Use of Methenamine for Urinary Tract Infection Prophylaxis: Systematic Review of Recent Evidence.

INTRODUCTION AND HYPOTHESIS: Antibiotic resistance is an unavoidable consequence of antibiotic use and growing rates of resistance are an urgent issue. Methenamine is a non-antibiotic alternative used for urinary tract infection (UTI) prophylaxis. The objective of this review is to evaluate recently published literature regarding the efficacy and safety of methenamine for UTI prophylaxis. METHODS: PubMed, Embase, and CENTRAL databases were queried in March 2023 using the following search terms: urinary tract infection, cystitis, bacteriuria, or dysuria, and methenamine. Studies prior to 2012 were excluded from this review to focus on appraisal of the most recent evidence. Prospective and controlled retrospective trials were included for review. RESULTS: A total of seven studies (three prospective and four retrospective) met the inclusion criteria for review. Two of the 3 prospective studies demonstrated no or non-inferior differences in clinical efficacy to prevent recurrent UTIs between methenamine and antibiotic prophylaxis and the third showed decreased rates of UTI with methenamine use in patients with short-term indwelling catheters compared with cranberry alone. The retrospective studies consistently supported the efficacy and safety of methenamine for UTI prophylaxis in a variety of populations and clinical settings. Adverse effects reported with methenamine were similar to comparators and included nausea, abdominal pain, and headache. CONCLUSIONS: The use of methenamine for UTI prophylaxis was shown to be effective in a variety of settings without an increased risk of adverse effects compared with prophylactic antibiotics. Larger blinded clinical trials are needed to further define the role of methenamine in UTI prophylaxis.

Standard Versus Extended Duration Direct-Acting Antiviral Therapy in Hepatitis C Patients With Slow Response to Treatment.

BACKGROUND: Response-guided hepatitis C therapy was standard with interferon-based regimens but is not used for direct-acting antivirals (DAAs). Week 4 viral kinetics may predict sustained virological response (SVR) with DAAs, but it is unclear whether extending therapy in slow responders affects outcomes. OBJECTIVES: The primary objective was to compare SVR rates between traditional and extended duration groups. Secondary objectives were to compare SVR rates among subgroups and to determine factors associated with SVR. METHODS: This institutional review board-approved, retrospective, single-center study identified patients with chronic hepatitis C virus (HCV) infection with detectable week 4 HCV RNA who were treated with DAAs. Patients were excluded for early discontinuation, treatment regimen not recommended first-line, or missing HCV RNA labs. Patients were stratified into traditional and extended duration groups. The primary end point was SVR. Secondary end points included factors associated with SVR and rationale for extension of therapy duration. RESULTS: A total of 363 patients were included; 58 (16%) received extended therapy. Patients were primarily genotype 1a (70%) and treatment naïve (80%). More than half had advanced fibrosis or cirrhosis. SVR12 rates were 100% in the extended duration group and 96.7% in the traditional duration group (P = 0.37). There were no associations with SVR and prespecified patient-specific factors. Sample size was limited. CONCLUSION AND RELEVANCE: Based on these findings, a recommendation for extension of therapy cannot be made for patients with detectable HCV RNA at week 4 of treatment at this time. Cost analyses may help guide recommendations to re-treat rare failures versus extend therapy in all slow responders.

Impact of prophylactic oseltamivir on INR in patients on stable warfarin therapy.

