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1.
J Hosp Infect ; 99(4): 481-486, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29477634

RESUMO

BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant enterococci (VRE) carriage are increasing worldwide. Faecal microbiota transplantation (FMT) appears to be an attractive option for decolonization. This study aimed to evaluate CRE vs VRE clearance by FMT among carriers. METHODS: A multi-centre trial was undertaken on patients with CRE or VRE digestive tract colonization who received FMT between January 2015 and April 2017. Adult patients with CRE or VRE colonization, confirmed by three consecutive rectal swabs at weekly intervals, including one in the week prior to FMT, were included in the study. Patients with immunosuppression or concomitant antibiotic prescription at the time of FMT were excluded. Successful decolonization was determined by at least two consecutive negative rectal swabs [polymerase chain reaction (PCR) and culture] on Days 7, 14, 21 and 28, and monthly for three months following FMT. RESULTS: Seventeen patients were included, with a median age of 73 years [interquartile range (IQR) 64.3-79.0]. Median duration of carriage of CRE or VRE before FMT was 62.5 days (IQR 57.0-77.5). One week after FMT, three of eight patients were free of CRE colonization and three of nine patients were free of VRE colonization. After three months, four of eight patients were free of CRE colonization and seven of eight patients were free of VRE colonization. Qualitative PCR results were concordant with culture. Six patients received antibiotics during follow-up, three in each group. No adverse events were reported. CONCLUSION: CRE and VRE clearance rates were not significantly different in this study, possibly due to the small sample size, but a trend was observed. These data should be confirmed by larger cohorts and randomized trials.


Assuntos
Enterobacteriáceas Resistentes a Carbapenêmicos/isolamento & purificação , Portador Sadio/terapia , Infecções por Enterobacteriaceae/terapia , Transplante de Microbiota Fecal , Infecções por Bactérias Gram-Positivas/terapia , Enterococos Resistentes à Vancomicina/isolamento & purificação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Técnicas Bacteriológicas , Portador Sadio/microbiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/patologia , Infecções por Enterobacteriaceae/microbiologia , Fezes/microbiologia , Feminino , Infecções por Bactérias Gram-Positivas/microbiologia , Humanos , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
2.
Rev Epidemiol Sante Publique ; 66(1): 7-17, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29233572

RESUMO

BACKGROUND: In a context of the evolution of severe morbidities in patients living with HIV (PLWH), the aim of this study was to describe reasons for hospitalization and the mode of care for the patients requiring hospitalization. METHODS: All admissions (≥24h) of PLWH to 10 hospitals in the south of Paris (COREVIH Ile-de-France Sud) between 1/1/2011 and 12/31/2011 were identified. The hospital database and the file of patients followed in the HIV referral department of each hospital were matched. Detailed clinical and biological data were collected, by returning to the individual medical records, for a random sample (65% of hospitalized patients). RESULTS: A total of 3013 hospitalizations (1489 patients) were recorded in 2011. The estimated rate of hospitalized patients was about 8% among the 10105 PLWH routinely managed in COREVIH Ile-de-France Sud in 2011. The majority (58.5%) of these hospitalizations occurred in a unit other than the HIV referral unit. Non-AIDS-defining infections were the main reason for admission (16.4%), followed by HIV-related diseases (15.6%), hepatic/gastrointestinal diseases (12.0%), and cardiovascular diseases (10.3%). The median length of stay was 5 days overall (IQR: 2-11), it was longer among patients admitted to a referral HIV care unit than to another ward. HIV infection had been diagnosed >10 years previously in 61.4% of these hospitalized patients. They often had associated comorbidities (coinfection HCV/HVB 40.5%, smoking 45.8%; hypertension 33.4%, dyslipidemia 28.8%, diabetes 14.8%). Subjects over 60 years old accounted for 15% of hospitalized patients, most of them were virologically controlled under HIV treatment, and cardiovascular diseases were their leading reason for admission. CONCLUSION: Needs for hospitalization among PLWH remain important, with a wide variety in causes of admission, involving all hospital departments. It is essential to prevent comorbidities to reduce these hospitalizations, and to maintain a link between the management of PLWH, that becomes rightly, increasing ambulatory, and recourse to specialized inpatient services.


