Successful control of a large outbreak of HIV infection associated with injection of cathinone derivatives in Tel Aviv, Israel.

OBJECTIVES: Outbreaks of HIV infection have been linked to injectable drug abuse, but specific triggers often remain obscure. We report on an outbreak of primary HIV infection among people who inject drugs (PWID) in Tel Aviv, associated with a local shift in drug-use practices. METHODS: A cluster of primary HIV infection cases in PWID was detected in May 2012. Retrospective and prospective multi-hospital case finding was initiated. PWID were interviewed and risk factors for primary HIV infection were identified. Starting in December 2012, a multifaceted intervention was implemented, including educational activities, increasing syringe exchange supplies, active screening, early initiation of antiretroviral therapy, and referral to drug withdrawal programmes. RESULTS: Forty-two PWID with primary HIV infection were detected between May 2012 and April 2013. Compared with the corresponding pre-outbreak period, the annual incidence of primary HIV infection in PWID increased from 0 to 20 cases/1000 population (p <0.0001). Sixty-nine per cent were hospitalized because of concomitant bacterial infections and sepsis. Phylogenetic analysis of HIV isolates from case patients showed tight clustering suggesting a single common source of infection. The outbreak was temporally related to a widespread shift from heroin to injectable cathinone-derivatives and buprenorphine, which entailed high-risk injection practices. Targeted intervention resulted in a dramatic and sustained reduction in HIV infection in the PWID population. CONCLUSIONS: Injectable amphetamines are gaining momentum among PWID worldwide. Tracing of this outbreak to cathinone use and implementing a targeted intervention programme effectively terminated the outbreak.

A comparative study of the use of selective digestive decontamination prophylaxis in living-donor liver transplant recipients.

INTRODUCTION: Bacterial infections are major causes of early morbidity and mortality after liver transplantation. Selective digestive decontamination (SDD) can be used pre-operatively for living-donor liver transplant (LD-LT), but its role in this setting remains controversial. METHODS: To evaluate this strategy, we retrospectively analyzed a cohort of consecutive LD-LTs performed in our center from March 2007 to February 2011 and compared the incidence and nature of early infectious complications, length of intensive care unit stay and hospitalization, antibiotic use, and emergence of resistant bacteria in patients with or without SDD prophylaxis. RESULTS: Of 148 LD-LTs in the study period, 111 received SDD prophylaxis while 37 did not. In a multivariate model, the independent factors associated with an increased risk of early post-transplant infections were length of postoperative mechanical ventilation (for every additional day odds ratio [OR] = 2.37, 95% confidence interval [CI] 1.4-4.0; P = 0.002), and choledochojejunostomy (OR = 4.5, 95% CI 1.95-10.5; P < 0.001). Use of SDD did not affect the rate or distribution of infectious complications, duration of hospitalization, antibiotic use, or acquisition of resistant bacteria (OR = 3.52, 95% CI 0.43-15.17; P = 0.376). CONCLUSION: In conclusion, the use of SDD prophylaxis in LD-LT was not beneficial and should be avoided, as it offers no advantage and could potentiate the emergence of multidrug-resistant organisms.

A case of hepatitis A vaccination failure in an HIV-positive man who had sex with men in Israel.

Hepatitis A virus (HAV) vaccination is recommended for men who have sex with men (MSM) and other susceptible populations, who are at increased risk for HAV infection, such as HIV-positive persons. Vaccines failures are uncommon, and in HIV-positive individuals whose CD4 count is ≥ 500 cells/mm(2), seroconversion is achieved in 73-94% of vaccinees following the second dose. Data were retrieved from the patient's file at the sexually transmitted disease clinic and the AIDS clinic describing this rare case of vaccine failure. A 35-year-old, HIV-positive MSM was vaccinated against HAV on 2007, while his CD4 count was 551 cells/mm(2). Two years later, he was hospitalized due to acute HAV. The patient's serum drawn two months prior to the onset of acute HAV was retrospectively tested and showed no response to the vaccine. The source of the HAV infection was not identified. The patient's partner who was HIV-negative and had been vaccinated simultaneously with the same batch developed protective antibodies. In conclusion, HIV-positive patients and their providers should be informed about HAV vaccine failure, and post-immunization serologies to hepatitis should be considered to evaluate immunization response. Alternative approaches to develop immunity are needed for non-responders.