Influenza prophylaxis with oseltamivir is recommended for exposed high-risk patients. Patients with many comorbidities have an increased likelihood of co-administration of oseltamivir and warfarin. Evidence of a drug interaction is conflicting in the literature and is limited to a 5-day treatment course. This study evaluates the impact of prophylactic oseltamivir on international normalized ratio (INR) in patients taking warfarin. This retrospective cohort study conducted within the Veterans Health Administration included patients on warfarin who received oseltamivir for influenza prophylaxis. The primary endpoint was change in INR from baseline to day 10 of oseltamivir treatment. Secondary endpoints included change in INR based on renal function and duration of oseltamivir prophylaxis, trend in INR, and frequency of bleeding and thrombosis events. A total of 1041 patients were included and received oseltamivir for a mean of 12.9 days. The mean post-oseltamivir INR was significantly increased compared to the pre-oseltamivir INR (2.39 to 2.52; p < 0.001). Patients with a creatinine clearance of 31-60 mL/min had a significant increase in INR (2.40 to 2.59; p < 0.01). There was an increase in INR when oseltamivir was used for 7 or 8-10 days. Of included patients, 5.1% and 1.8% had a recorded thrombosis or bleeding event, respectively. There was a significant increase in INR in patients on chronic warfarin therapy and concomitant prophylactic oseltamivir, but this change may only be clinically significant for certain patient populations. The most impact on INR was within 7-10 days of oseltamivir initiation and in patients with impaired renal function.

Impact of Substance Use Disorder on the Rate of Sustained Virological Response in Veterans With Chronic Hepatitis C Treated With Direct-Acting Antivirals.

BACKGROUND: Substance use disorders (SUDs) are commonly encountered in patients with chronic hepatitis C virus (HCV) infection. It is important to consider the impact of SUDs on HCV treatment. OBJECTIVE: To compare the rate of clinical cure (sustained virological response at least 12 weeks after end of therapy [SVR12]) in veterans with chronic HCV infection treated with direct-acting antivirals (DAAs) with and without ongoing or recent substance use. METHODS: This single-center, retrospective cohort study evaluated 220 HCV patients treated with DAAs based on 2 groups: SUD (ongoing or recent substance use) or non-SUD (without ongoing or recent substance use). The primary end point was SVR12 achievement. Secondary end points included safety, adherence, early discontinuation, SVR12 achievement among SUD subgroups, and enrollment in a SUD treatment program. RESULTS: Most patients were African American men with an average age of 60 years and infected with HCV genotype 1. Almost half of the patients had advanced fibrosis or cirrhosis. There was no difference in SVR12 between groups (SUD: 96.2%; non-SUD: 94.3%; P = 0.54). Overall, 35.5% of patients missed at least 1 dose of DAA therapy, with a significant difference noted between groups (SUD: 44.5%; non-SUD: 26.4%; P = 0.005). Early discontinuation of DAA therapy was similar between groups. SVR12 among SUD subgroups ranged from 92.9% to 100%. In the SUD group, 27.3% of patients were enrolled in a SUD treatment program. Conclusion and Relevance: This study suggests that recent/ongoing substance use does not affect achievement of clinical cure of chronic HCV and reinforces treatment in this patient population.

Incidence of Drug Interactions Identified by Clinical Pharmacists in Veterans Initiating Treatment for Chronic Hepatitis C Infection.

BACKGROUND: Many direct-acting antivirals (DAAs) have drug-drug interactions (DDIs) with the potential to affect efficacy and safety. OBJECTIVE: To describe the incidence and severity of DDIs with DAAs identified by the hepatitis C virus (HCV) clinical pharmacist within a Veterans Affairs health care system. METHODS: This single-center, retrospective cohort study evaluated patients with HCV treated with DAA therapy. Primary end points included the total number of identified DDIs, percentage of patients with at least 1 DDI, mean number of DDIs per patient, and the number of DDIs by severity category. Additional end points included characterization of interacting drugs, clinical consequence of interaction, intervention recommended, acceptance rate of actionable recommendations, and achievement of sustained virological response 12 weeks after treatment (SVR12). RESULTS: A total of 300 patients were included. There were 554 identified DDIs, and 80.3% of patients had at least 1 DDI, with an average of 1.85 DDIs per patient; 76% of the DDIs identified were categorized as either a potentially clinically significant or critical interaction. The most common DDIs involved acid suppression agents (20%). Patient monitoring was the most commonly recommended intervention (59%), followed by dose modification of the interacting medication (30%). There was no difference in SVR12 between patients with at least 1 DDI compared with those with no DDIs (94.8% vs 95.8%; P = 0.73). There were a total of 227 actionable recommendations, with an acceptance rate of 84.1%. CONCLUSIONS: This study suggests that DDIs are prevalent among patients treated with DAAs for HCV. A HCV clinical pharmacist can help optimize patient care by identifying DDIs and recommending interventions to providers.