Assuntos
Atenção à Saúde/estatística & dados numéricos , Infecções por HIV/epidemiologia , Necessidades e Demandas de Serviços de Saúde , Hospitalização/estatística & dados numéricos , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Adulto , Comorbidade , Atenção à Saúde/normas , Feminino , Infecções por HIV/complicações , HIV-1 , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/tendências , Departamentos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Paris/epidemiologia , Adulto Jovem
3.
J Hosp Infect ; 95(4): 433-437, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28237504

RESUMO

Carbapenem-resistant Enterobacteriaceae (CRE) or vancomycin-resistant enterococci (VRE) carriage present a major public health challenge. Decolonization strategies are lacking. We aimed to evaluate the impact of faecal microbiota transplantation (FMT) on a cohort of patients with digestive tract colonization by CRE or VRE. Eight patients were included: six carrying CRE and two colonized by VRE. One month after FMT, two patients were free from CRE carriage, and another patient was free from VRE after three months. In our experience, this strategy is safe.


Assuntos
Portador Sadio/microbiologia , Portador Sadio/terapia , Farmacorresistência Bacteriana , Enterobacteriaceae/isolamento & purificação , Transplante de Microbiota Fecal/métodos , Enterococos Resistentes à Vancomicina/isolamento & purificação , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções por Enterobacteriaceae/microbiologia , Infecções por Enterobacteriaceae/terapia , Feminino , Infecções por Bactérias Gram-Positivas/microbiologia , Infecções por Bactérias Gram-Positivas/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Resultado do Tratamento
4.
Med Mal Infect ; 47(1): 42-49, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27765474

RESUMO

OBJECTIVE: We aimed to document amoxicillin-clavulanic acid prescription to improve the proper use of antibiotics in hospital settings. We used three criteria: quality of medical charts, adequacy of indications, and adequacy of treatment duration. METHOD: This study was designed as a one-day point prevalence survey carried out by antibiotic lead specialists. RESULTS: We included 387 prescriptions from 32 hospitals. Immunodeficiency was recorded as a risk factor in 30% of patients. Computerized prescriptions were observed in 79% of cases. The indication was mentioned in 73% of cases and a 48/78-hour re-assessment of the antibiotic therapy was performed in 54% of cases. The antibiotic indication was primarily for pneumonia and was deemed appropriate in 75% of patients. Adult mean treatment duration was 11.1 days. Use of dual combination therapy and/or treatment duration exceeding two weeks accounted for the main reasons for an inappropriate use of antibiotics. Prescriptions recorded as having been made by senior physicians were of the shortest treatment duration (P=0.0163). CONCLUSION: Medical charts should be better filled in. Reinforcing the role of senior physicians in supervising antibiotic prescriptions is likely to result in a better control of treatment duration and ultimately in a reduced antibiotic consumption. By reinforcing the collaboration between pharmacists and antibiotic lead specialists, the improvement of computerized prescriptions at hospital level should help better detect the "at risk" prescriptions, namely those exceeding seven days or those combining antibiotics.


Assuntos
Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Hospitais Universitários , Inibidores de beta-Lactamases/uso terapêutico , Adulto , Criança , Prescrições de Medicamentos/estatística & dados numéricos , Humanos , Paris
5.
Transpl Infect Dis ; 17(5): 662-70, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26192379