Emergence of an HIV-1 cluster harbouring the major protease L90M mutation among treatment-naïve patients in Tel Aviv, Israel.

OBJECTIVE: Drug resistance-associated mutations (DRMs) among HIV-1 treatment-naïve patients have increased in recent years. Their incidence and prevalence in various exposure risk categories (ERCs) were evaluated. DESIGN: Plasma samples of HIV-1 treatment-naïve patients diagnosed between 2001 and 2009 at the Tel Aviv Medical Center were screened for DRMs. METHODS: Samples obtained from patients following the HIV diagnosis were analysed retrospectively. Genotyping was carried out using the Trugene HIV-1 genotype kit (Siemens, Berkeley, CA, USA). Phylogenetic relationships among viral sequences were estimated using the maximum likelihood method. RESULTS: Thirty-eight of the 266 analysed sequences (14.3%) had DRMs, all occurring exclusively in the group of men who have sex with men (MSM). The rate of DRMs has constantly risen, reaching a peak of 21.9% in 2009. Notably, protease inhibitor (PI) DRMs became the most frequent DRMs in 2009. Phylogenetic analysis showed a tight cluster comprising 13 of 14 viruses harbouring the L90M major PI resistance mutation, suggesting a single infection source. CONCLUSION: There was an unexpectedly high rate of the major L90M PI resistance mutation in the MSM group. The clustered transmission of this mutation might be related to a high-risk sexual behaviour. Added to nonnucleoside reverse transcriptase inhibitor and nucleoside reverse transcriptase inhibitor resistance mutations, such a PI mutation may limit future therapeutic options for this particular patient population.

Duration of antibacterial treatment for uncomplicated urinary tract infection in women.

BACKGROUND: Uncomplicated urinary tract infection (UTI) is a common disease, occurring frequently in young sexually active women. In the past, seven day antibiotic therapy was recommended while the current practice is to treat uncomplicated UTI for three days. OBJECTIVES: TO compare the efficacy and safety of three-day antibiotic therapy to multi-day therapy (five days or longer) on relief of symptoms and bacteriuria at short-term and long-term follow-up. SEARCH STRATEGY: The Cochrane Library (Issue 1, 2004), the Cochrane Renal Group's Register of trials (July 2003), EMBASE (January 1980 to August 2003), and MEDLINE (January 1966 to August 2003) were searched. We scanned references of all included studies and contacted the first or corresponding author of included trials and the pharmaceutical companies. SELECTION CRITERIA: Randomised controlled trials comparing three-days oral antibiotic therapy with multi-day therapy (five days and longer) for uncomplicated cystitis in 18 to 65 years old non-pregnant women without signs of upper UTI. DATA COLLECTION AND ANALYSIS: Data concerning bacteriological and symptomatic failure rates, occurrence of pyelonephritis and adverse effects were extracted independently by two reviewers. Relative risk (RR) and their 95% confidence intervals (CI) were estimated. Outcomes were also extracted by intention-to-treat analysis whenever possible. MAIN RESULTS: Thirty-two trials (9605 patients) were included. For symptomatic failure rates, no difference between three-day and 5-10 day antibiotic regimen was seen short-term (RR 1.06, 95% CI 0.88 to 1.28) and long-term follow-up (RR 1.09, 95% CI 0.94 to 1.27). Comparison of the bacteriological failure rates showed that three-day therapy was less effective than 5-10 day therapy for the short-term follow-up, however this difference was observed only in the subgroup of trials that used the same antibiotic in the two treatment arms (RR 1.37, 95% CI 1.07 to 1.74, P = 0.01). This difference was more significant at long-term follow-up (RR 1.43, 95% CI 1.19 to 1.73, P = 0.0002). Adverse effects were significantly more common in the 5-10 day treatment group (RR 0.83, 95% CI 0.74 to 0.93, P = 0.0010). Results were consistent for subgroup and sensitivity analyses. AUTHORS' CONCLUSIONS: Three days of antibiotic therapy is similar to 5-10 days in achieving symptomatic cure during uncomplicated UTI treatment, while the longer treatment is more effective in obtaining bacteriological cure. In spite of the higher rate of adverse effects, treatment for 5-10 days could be considered for treatment of women in whom eradication of bacteriuria is important.