Reducing Inappropriate Antibiotic Prescribing for Adults With Acute Bronchitis in an Urgent Care Setting: A Quality Improvement Initiative.

Acute bronchitis is a predominantly viral illness and, according to clinical practice guidelines, should not be treated with antibiotics. Despite clear guidelines, acute bronchitis continues to be the most common acute respiratory illness for which antibiotics are incorrectly prescribed. Although the national benchmark for antibiotic prescribing for adults with acute bronchitis is 0%, a preliminary record review before implementing the intervention at the project setting showed that 96% (N = 30) of adults with acute bronchitis in this setting were prescribed an antibiotic. This quality improvement project utilized a single-group, pre-post design. The setting for this project was a large urgent care network with numerous locations in central North Carolina. The purpose was to determine whether nurse practitioners and physician assistants, after participating in a multifaceted provider education session, would reduce inappropriate antibiotic prescribing for healthy adults with acute uncomplicated bronchitis. Twenty providers attended 1 of 4 training sessions offered in October and November 2015. The face-to-face interactive training sessions focused on factors associated with inappropriate antibiotic prescribing, current clinical practice guidelines, and patient communication skills. Retrospective medical record review of 217 pretraining and 335 posttraining encounters for acute bronchitis by 19 eligible participating providers demonstrated a 61.9% reduction in immediate antibiotic prescribing from 91.7% to 29.8%. Delayed prescribing, which accounted for a small percentage of the total prescriptions given, had a small but significant increase of 9.3% after training. Overall, this multifaceted, interactive provider training resulted in significant reductions in inappropriate prescriptions.

Risk factors associated with unfavorable short-term treatment outcome in patients with documented Pseudomonas aeruginosa infection.

BACKGROUND: Invasive infections with Pseudomonas aeruginosa (PA) are associated with significant morbidity and mortality. While risk factors for mortality have been identified, their influence on short-term outcomes impacting treatment selection has not been reported. OBJECTIVES: The objective of this study was to evaluate the relationship between select patient- and treatment-related factors and short-term outcomes in patients with PA pneumonia and/or bacteremia. SETTING: Large academic medical center in the United States. METHODS: This IRB-approved single-center, retrospective case-cohort study included patients >18 years of age with culture-confirmed PA bacteremia and/or pneumonia receiving antimicrobial agent(s) active against PA. MAIN OUTCOME MEASURE: Risk of unfavorable short-term treatment result. RESULTS: The population consisted of 117 patients (40 [34 %] and 77 [66 %] in the unfavorable and not-unfavorable groups, respectively). Baseline characteristics including age (mean of 63 years), gender (55 % male), Charlson score, creatinine clearance, and body mass index were comparable between groups. Piperacillin/tazobactam was the most common monotherapy antibiotic (46 and 33 % in unfavorable and not-unfavorable groups, respectively). Combination therapy primarily consisted of a beta-lactam plus ciprofloxacin in both unfavorable (10 %) and not-unfavorable (20 %) outcome groups. The preliminary regression model indicated that SIRS, direct ICU admission, and vasopressor therapy were associated with an unfavorable outcome. In addition, patients who received more than two active antimicrobials had a reduced risk of an unfavorable outcome. The final regression model revealed that vasopressor therapy (odds ratio [OR] 6.0; 95 % confidence interval [95 % CI] 2.3, 17) was associated with an unfavorable outcome, while receipt of greater than two active antibiotics was associated with a reduced risk of an unfavorable outcome (OR 0.26; 95 % CI 0.07, 0.83). CONCLUSIONS: Treatment with more than two agents with activity against PA was associated with a reduced risk of an unfavorable short-term treatment outcome in patients with bacteremia and/or pneumonia.

Predictors of glycaemic control among HIV-positive veterans with diabetes.