RESUMO

BACKGROUND: Few studies have investigated infections in human immunodeficiency virus (HIV)-infected liver transplant patients. The aim of this study was to describe the prevalence, time of onset, mortality of infectious complications, other than hepatitis C virus (HCV), and to identify risk factors for their development in a large single-center cohort of HIV-infected liver transplant patients. METHODS: We studied 109 consecutive HIV-infected patients who underwent liver transplantation (LT) between 1999 and 2010 and followed until December 2012. RESULTS: The median age was 44 years (interquartile range [IQR] 41-49), 82.6% were male, and the median follow-up was 45.7 months (IQR 14-65). The major indications for LT were HCV cirrhosis (61%) and hepatocellular carcinoma (19%). Forty patients (37%) developed at least 1 infection during the first year after LT. Twenty-eight (26%) patients had an episode of bacteremia. Five (4.6%) patients developed a cytomegalovirus infection. Fungal infections occurred in 5 (4.5%) patients. Four (3.6%) patients developed an HIV-related opportunistic infection. A total of 43 (39.4%) patients died during follow-up. Mortality related to infection occurred in 9 (7%) cases, and 20 (42.5%) patients died because of HCV recurrence. No patients died from opportunistic infections. Model for end-stage liver disease (MELD) score >17 was associated with a 2-fold higher risk (hazard ratio 1.96; 95% confidence interval 1.01-3.80) of developing infectious complications. CONCLUSIONS: Infections are not a major cause of mortality after LT in HIV patients and opportunistic infections of acquired immunodeficiency syndrome are infrequent. A MELD score >17 increased the risk of developing post-LT infectious complications. Recurrence of HCV infection remains a major cause of mortality.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/etiologia , Hospedeiro Imunocomprometido , Transplante de Fígado , Complicações Pós-Operatórias/etiologia , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/imunologia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/imunologia , Prevalência , Fatores de Risco , Análise de Sobrevida
6.
Transpl Infect Dis ; 17(2): 322-7, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25645691

RESUMO

Immunization against meningococcal disease is recommended for solid organ transplant (SOT) recipients at high risk for meningococcal disease or travelling to an endemic country. However, the immunogenicity of meningococcal vaccines has not been studied in this population. We analyzed the immune response of quadrivalent (against Neisseria meningitidis serogroups A, C, Y, and W) polysaccharidic non-conjugate and conjugate meningococcal vaccines in kidney- and liver-transplant patients using bactericidal assays against the targeted serogroups. Upon vaccination with a non-conjugate (n = 5) or a conjugate vaccine (n = 10), respectively, 40% and 50% of patients were able to mount an immune response, achieving at least the threshold correlated with protection defined as human serum bactericidal antibody titers of ≥4. Responders showed only partial and low responses (titers ≤64), thus predicting a rapid decline in bactericidal response. Only 1 patient developed a booster response to preexisting immunity. Our data argue for the need of additional measures for SOT recipients, when they are at risk of meningococcal disease.


Assuntos
Anticorpos Antibacterianos/imunologia , Hospedeiro Imunocomprometido/imunologia , Transplante de Rim , Transplante de Fígado , Infecções Meningocócicas/prevenção & controle , Vacinas Meningocócicas/uso terapêutico , Neisseria meningitidis/imunologia , Adulto , Idoso , Estudos de Coortes , Feminino , Rejeição de Enxerto/prevenção & controle , Humanos , Imunossupressores/uso terapêutico , Masculino , Vacinas Meningocócicas/imunologia , Pessoa de Meia-Idade , Neisseria meningitidis Sorogrupo A/imunologia , Neisseria meningitidis Sorogrupo C/imunologia , Neisseria meningitidis Sorogrupo W-135/imunologia , Neisseria meningitidis Sorogrupo Y/imunologia , Estudos Prospectivos , Transplantados , Vacinas Conjugadas/imunologia , Vacinas Conjugadas/uso terapêutico
7.
Euro Surveill ; 19(14)2014 Apr 10.
Artigo em Inglês | MEDLINE | ID: mdl-24739981

RESUMO

Healthy travellers to countries where carbapenemases-producing Enterobacteriaceae (CPE) are endemic might be at risk for their acquisition, even without contact with the local healthcare system. Here, we report the acquisition of CPE (two OXA-181, one New Delhi metallo-beta-lactamase 1 (NDM-1)) in three healthy travellers returning from India. The duration of CPE intestinal carriage was less than one month. The results indicate that healthy travellers recently returning from India might be considered as at risk for CPE carriage.


