Roberto Posada

A hybrid strategy for the prevention of cytomegalovirus-related complications in pediatric liver transplantation recipients.

Background. This single center, retrospective study describes experience with a hybrid prevention strategy combining short-course antiviral prophylaxis and preemptive cytomegalovirus (CMV) polymerase chain reaction (PCR) monitoring. Methods. One hundred twenty-two pediatric liver transplantation recipients were followed up for a median of 2.3 years posttransplantation. Subjects received a minimum of 14 days of postoperative ganciclovir, followed by monthly CMV PCR monitoring. Results. Forty-three CMV seronegative recipients received seropositive grafts and were considered high risk for CMV; 79 subjects were routine risk. CMV was detected by PCR in the absence of symptoms in 34.4% of subjects and was more likely in high risk than in routine risk recipients (58.1% vs. 21.8%, P=0.0001). Twelve subjects (9.8%) developed CMV disease (8 high risk vs. 4 routine risk, P=0.03). Three subjects developed acute rejection in the 6 months after detection of CMV, but CMV was preceded by rejection in 13 subjects. There were no mortalities secondary to CMV. A total of 38.5% of subjects were spared antiviral medications beyond their initial postoperative prophylaxis. Conclusions. These results suggest that a hybrid preventative approach for CMV is a reasonable alternative to prolonged antiviral prophylaxis and may reduce unnecessary exposure to antiviral therapy. However, patients who receive intensified immunosuppression after acute rejection are at increased risk for CMV and may require extended prophylaxis and closer monitoring.

An update on immunizations before and after transplantation in the pediatric solid organ transplant recipient

Abuali MM, Arnon R, Posada R. An update on immunizations before and after transplantation in the pediatric solid organ transplant recipient. 
Pediatr Transplantation 2011: 15: 770–777.

Psychiatric symptoms and antiretroviral nonadherence in US youth with perinatal HIV: a longitudinal study.

Objectives:The relationship of specific psychiatric conditions to adherence has not been examined in longitudinal studies of youth with perinatal HIV infection (PHIV). We examined associations between psychiatric conditions and antiretroviral nonadherence over 2 years. Design:Longitudinal study in 294 PHIV youth, 6–17 years old, in the United States and Puerto Rico. Methods:We annually assessed three nonadherence outcomes: missed above 5% of doses in the past 3 days, missed a dose within the past month, and unsuppressed viral load (>400 copies/ml). We fit multivariable logistic models for nonadherence using Generalized Estimating Equations, and evaluated associations of psychiatric conditions (attention deficit hyperactivity disorder, disruptive behavior, depression, anxiety) at entry with incident nonadherence using multivariable logistic regression. Results:Nonadherence prevalence at study entry was 14% (3-day recall), 32% (past month nonadherence), and 38% (unsuppressed viral load), remaining similar over time. At entry, 38% met symptom cut-off criteria for at least one psychiatric condition. Greater odds of 3-day recall nonadherence were observed at week 96 for those with depression [adjusted odds ratio (aOR) 4.14, 95% confidence interval (CI) 1.11–15.42] or disruptive behavior (aOR 3.36, 95% CI 1.02–11.10], but not at entry. Those with vs. without attention deficit hyperactivity disorder had elevated odds of unsuppressed viral load at weeks 48 (aOR 2.46, 95% CI 1.27–4.78) and 96 (aOR 2.35, 95% CI 1.01–5.45), but not at entry. Among 232 youth adherent at entry, 16% reported incident 3-day recall nonadherence. Disruptive behavior conditions at entry were associated with incident 3-day recall nonadherence (aOR 3.01, 95% CI 1.24–7.31). Conclusion:In PHIV youth, comprehensive adherence interventions that address psychiatric conditions throughout the transition to adult care are needed.

Prevention of cytomegalovirus following solid organ transplantation: a literature review.