Antiretroviral therapy has decreased HIV-related mortality. However, the incidence of diabetes as a co-morbidity is increasing as HIV-positive patients age. The purpose of this study was to assess the correlation between markers of HIV-infection and diabetes and to determine the proportion of patients achieving an haemoglobin A1c (HbA1c) goal <7% according to specific antiretroviral therapy regimens and adherence. In this retrospective study, HIV-positive veterans with diabetes from 2007 to 2012 were identified. Patients were required to be on the same antiretroviral therapy and diabetes regimen for ≥3 months. In 56 patients, it was identified that for each unit increase in log10 viral load, HbA1c increased 0.67 units (p = 0.0085). Only 38% of patients prescribed a protease inhibitor-based regimen vs. 56% of patients not on a protease inhibitor-based regimen achieved an HbA1c goal (p = 0.1864). Additionally, patients on an insulin-based regimen and patients that were less adherent were less likely to be at HbA1c goal (p = 0.018 and p = 0.0378, respectively). Patients with higher viral loads and patients that were less adherent to antiretroviral therapy were more likely to have a higher HbA1c demonstrating that poor adherence to antiretroviral therapy leads to poor control of both disease states.

Antifungal catheter lock therapy for the management of a persistent Candida albicans bloodstream infection in an adult receiving hemodialysis.

Antifungal catheter lock therapy (AfLT) with liposomal amphotericin B has been used in the treatment of pediatric central line infections caused by Candida species; however, reports describing the use of liposomal amphotericin B lock therapy in the adult hemodialysis patient population are lacking. Management of central line-associated candidemia with systemic therapy alone is often challenging due to the propensity of Candida species to form biofilms on foreign bodies. We describe a 64-year-old woman who was receiving hemodialysis 3 times/week and was hospitalized with persistent fungemia. Despite receiving intravenous micafungin, she had multiple positive blood cultures for Candida albicans, which finally cleared after 7 days. Her double-lumen catheter was considered the most likely nidus of infection. Although catheter removal would have been preferred, this was not possible given her vasculopathy, history of multiple bloodstream infections, and lack of other available sites for vascular access. Catheter exchange was performed, and liposomal amphotericin B AfLT was administered in combination with intravenous micafungin for a total of 6 days. During this time, the patient experienced no discernible adverse effects secondary to AfLT. At discharge, AfLT was discontinued, and intravenous micafungin was changed to oral fluconazole. After 6 months of treatment, the patient remained culture negative and maintained her dialysis access. To our knowledge, this is the first case report of liposomal amphotericin B catheter lock therapy used to manage a persistent C. albicans bloodstream infection in an adult receiving hemodialysis. AfLT is a novel concept for treating catheter-associated fungal infections. Liposomal amphotericin B was chosen based on its favorable in vitro activity against Candida species biofilms in catheter lock environments. We identified several barriers to implementing AfLT, and these issues may prohibit the use of AfLT. This case report illustrates the benefits and challenges of managing catheter-associated fungal infections with AfLT. Further study is required to examine the efficacy, safety, and feasibility of this approach.

Impact of phosphodiesterase type 5 inhibitor treatment on the rates of sexually transmitted diseases in a Veterans Affairs Medical Center patient population.

OBJECTIVE: The objective of this study was to investigate whether the rates of sexually transmitted diseases (STDs) are higher in a veteran population prescribed phosphodiesterase type 5 (PDE5) inhibitors for erectile dysfunction compared to individuals not prescribed these medications. METHODS: This retrospective cohort study included male veterans who filled at least 1 prescription for a PDE5 inhibitor at a Veterans Affairs Medical Center (VAMC) between January 1, 2007, and December 31, 2009. A comparator cohort of male veterans was matched for age and marital status. RESULTS: A total of 10 154 subjects were evaluated. The number of unique subjects with confirmed STDs within the study period was not significantly different between the PDE5 inhibitor cohort and the comparator cohort (n = 8 vs 10, P = .638) nor was there a significant difference in the total number of STDs acquired (n = 8 vs 13, P = .267). Characteristics of subjects who contracted an STD included younger age, African American race, and single marital status. CONCLUSIONS: This study demonstrated that the use of a PDE5 inhibitor in this VAMC patient population was not associated with an increase in the incidence of STDs. Individuals who contracted a new STD tended to be younger, not married, and African American.