Assuntos
Proteínas de Bactérias/metabolismo , Infecções por Enterobacteriaceae/diagnóstico , Enterobacteriaceae/isolamento & purificação , Viagem , beta-Lactamases/metabolismo , Adulto , Enterobacteriaceae/efeitos dos fármacos , Enterobacteriaceae/enzimologia , Enterobacteriaceae/genética , Infecções por Enterobacteriaceae/microbiologia , Fezes/microbiologia , Feminino , França , Humanos , Índia , Pessoa de Meia-Idade , Fatores de Risco
8.
Ann Rheum Dis ; 73(5): 831-7, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-23606708

RESUMO

BACKGROUND: The standard-of-care treatment of patients with hepatitis C virus (HCV)-mixed cryoglobulinemia (MC) vasculitis includes pegylated interferon α (PegIFN)-α plus ribavirin and/or rituximab. About 30-40% of patients are non-responders or relapsers to such combination. OBJECTIVE: To analyse the safety and efficacy of Peg-IFNα/ribavirin/protease inhibitor combination in HCV-MC vasculitis. PATIENTS AND METHODS: Open-label, prospective, cohort study including 23 patients with HCV-MC vasculitis. Peg-IFNα/ribavirin was associated to telaprevir (375 mg three times daily, for 12 weeks, (n=15)) or boceprevir (800 mg three times daily, for 44 weeks, (n=8)) for 48 weeks. RESULTS: The median age was 59 (52.5-66) years, with 48.8% women. Thirteen patients (56.5%) were complete clinical responders, and 10 (43.5%) were partial responders at week 24. The virological response (ie, HCV RNA negativation) was of 69.6% at week 24 (p=0.005). The cryoglobulin level decreased from 0.44 to 0.06 g/l (p=0.0006) and the C4 level increased from 0.09 to 0.15 g/l (p=0.045). Grades 3 and 4 adverse events (mainly anaemia, neutropenia and thrombocytopenia) were observed in 10 cases (43.5%). Twenty patients (87%) received erythropoietin, 9 (39.1%) had red cell transfusion, and 2 (8.7%) had granulocyte stimulating agents. Antiviral therapy discontinuation was required in 8 (34.7%) patients for virological non-response (n=5), virological relapse (n=2) and depression (n=1). CONCLUSIONS: Peg-IFNα/ribavirin/protease inhibitor combination seems highly effective in HCV-MC. Such therapeutic regimen should be administered cautiously considering the high rate of side effects.


Assuntos
Antivirais/administração & dosagem , Crioglobulinemia/tratamento farmacológico , Hepatite C Crônica/tratamento farmacológico , Interferon-alfa/administração & dosagem , Polietilenoglicóis/administração & dosagem , Inibidores de Proteases/administração & dosagem , Ribavirina/administração & dosagem , Idoso , Antivirais/efeitos adversos , Estudos de Coortes , Crioglobulinemia/virologia , Quimioterapia Combinada , Feminino , Hepacivirus , Hepatite C Crônica/complicações , Humanos , Interferon-alfa/efeitos adversos , Masculino , Pessoa de Meia-Idade , Oligopeptídeos/administração & dosagem , Oligopeptídeos/efeitos adversos , Polietilenoglicóis/efeitos adversos , Prolina/administração & dosagem , Prolina/efeitos adversos , Prolina/análogos & derivados , Inibidores de Proteases/efeitos adversos , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Ribavirina/efeitos adversos , Resultado do Tratamento , Vasculite/tratamento farmacológico , Vasculite/virologia
9.
Am J Transplant ; 13(9): 2458-61, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23834702

