection of a prosthetic joint

A 73-year-old man was admitted to hospital with an 8-month history of pain in his left hip. The patient was systemically well. He was known to have suffered from osteoarthritis for which he was treated with diclofenac for 9 months but due to the progressive nature of the illness, he had subsequently undergone a left total hip replacement 3 years earlier. He did not have rheumatoid arthritis (RA) and was not on steroids. On examination, the operative wound on the left side had two broken areas neither of which was inflamed. The left leg was 1 cm shorter than the right with a fixed flexion deformity of 10 and a positive Trendelenburg test. Radiograph of the left hip showed marked osteolysis around the polythene acetabular cup and the proximal end of the femoral component. Two-stage hip revision surgery was planned. In the first stage, all cement and both components were removed and samples were taken for culture. Three out of the five intra-operative samples grew S. aureus susceptible to flucloxacillin, rifampicin, vancomycin, and teicoplanin while one sample grew L. monocytogenes susceptible to amoxicillin, rifampicin, vancomycin, and teicoplanin. The patient was treated with flucloxacillin for the first 10 days but due to its poor efficacy against listeria, therapy was switched to intravenous teicoplanin plus oral rifampicin. Antibiotics were administered for 6 weeks. A second stage operation was successfully performed 3 months after the initial surgery. Aspirates from the joint taken at the second operation were sterile.

Invasive Staphylococcus aureus infections in diabetes mellitus

Staphylococcus aureus, the most virulent of the many staphylococcal species, has remained a major cause of morbidity and mortality despite the availability of numerous effective anti-staphylococcal antibiotics. S. aureus causes disease through both toxin-mediated and non-toxin-mediated mechanisms. This organism is responsible for both healthcare associated and community-based infections ranging from relatively minor skin and soft tissue infections to severe life threatening systemic infections. Patients with diabetes mellitus are at increased risk of invasive S. aureus infections. This article focuses on the spectrum of invasive S. aureus infections and discusses the clinical features, investigations and management of these infections in patients with diabetes mellitus.

Takayasu’s arteritis and an elevated antistreptolysin O titre – a potentially expensive diagnostic conundrum

Lesson Takayasus arteritis is a chronic large vessel vasculitis which may be associated with a false positive antistreptolysin O titre.

Duration of intravenous therapy and hospital stay according to choice of empirical antimicrobial treatment for community-acquired respiratory infection.

A review of patients admitted to medical wards with respiratory infection was undertaken to look for differences in duration of intravenous (IV) therapy and length of patient stay based on the class of IV antimicrobial used in treatment. Data was analysed from 231 patients with community-acquired respiratory infection who were treated empirically for at least 24 h with either an IV cephalosporin (146 patients) or an IV penicillin or macrolide (85 patients). The severity of illness and indication for IV treatment was similar in each group. Those treated with a cephalosporin received IV therapy for a significantly longer period (mean = 4.44 days, SD = 2.6) than those given a penicillin or macrolide (mean = 3.3 days, SD = 1.8): P < 0.001. Patient stay was significantly longer in the cephalosporin group (mean = 11.6 days, SD = 10.4) than the penicillin/macrolide group (mean = 9.4 days, SD = 6.3): P = 0.04. These differences are most readily accounted for by the absence from the hospital formulary of a third generation oral cephalosporin, a drug that might be regarded as an obvious form of follow-on therapy in patients treated empirically with an injectable cephalosporin.

Odontoid peg and skull base osteomyelitis presenting as Streptococcus pneumoniae meningitis in diabetes mellitus

Skull base osteomyelitis (SBO) is a severe infection that is most frequently seen in elderly patients with diabetes. It is associated with high morbidity and mortality rates despite intensive antibiotic therapy. This condition, which often has a subtle course and nonspecific symptoms, is difficult to diagnose clinically. Meningitis is a rare presentation of this uncommon infection. This case report describes a 65-year-old man with type 2 diabetes who presented acutely with Streptococcus pneumoniae meningitis and was diagnosed with skull base osteomyelitis, retropharyngeal abscess, cervical spine osteomyelitis and discitis. The literature on SBO was reviewed and management discussed.

Assessment of antiretroviral adherence in a cohort of HIV positive patients

Aim: To quantify adherence and understand the reasons behind reduced adherence to antiretroviral medication in a small cohort of HIV +ve patients. Method: 3 1 point verbal questionnaire administered by investigator to 23 patients attending outpatient follow-up clinics. Results: 18 male and 5 female patients completed the questionnaire. Average no. of pills per patient was nine. 17/23 patients had missed at least one dose during treatment. 19/23 estimated >90% adherence, 1123 between 80-90% and 3123 ~80%. Reasons for missed doses were forgetting 66%, interference with everyday activities 48% and side effects 46 % Two of the 23 patients (9 %) cited being drunk as a reason for missing medication. High levels of adherence were associated with undetectable or very low viral loads. Conclusions: Adherence to antiretrovirals is vital to successful treatment. Levels of adherence in our group were similar to those in previous trials’. The importance of adherence in the suppression of viral load was apparent even in our small group. AN ASSESSMENT OF THE POTENTIAL IMPACT OF MOLECULAR DIAGNOSIS ON THE MANAGEMENT OF PATIENTS WITH ENTEROVIRAL MENINIGITIS. S. Majumdar and J. Cheesbrough. Royal Preston Hospital and Chorley and South Ribble District General Hospital UK. Study sample: Patients admitted to medical wards between 01/4/01-30/9/01 from whom a CSF sample compatible with viral meningitis was collected. Study models: The impact of three different models of enterovims reverse transcriptase polymerase chain reaction (RT-PCR) test provision on the care of each patient have been examined. Model: A. Test available off site from Monday to Friday with result is available on the same day but 1 day delay in transit. B. Test available on site from 9 am to 3 pm Monday to Friday with result is available by 5pm. C. Test available on the site on an emergency basis with result within 2 hours. Sensitivity and specificity of the test is taken as 100%. The first day on which patient was ambulatory and self caring was taken as the date of earliest possible discharge providing 24 hours had elapsed post lumbar puncture. Time of stopping antibiotics was taken as immediately after result available. Results: The records of 15 patients were examined. With each model the following mean number of hospital days were saved A 1.2, B 2.1, C 2.2. Estimated total savings at lE18K; B &31K; C &33K. Total antibiotic costs avoided were A &1156; B 51954 and C &2773.