CMV is the most common opportunistic infection affecting SOT recipients. Although current strategies to prevent both CMV infection and disease have been effective, CMV related complications continue to occur, particularly late‐onset CMV disease. This literature review article examines the benefits and disadvantages of different prevention modalities, and presents emerging strategies to better prevent CMV in organ transplant recipients.

Small for Gestational Age Birth Outcomes in Pregnant Women with Perinatally Acquired HIV

Objective:To compare small for gestational age (SGA) birth weight in children born to women with perinatally acquired HIV (PAH) vs. those with behaviorally acquired HIV (BAH). Design:Retrospective cohort study of HIV-infected pregnant women who received care and delivered a live born at a single hospital in New York City from January 2004 to April 2011. Methods:We collected data via chart review on demographics, behavioral risk factors, HIV clinical markers, antiretroviral therapy (ART), mode of HIV acquisition, and pregnancy outcomes on study participants. We compared rates of these exposures among participants by method of HIV acquisition. Generalized Estimating Equation was applied to evaluate the effect of HIV acquisition type on SGA birth weight, adjusting for potential confounders. Results:Of 87 live births evaluated, 17 were born to 14 women with PAH. Overall, 20 (23%) were SGA. Eight of these SGA neonates were born preterm. Live births to women with PAH were more likely to be born SGA in our unadjusted analysis [odds ratio (OR) = 4.13, 95% confidence interval (CI) = 1.38–12.41). After adjusting for mothers age, substance use during pregnancy, nadir CD4 cell count during pregnancy, viral suppression at delivery, and second-line ART use during pregnancy, this relationship persisted with an adjusted OR of 5.7 (95% CI = 1.03–31.61). Conclusion:In comparison to infants born to women with BAH, infants born to women with PAH were at high risk for compromised intrauterine growth. Future studies are warranted to determine possible causal mechanisms.

Growth patterns in the first year of life differ in infants born to perinatally vs. nonperinatally HIV-infected women.

Objective:To compare the growth patterns in the first year of life between children born to perinatally HIV-infected (PHIV) vs. nonperinatally HIV-infected (NPHIV) women in the United States. Design:Retrospective cohort study of HIV-infected pregnant women who received care and delivered a live-born at two urban tertiary centers from January 2004 to March 2012. Methods:We collected data via chart review on demographics, behavioral risk factors, HIV clinical markers, combination antiretroviral therapy (cART), mode of HIV acquisition, pregnancy outcomes, and infant anthropometrics on study participants. Mixed-effects models were used to assess the association between maternal mode of HIV acquisition and weight-for-age z-score (WAZ), length-for-age z-score (LAZ), and weight-for-length z-score (WLZ). Results:Of the 152 pregnancies evaluated, 32 and 120 infants were born to 25 PHIV and 99 NPHIV women, respectively. Infants of PHIV women exhibited lower mean WAZ and LAZ throughout the first year of life in unadjusted analyses. After adjusting for potential confounders, the relationship between PHIV women and LAZ persisted (&bgr; = −0.54, P = 0.026). Small-for-gestational age for each birth anthropometric parameter (birth length, birth weight, and both birth length and weight) was associated with decreased LAZ (&bgr; = −0.48, P = 0.007), WAZ (&bgr; = −0.99, P < 0.001), and WLZ (&bgr; = −0.36, P = 0.027), respectively. A delivery HIV RNA level below 400 copies/ml was associated with increased WAZ and WLZ (&bgr; = 0.43, P = 0.015 and &bgr; = 0.38, P = 0.021, respectively). Conclusions:Infants of PHIV women may remain at persistently decreased lengths throughout the first year of life. Further studies aimed at understanding intrauterine and environmental factors in PHIV women are warranted.