RESUMO

Immunization using live attenuated vaccines represents a contra-indication after solid organ transplantation (SOT): consequently, transplant candidates planning to travel in countries where yellow fever is endemic should be vaccinated prior to transplantation. The persistence of yellow fever vaccine-induced antibodies after transplantation has not been studied yet. We measured yellow-fever neutralizing antibodies in 53 SOT recipients vaccinated prior to transplantation (including 29 kidney recipients and 18 liver recipients). All but one (98%) had protective titers of antibodies after a median duration of 3 years (min.: 0.8, max.: 21) after transplantation. The median antibody level was 40 U/L (interquartile range: 40-80). For the 46 patients with a known or estimated date of vaccination, yellow-fever antibodies were still detectable after a median time of 13 years (range: 2-32 years) post-immunization. Our data suggest there is long-term persistence of antibodies to yellow fever in SOT recipients who have been vaccinated prior to transplantation.


Assuntos
Anticorpos Antivirais/análise , Transplante de Rim , Transplante de Fígado , Imunologia de Transplantes , Vacina contra Febre Amarela/imunologia , Humanos , Estudos Prospectivos
10.
J Fr Ophtalmol ; 36(3): 197-201, 2013 Mar.
Artigo em Francês | MEDLINE | ID: mdl-23159537

RESUMO

Measles is a disease due to morbillivirus, which belongs to the paramyxoviridae subfamily. It affects mostly young patients, and evolves through four phases: incubation, invasion, eruption and desquamation. Ophthalmic manifestations may occur during the invasive and eruptive phases. Conjunctivitis is the most common ophthalmologic manifestation and is often asymptomatic. Measles keratitis is the most concerning manifestation, with possible corneal ulcer, bacterial superinfection and corneal perforation. We report two cases of acute keratitis occurring during the eruptive phase of measles in two unvaccinated young adults. The involvement was central and strictly epithelial in both patients. The outcome was favorable with symptomatic treatment.


Assuntos
Úlcera da Córnea/etiologia , Sarampo/complicações , Adulto , Conjuntivite/etiologia , Úlcera da Córnea/tratamento farmacológico , Úlcera da Córnea/patologia , Surtos de Doenças , Quimioterapia Combinada , Feminino , França/epidemiologia , Humanos , Sarampo/epidemiologia , Soluções Oftálmicas/uso terapêutico , Piperazinas/uso terapêutico , Vacinação , Vitamina A/uso terapêutico , Adulto Jovem
11.
Eur J Intern Med ; 22(5): e45-9, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21925042

RESUMO

AIMS: Systematic generic prescription at discharge could reduce confusion on drug-name usage, decrease commercial influence on medicine, and reduce drug-related expenditures. This study aimed to analyze generic drug prescriptions at discharge from hospital and to estimate the potential savings associated with a total substitution policy (substitution of every substitutable drug for its cheapest generic counterpart). METHODS: Drug prescriptions before admission and at discharge of all patients from three medical units of a university hospital were prospectively collected for five weeks without informing prescribers. RESULTS: Prescriptions from 85 patients were analyzed. On admission, 68 patients (80%) received 413 drugs; 141 were substitutable brand-name drugs and 23 (16%), which were directly prescribed as generics. At discharge, 488 drugs were prescribed to the 85 patients; 180 were substitutable drugs but only 5 (2.8%) were written as generics on prescription pads, a decrease of 78% (p<0.0001) compared to admission. In average, generics were 18% less expensive than brand-name drugs. Some common therapeutic classes offered even greater price difference, such as proton-pump inhibitors (42%), statins (32%), or antihypertensive agents (28%). Potential savings from a total substitution policy at discharge were estimated to €1512 per 1000 patients per week; for lifetime drugs, savings amounted to €18,960 per 1000 patients per year. CONCLUSIONS: Very few drugs are written as generics on medical forms at discharge in France. Hospital practitioners should be encouraged to prescribe generics, particularly in chronic diseases. A broad generic prescription policy at hospital discharge would result in substantial savings for health insurance.