Recent advances in the treatment of life-threatening, invasive fungal infections.

INTRODUCTION: Invasive fungal infections (IFIs) pose significant morbidity and are often life-threatening to many high-risk patients. Timely diagnosis and treatment of these infections with optimal therapy is imperative. AREAS COVERED: Advances have been made in diagnostic biomarkers such as peptide nucleic acid fluorescent in situ hybridization, ß-D-glucan and galactomannan, although more research is needed in this area to assist with both diagnosis and monitoring for improvement of IFI management. Novel antifungal agents (azole antifungals and echinocandins) are being investigated that have activity against Candida spp. and Aspergillus spp. Optimizing the pharmacodynamics (PD) of our current antifungal therapies through such strategies as continuous infusion of amphotericin B and dose escalation of echinocandins and liposomal formulations of amphotericin B have also been investigated with mixed results. Therapeutic drug monitoring (TDM) shows promise as evident from data with such agents as flucytosine, itraconazole, voriconazole and posaconazole. EXPERT OPINION: The goal for the future of biomarkers in IFIs will be to have excellent sensitivity and specificity to ideally identify a particular fungus causing the infection or eliminate its existence to prevent unnecessary costs, resistance and antifungal usage. In addition, further developments of new antifungals are needed and judicious use of the current regimens needs to be optimized through antifungal PD properties and TDM.

Potential role of tigecycline in the treatment of community-acquired bacterial pneumonia.

Tigecycline is a member of the glycylcycline class of antimicrobials, which is structurally similar to the tetracycline class. It demonstrates potent in vitro activity against causative pathogens that are most frequently isolated in patients with community-acquired bacterial pneumonia (CABP), including (but not limited to) Streptococcus pneumoniae (both penicillin-sensitive and -resistant strains), Haemophilus influenzae and Moraxella catarrhalis (including ß-lactamase-producing strains), Klebsiella pneumoniae, and 'atypical organisms' (namely Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila). Comparative randomized clinical trials to date performed in hospitalized patients receiving tigecycline 100 mg intravenous (IV) × 1 and then 50 mg IV twice daily thereafter have demonstrated efficacy and safety comparable to the comparator agent. Major adverse effects were primarily gastrointestinal in nature. Tigecycline represents a parenteral monotherapy option in hospitalized patients with CABP (especially in patients unable to receive respiratory fluoroquinolones). However, alternate and/or additional therapies should be considered in patients with more severe forms of CABP in light of recent data of increased mortality in patients receiving tigecycline for other types of severe infection.

Overview of treatment options for invasive fungal infections.

The introduction of several new antifungals has significantly expanded both prophylaxis and treatment options for invasive fungal infections (IFIs). Relative to amphotericin B deoxycholate, lipid-based formulations of amphotericin B have significantly reduced the incidence of nephrotoxicity, but at a significant increase in drug acquisition cost. Newer, broad-spectrum triazoles (notably voriconazole and posaconazole) have added significantly to both the prevention and treatment of IFIs, most notably Aspergillus spp. (with voriconazole) and the treatment of some emerging fungal pathogens. Finally, a new class of parenteral antifungals, the echinocandins, is employed most frequently against invasive candidal infections. While the role of these newer agents continues to evolve, this review summarizes the activity, safety and clinical applications of agents most commonly employed in the treatment of IFIs.

Medication adherence in combat veterans with traumatic brain injury.