Factors associated with inconsistent condom use in adolescents with negative or unknown HIV status in Northwest Cameroon

The purpose of this study is to evaluate the association between utilization of HIV testing and condom use amongst Cameroonian youths/adolescents who are not known to be HIV-infected. Worldwide, HIV is spreading most quickly amongst youths/adolescents. Between 44% and 82% of sexually active youths in Cameroon report inconsistent condom use. Data regarding utilization of HIV testing and condom use are lacking. A cross-sectional survey was administered to 431 youths ages 12–26 years in Cameroon from September 2011 to December 2011. Data on sociodemographics, sexual risk behaviors, self-reported HIV status, and condom use were collected. We compared rates of inconsistent condom use between those with known HIV negative status who utilized testing (HIV-N) and those with unknown status due to unutilized testing (HIV-U). Inconsistent condom use was defined as responding “never,” “sometimes,” or “usually,” while consistent condom use was defined as responding “always” to questions regarding frequency of condom use. Generalized estimating equations were applied to assess the association between HIV testing and inconsistent condom use, adjusting for other confounders. Of 414 eligible respondents, 205 were HIV-U and 209 were HIV-N. HIV-U subjects were younger (mean age = 16.4 vs. 17.9, p < 0.001) and more likely to report living in an urban area (p = 0.002) than HIV-N subjects. Seventy-two percent (137/191) of sexually active youths reported inconsistent condom use. After adjusting for potential confounders, HIV-U status (odds ratio [OR] = 3.97, 95% confidence interval [CI] = 1.68–6.01) was associated with inconsistent condom use. Similarly, female gender (OR = 3.2, 95% CI = 1.29–7.89) was associated with inconsistent condom use, while older age at sexual debut was associated with a decreased risk for inconsistent condom use (OR = 0.67, 95% CI = 0.56–0.81). Cameroonian adolescents report high rates of inconsistent condom use which we found to be associated with self-reported unknown HIV status due to unutilized HIV testing. Successful HIV prevention programs among African youths/adolescents may benefit from expanded HIV testing programs.

Salvage Regimens Containing Darunavir, Etravirine, Raltegravir, or Enfuvirtide in Highly Treatment-Experienced Perinatally Infected Pregnant Women

Combination antiretroviral therapy in pregnant women with human immunodeficiency virus has dramatically decreased maternal-to-child transmission. Highly treatment-experienced pregnant patients have limited effective treatment options due to past toxicities and viral resistance. We present 8 pregnancies in 7 perinatally infected women successfully treated with salvage regimens containing darunavir, etravirine, raltegravir, or enfuvirtide.

Impact of surveillance stool culture guided selection of antibiotics in the management of pediatric small bowel transplant recipients.

Abstract:  Surveillance stool cultures (SSC) have been used in immunocompromised populations to predict the organisms associated with invasive infections and aid in the selection of empiric antibiotic regimens. To evaluate the utility of this approach in pediatric small bowel transplant (SBT) recipients, we conducted a retrospective review of 33 patients who underwent SBT, 16 of whom had SSC done. In no case was the same organism isolated from SSC and subsequent blood, peritoneal fluid or wound cultures. In the first month post‐transplantation, blood cultures were positive in 44% and 35% of patients that had and did not have SSC done, respectively (p = 0.73); peritoneal fluid cultures in 44% and 65% (p = 0.30); and wound cultures in 44% and 24% (p = 0.28). There were no significant differences among both groups in time to first infection, duration of ICU stay following SBT, graft survival or long‐term patient survival. We conclude that SSC‐guided antibiotic selection does not have a significant impact on the incidence of invasive infections in the first month following SBT or on specific indicators of patient outcome. This suggests that empiric antibiotic regimens should be selected based on clinical presentation and hospital flora and susceptibility patterns.

Susceptibility to Measles Among Perinatally HIV-Infected Adolescents and Young Adults

Among our cohort of adolescents and young adults with perinatally acquired human immunodeficiency virus, few (17.6%) had measles protective antibodies by plaque reduction neutralization (PRN). Agreement was demonstrated between the commercial enzyme immunoassay and the PRN assay (K = 0.59 [95% confidence interval: 0.23-0.95]). Further studies are needed to understand the determinants of immunity in this population.