Assuntos
Custos de Medicamentos/estatística & dados numéricos , Prescrições de Medicamentos , Medicamentos Genéricos/economia , Gastos em Saúde , Hospitais Universitários , Alta do Paciente/economia , Idoso , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
12.
Am J Transplant ; 11(8): 1686-95, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21749638

RESUMO

We characterized fibrosing cholestatic hepatitis (FCH) in a large cohort of HIV/HCV co-infected patients. Between 1999 and 2008, 59 HIV infected patients were transplanted for end-stage liver disease due to HCV. Eleven patients (19%) developed FCH within a mean period of 7 months [2-27] after liver transplantation (LT). At Week 1 post-LT, the mean HCV viral load was higher in the FCH group: 6.13 log(10) IU/mL ± 1.30 versus 4.9 log(10) IU/mL ± 1.78 in the non-FCH group, p = 0.05. At the onset of acute hepatitis after LT, activity was moderate to severe in 8/11 HIV+/HCV+ patients with FCH (73%) versus 13/28 (46%) HIV+/HCV+ non-FCH (p = 0.007) patients. A complete virological response to anti-HCV therapy was observed in 2/11 (18%) patients. Survival differed significantly between the two groups (at 3 years, 67% in non-FCH patients versus 15% in FCH patients, p = 0.004). An early diagnosis of FCH may be suggested by the presence of marked disease activity when acute hepatitis is diagnosed and when a high viral load is present. The initiation of anti-HCV therapy should be considered at this point.


Assuntos
Biomarcadores/sangue , Infecções por HIV/sangue , Hepatite C/cirurgia , Transplante de Fígado , Adulto , Idoso , Colestase Intra-Hepática , Estudos de Coortes , Feminino , Infecções por HIV/complicações , Hepatite C/sangue , Hepatite C/complicações , Humanos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Carga Viral
13.
Med Mal Infect ; 40(3): 129-34, 2010 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-20153591

RESUMO

New antibiotics are needed because of the increasing resistance of bacteria but they will be available in years to come only if drastic changes are implemented in development strategies, evaluation, use, and financing. Over the last decade, various opinions were stated and limited action was undertaken. Optimizing antibiotic use (as the "antibiotic plan" in France) was indispensable, but the process is still on going, and this is only part of the problem. Major questions are recurrently raised such as improvement of development procedures for new antibiotics, optimizing diagnostic methods, innovating financing modalities, or rescue of "old" antibiotics at risk of being withdrawn from the market. The symposium organized in September 2009 by the Swedish EU presidency helped to support previous recommendations. But conclusions remain unspecific. The propositions which are made here, after a work session, have for aim to be more detailed and innovating, even if they can be discussed, or even provocative.


Assuntos
Antibacterianos , Farmacorresistência Bacteriana , Drogas em Investigação , Humanos
14.
Am J Transplant ; 9(8): 1946-52, 2009 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-19519819

RESUMO

Solid organ transplantations (SOT) are performed successfully in selected HIV-infected patients. However, multiple and reciprocal drug-drug interactions are observed between antiretroviral (ARV) drugs and calcineurin inhibitors (CNIs) through CYP450 metabolization. Raltegravir (RAL), a novel HIV-1 integrase inhibitor, is not a substrate of CYP450 enzymes. We retrospectively reviewed the outcomes of 13 HIV-infected transplant patients treated by an RAL + two nucleosidic reverse transcriptase inhibitor (NRTI) regimen, in terms of tolerability, ARV efficacy (plasma viral load, CD4 cell count), drug interactions, RAL pharmacokinetics and transplant outcome. Thirteen patients with liver (n = 8) or kidney (n = 5) transplantation were included. RAL was initiated (400 mg BID) either at time of transplantation (n = 6), or after transplantation (n = 7). Median RAL trough concentration was 507 ng/mL (176-890), which is above the in vitro IC95 for wild type HIV-1 strains (15 ng/mL). Target trough levels of CNIs were promptly obtained with standard dosages of tacrolimus or cyclosporine. RAL tolerability was excellent. There was no episode of acute rejection. HIV infection remained controlled. After a median follow-up of 9 months (range: 6-14), all patients were alive with satisfactory graft function. The use of an RAL + two NRTI-based regimen is a good alternative in HIV-infected patients undergoing SOT.