PURPOSE: Medication adherence in combat veterans with traumatic brain injury (TBI) was evaluated. METHODS: Patients with a diagnosis of TBI were identified by a computer search of veterans enrolled in the Operation Enduring Freedom/Operation Iraqi Freedom or TBI/polytrauma clinics at Durham Veterans Affairs Medical Center (VAMC) between September 15, 2007, and September 15, 2008. Patients were included if they were at least 18 years old, received medical care and medications at the VAMC for at least 12 continuous months, and were taking at least one maintenance medication. A randomly selected age-matched comparator group without TBI was obtained through a computer-generated convenience sample. A composite adherence score for each patient was calculated using the medication possession ratio (MPR). The most commonly prescribed medications and indicators of increased adherence among the TBI group were also identified. RESULTS: The composite MPR did not significantly differ between groups. The most commonly prescribed medications were selective serotonin-reuptake inhibitors and serotonin-norepinephrine-reuptake inhibitors and other antidepressants; however, these classes were associated with the lowest adherence rates. Factors associated with increased adherence included taking more than five maintenance medications (78%), living with a spouse or significant other (77%), owning a memory-assistance device (74%), and comorbid diagnosis of posttraumatic stress disorder (PTSD) (74%). CONCLUSION: Medication adherence rates were similar among combat veterans with a diagnosis of TBI and an age-matched comparator group. Factors associated with increased adherence included taking more than five maintenance medications, living with a spouse or significant other, owning a memory-assistance device, and a comorbid diagnosis of PTSD.

Trimethoprim-sulfamethoxazole-induced hepatotoxicity in a pediatric patient.

Due to the escalating rates of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection, trimethoprim-sulfamethoxazole (TMP-SMX) is being used increasingly in the pediatric population for skin and soft tissue infections. Although this combination agent has been associated with a hypersensitivity syndrome involving cutaneous skin eruptions, pediatric cases of TMP-SMX-induced hepatotoxicity are rare. We describe a relatively healthy, 9-year-old boy who developed a CA-MRSA skin and soft tissue infection and was treated with TMP-SMX. After 14 days of therapy, he was taken to the emergency department with a 3-day history of fever, headache, and neck pain. He was diagnosed with a viral syndrome, acetaminophen was prescribed, and he was sent home. Three days later, the patient returned to the emergency department with fever, vomiting, decreased energy and appetitie, and suprapubic abdominal pain, and he was hospitalized. Laboratory test results revealed elevated liver function test values. After other potential causes of liver toxicity were excluded, TMP-SMX was determined to be the cause of his acute liver toxicity. The drug was discontinued, his symptoms resolved, and his liver function tests returned to normal. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 5) between the patient's development of hepatotoxicity and the TMP-SMX therapy. This rare adverse reaction to TMP-SMX has been reported in adults; however, to our knowledge, it has been reported in only five other children. Due to the increasing use of TMP-SMX in children, clinicians should be aware of this potentially life-threatening, immunemediated hypersensitivity reaction. Fortunately, however, the hepatotoxicity appears to resolve after discontinuation of the TMP-SMX therapy in most reported cases. This case report illustrates the importance of early detection of drug-induced hepatotoxicity and timely drug discontinuation to prevent the need for liver transplantation.

Echinocandin pharmacodynamics: review and clinical implications.

Echinocandins have made a significant impact in the treatment of select invasive fungal infections, most notably invasive candidiasis and aspergillosis. However, treatment outcomes for such infections are still less than optimal, prompting an examination of dosing and administration techniques in an attempt to exploit known pharmacodynamic properties and improve outcomes. Echinocandins generally exhibit concentration-dependent, fungicidal activity against Candida spp. and fungistatic activity against Aspergillus spp. However, increasing drug concentrations of echinocandins above the organism's MIC may result in a paradoxical increase in fungal growth as demonstrated in some in vitro and in vivo models (known most commonly as the 'Eagle effect'). Therefore, the potential impact of dose escalations on improving the clinical efficacy of echinocandins based on in vitro and animal models are uncertain and are still being evaluated. In addition, such strategies have to consider the potential for increased treatment-related toxicities and costs. To date, published clinical studies (both superiority and non-inferiority) demonstrating the potential for dose-related improvements in treatment outcomes have been limited to mucocutaneous and oesophageal candidiasis. Further research is needed to determine if a role exists for optimizing echinocandin pharmacodynamics in various clinical settings.