Assuntos
Rejeição de Enxerto/prevenção & controle , Infecções por HIV/tratamento farmacológico , Imunossupressores/uso terapêutico , Transplante de Rim/imunologia , Transplante de Fígado/imunologia , Pirrolidinonas/efeitos adversos , Pirrolidinonas/uso terapêutico , Adulto , Antirretrovirais/uso terapêutico , Inibidores de Calcineurina , Ciclosporina/uso terapêutico , Relação Dose-Resposta a Droga , Interações Medicamentosas , Feminino , Rejeição de Enxerto/imunologia , Integrase de HIV/efeitos dos fármacos , Integrase de HIV/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Pirrolidinonas/farmacologia , Raltegravir Potássico , Estudos Retrospectivos , Tacrolimo/uso terapêutico , Resultado do Tratamento
15.
Med Mal Infect ; 39(4): 225-33, 2009 Apr.
Artigo em Francês | MEDLINE | ID: mdl-19111416

RESUMO

Progress in transplantation technique has offered a growing number of solid organ transplant recipients the opportunity to travel to tropical and low-income countries. The issue of vaccine-preventable diseases is a challenging question in immunocompromised patients including those with solid organ transplant. Since the response to vaccines is weakened in case of chronic organ failure, candidates should be vaccinated early in the course of the disease. Clinicians should implement a vaccinal strategy until the patient is scheduled for transplantation and monitor its efficacy by serological assays. Live attenuated vaccines (such as yellow fever, measles-mumps-rubella, or chicken pox) are contra-indicated in solid organ transplant recipients and, when indicated, should be administered prior to transplantation, particularly in foreign-born patients highly likely to visit friends and relatives in endemic areas. Vaccinations for transplant recipients considering international travel should be realized according to the risk of acquiring vaccine-preventable diseases but also on both tolerance and immune response which are affected by degree and duration of immunosuppression, comorbidities, and type of organ transplanted. Routine and specific vaccinations for solid organ transplant recipients, as well as travel-related vaccination (such as hepatitis A, typhoid, meningococcal meningitis, rabies, tick-born encephalitis, Japanese encephalitis, and cholera) should be considered during a specific pretravel medical consultation. However, vaccination should be avoided in the 6 months following transplantation when patients are usually receiving the highest doses of immunosuppressive drugs. In this comprehensive review, we provide vaccination schedules based on published studies and guidelines for vaccination of solid organ transplant recipients.


Assuntos
Transplante de Órgãos , Viagem , Vacinas , Adulto , Humanos
16.
Med Mal Infect ; 39(1): 21-8, 2009 Jan.
Artigo em Francês | MEDLINE | ID: mdl-18723304

RESUMO

Human immunodeficiency virus (HIV) positive international travelers are at higher risk of infectious complications. The pretravel assessment often provides an opportunity to update routine vaccinations and HIV patient specific vaccinations including pneumococcus, hepatitis A, hepatitis B, and influenza. Other vaccinations may be required or recommended. Decision for vaccination require considering the risk and severity of the vaccine, preventable diseases in the destination area, the nature of the vaccine (live attenuated vaccines or not), the patient's immune status, and the risk of virological rebound as a consequence of vaccination. The immunogenicity of vaccines is decreased in HIV patient with low CD4 cell counts (above 500 cells per cubic millimetres and particularly above 200 cells per cubic millimetres) and in patients with a persistent HIV RNA viral load. Vaccines should be administered to patients whose HIV infections are in the early stage or in patients receiving HAART with a satisfactory immune status and reduced HIV RNA level. Testing of postvaccination antibodies is useful if serological protective levels are defined. In case of non-response after vaccination, few studies suggest that additional revaccination, increase of vaccine dose, intradermic vaccination, or use of prime-boost combination may be successful. Further research is needed to define vaccination strategies, adapted to the immune status of the HIV patient.


Assuntos
Vacinas contra a AIDS/uso terapêutico , Infecções por HIV/imunologia , Viagem , Anticorpos Antivirais/sangue , Linfócitos T CD4-Positivos/efeitos dos fármacos , Linfócitos T CD4-Positivos/imunologia , HIV/classificação , HIV/crescimento & desenvolvimento , HIV/imunologia , Infecções por HIV/prevenção & controle , Infecções por HIV/transmissão , Humanos , RNA Viral/sangue , Carga Viral
18.
AIDS Care ; 19(4): 523-31, 2007 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-17453593

RESUMO

We explored changes in the survival of patients with AIDS (PWA) according to the availability of antiretroviral drugs (1994-2002). We tested whether changes in the hazard ratio of progression to death (HR) have been homogeneous among various groups of PWA. We included 4158 PWA diagnosed in Paris, notified to the French National Surveillance Institute by 2002. Four calendar periods were defined: monotherapy (1994-95), bitherapy-HAART transition (1996), early HAART (1997-99), late HAART (2000-October 2002). HR were calculated with Cox models, including the calendar period, modelled as a time dependent covariate. Models were stratified by age, transmission category, CD4 cell count, and AIDS-defining illnesses (ADI) group. Cumulative survival at 60 months increased from 44.0% (before July 1996) to 75.6% (after July 1996) and median survival increased from 31.9 months to >76 months. Adjusted HR reached a minimum in the late HAART period (HR 0.22, 95% CI: 0.19-0.26). No difference in the decrease of the HR has been found by age. HR decreased and was marked during the late HAART period across all HIV transmission categories, including intravenous drug use. HR decreased significantly for all ADIs groups, including tumours. Among PWA diagnosed with tuberculosis, the HR decreased significantly only in the late HAART period. HR decrease was stronger for PWA with a CD4 cell count < or =200/mm(3). Substantial improvements in survival after the introduction of HAART were found for all PWA but varied by specific ADIs and the degree of immunosuppression.


Assuntos
Terapia Antirretroviral de Alta Atividade/mortalidade , Infecções por HIV/mortalidade , Adolescente , Adulto , Progressão da Doença , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Paris/epidemiologia , Modelos de Riscos Proporcionais , Análise de Sobrevida , Resultado do Tratamento
20.
Pathol Biol (Paris) ; 51(8-9): 525-7, 2003 Oct.
Artigo em Francês | MEDLINE | ID: mdl-14568603

RESUMO

The prognosis of HIV infection has been modified by antiretroviral therapy. However, the morbidity and the mortality of HCV co-infection increase and may be a major problem of health service. Up to now co-infected patients are excluded of transplantation due to complexity, the ethical aspects, the immunodeficiency and the co-infection. This study tries to estimate the feasibility in this population. Between December 1999 and March 2002, seven patients were transplanted. The average of CD4 was 332/ml; the viral load was <50 copies/ml. Before transplantation, no patient had experienced opportunist infection and all patients received antiretroviral therapy adapted to their history. The average follow-up is of 14 months: one patient died 3 months after transplantation, the other one presented a candida in oesophagus, the average of CD4 was 280/ml, and viral load was <50 copies/ml in five patients. A relapse of HVC was observed in all patients. Interferon/rivabirine therapy was proposed for four patients. Every patient received tacrolimus and corticoids. HAART were modified four times for toxicity and one time for virological failure. We observed two cases of transient renal insufficiency, two cases of diabetes, two cases of pancreatitis, and abnormalities of the respiratory mitochondrial chain in four patients. Finally, liver transplantation in HIV-HCV co-infected patients seems to be feasible when strict criteria of selection are taken into account. This still experimental strategy requires a multidisciplinary partnership.


Assuntos
Infecções por HIV/complicações , Hepatite C/complicações , Hepatite C/cirurgia , Transplante de Fígado , Adulto , Contagem de Linfócito CD4 , Infecções por HIV/imunologia , Humanos , Reprodutibilidade dos Testes
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