Incidence of Severe Hepatotoxicity Related to Antiretroviral Therapy in HIV/HCV Coinfected Patients.

Introduction. Hepatotoxicity is a concern in HIV/hepatitis C virus (HCV) coinfected patients due to their underlying liver disease. This study assessed the incidence of hepatotoxicity in HIV/HCV co-infected patients in two outpatient infectious diseases clinics. Methods. HIV/HCV co-infected adults were included in this retrospective study if they were PI or NNRTI naïve at their first clinic visit and were initiated on an NNRTI- and/or PI-based antiretroviral regimen. Patients were excluded if they had active or chronic hepatitis B virus (HBV). The primary objective was to determine the overall incidence of severe hepatotoxicity. Results. Fifty-six of the 544 patients identified met inclusion criteria. The incidence of severe hepatotoxicity was 10.7% (6/56 patients). Severe hepatotoxicity occurred with efavirenz (N = 2), nevirapine (N = 1), indinavir (N = 1), nelfinavir (N = 1), and saquinavir/ritonavir (N = 1). Conclusion. The incidence of severe hepatotoxicity appears to be low in this retrospective analysis of HIV/HCV co-infected patients receiving a PI-and/or NNRTI-based regimen.

A comparison of the effectiveness of lipid-lowering therapy between HIV- and non-HIV-infected subjects with hyperlipidaemia.

This retrospective cohort study conducted at the Durham Veterans Affairs Medical Center evaluated the effectiveness and safety of lipid-lowering therapy (LLT) in a HIV-infected population as compared with a general population with hyperlipidaemia. Fifty-three HIV-infected subjects who developed dyslipidaemia and 53 age-matched non-HIV-infected subjects receiving LLT were selected. Efficacy of LLT was assessed after three and six months. Non-HIV-infected subjects were more likely to achieve total cholesterol (TC) goals at three and six months (P = 0.045, P = 0.005) and triglyceride (TG) goals at six months (P = 0.017). Less than 45% of HIV-infected subjects met National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) goals at three or six months. While non-HIV-infected subjects were more likely to achieve TC and TG goals than HIV-infected subjects, overall achievement of NCEP III goals was poor. This result was likely due to treatment with inappropriately low doses of statins.

Association between pharmacy medication refill-based adherence rates and cd4 count and viral-load responses: A retrospective analysis in treatment-experienced adults with HIV.

BACKGROUND: Current guidelines and most contemporary statements in the literature indicate that, like other medical conditions, HIV infection requires exceptionally high adherence to highly active antiretroviral therapy (HAART) for successful treatment. OBJECTIVE: This study was conducted to determine the association between pharmacy medication refill rates-a surrogate marker for adherence to HAART- and CD4-count/viral-load responses in patients with HIV METHODS: This retrospective study was conducted at the HIV Clinic, Veterans Affairs Medical Center, Durham, North Carolina. Male and female patients aged >/=18 years with a history of HIV who attended clinic appointments on 3 consecutive clinic days were enrolled. Pharmacy medication refill-based adherence rates over the 6 months before the study were determined by examining electronic pharmacy records. The most recent viral load and the change (Delta) in CD4 count over the past year-surrogate measures of outcome-were also collected from each patient's electronic medical record and compared with refill adherence rates. The incidence of AIDS-related events and past antiretroviral experience were also compared with the DeltaCD4 count and adherence rates. RESULTS: Data from 58 patients were included in the study. Thirty-nine patients were black men; the mean age was 51.5 years. There was a nonsignificant correlation between 6-month pharmacy medication refillbased adherence rates and viral loads (r = 0.10). The relationship between DeltaCD4 count and adherence was complex. With adherence rates >70%, the DeltaCD4 count ranged from +414 to -238, with no indication that increasing adherence led to a greater CD4 count increase. The DeltaCD4 count progressively declined with adherence rates 70%, there was no significant correlation between adherence rates and DeltaCD4 counts or viral-load responses.