Bacterial pneumonia is more frequent in HIV-positive persons than in seronegative controls, and the risk is highest among those with CD4 lymphocyte counts below 200 per cubic millimeter and among injection-drug users.

4. Prophylaxis of disseminated M. avium complex disease. Prophylaxis should be given to adults with AIDS with CD4 counts Ͻ 50 cells, especially with a history of a prior opportunistic infection. Rifabutin 300 mg/d, clarithromycin 500 mg twice daily, azithromycin 1,200 mg once weekly, and azithromycin 1,200 mg once weekly plus rifabutin 300 mg daily are all proven effective regimens. 5. Treatment of nontuberculous mycobacteria cervical lymphadenitis. Nontuberculous mycobacteria cervical lymphadenitis is still treated primarily by surgical excision alone, with a 95% cure rate. A clarithromycin-containing regimen should be considered for patients with extensive disease or a poor response to surgery. 6. Treatment of nonpulmonary rapidly growing mycobacteria. Therapy of nonpulmonary disease caused by M. fortuitum, M. abscessus , and M. chelonae should include drugs such as amikacin and clarithromycin, based on in vitro susceptibility tests.

No abstract

We examined trends in the incidence of specific respiratory disorders in a multicenter cohort with progressive human immunodeficiency virus (HIV) disease during a 5-yr period. Individuals with a wide range of HIV disease severity belonging to three transmission categories were evaluated at regular intervals and for episodic respiratory symptoms using standard diagnostic algorithms. Yearly incidence rates of respiratory diagnoses were assessed in the cohort as a whole and according to CD4 count or HIV transmission category. The most frequent respiratory disorders were upper respiratory tract infections, but the incidence of lower respiratory tract infections increased as CD4 counts declined. Specific lower respiratory infections followed distinctive patterns according to study-entry CD4 count and transmission category. Acute bronchitis was the predominant lower respiratory infection of cohort members with entry CD4 counts > or = 200 cells/mm3. In cohort members with entry CD4 counts of 200 to 499 cells/mm3, the incidence of bacterial and Pneumocystis carinii pneumonia each increased an average of 40% per year. In members with entry CD4 counts < 200 cells/mm3, acute bronchitis, bacterial pneumonia, and P. carinii pneumonia occurred at high rates without discernible time trends, despite chemoprophylaxis in more than 80% after Year 1, and the rate of other pulmonary opportunistic infections increased over time. Each year, injecting drug users had a higher incidence of bacterial pneumonia than did homosexual men. The yearly rate of tuberculosis was < 3 episodes/100 person-yr in each entry CD4 and HIV-transmission group. We conclude that the time trends of HIV-associated respiratory disorders are determined by HIV disease stage and influenced by transmission category. Whereas acute bronchitis is prevalent during all stages of HIV infection, incidence rates of bacterial pneumonia and P. carinii pneumonia rise continuously during progression to advanced disease. In advanced disease, the incidence of acute bronchitis, bacterial pneumonia and P. carinii pneumonia is high despite widespread chemoprophylaxis.

Human immunodeficiency virus (HIV)-associated respiratory infections, most notably Pneumocystis carinii pneumonia (PCP), but also bacterial pneumonia (BP), result in reductions in lung function that have been studied mainly during the course of acute infection. Whether HIV-associated pneumonias also cause permanent changes in pulmonary function is unknown. In this study we investigated the long-term effects of PCP and BP on pulmonary function in a cohort of HIV-infected persons. One thousand, one hundred forty-nine HIV-infected persons were followed in a prospective, observational cohort study at six centers in the United States. Study participants had pulmonary function testing performed at regular preset intervals. PCP and BP diagnoses were verified with defined criteria. Longitudinal multivariate analysis was used to model pulmonary function in terms of demographic data and occurrence of PCP or BP. We found that PCP or BP was associated with permanent decreases in FEV(1), FVC, FEV(1)/FVC, and the diffusing capacity of carbon monoxide. Neither infection resulted in statistically significant changes in TLC. We conclude that PCP and BP result in expiratory airflow reductions that persist after the acute infection resolves. The clinical implications of these changes are unknown, but they may contribute to prolonged respiratory complaints in HIV-infected patients who have had pneumonia.

Incidence of tuberculosis was higher in the eastern United States, in patients with CD4 counts of less than 200 cells/mm3, and in PPD-positive patients. Analysis of tuberculin reaction size supports the current interpretive criteria of the Centers for Disease Control and Prevention. Nonreactivity to mumps antigen indicated increased risk for tuberculosis independent of PPD response.

This prospective, cohort study analyzed the prevalence of alcoholism and patterns of alcohol intake over time in a cohort of HIV-infected patients, predominantly homosexual/bisexual men. One hundred eleven HIV-positive subjects were recruited from a comprehensive HIV clinic associated with a large Midwestern university hospital. Each participant completed the Michigan Alcoholism Screening Test (MAST) survey and a standardized quantity-frequency questionnaire on alcohol intake at enrollment. The quantity-frequency scale was repeated every six months for a total of 30 months. Forty-five of the 111 subjects (41%) met the criteria for alcoholism, as defined by a MAST score 5 or higher. There was a significant decrease in alcohol consumption over time, from 6.4 drinks/week in the initial time period to 3.9 drinks/week by the final time period (p < 0.001).

Because of numerous criticisms of the content and structure of residency training, redesigning graduate medical education (GME) has become a high priority for the internal medicine community. From 2005 to 2007, the leadership of the internal medicine community, working under the auspices of the Alliance for Academic Internal Medicine Education Redesign Task Force, developed six recommendations it will pursue to improve residency education: (1) focus education around a "core" of internal medicine, which provides the framework for both the structure and content of residents' educational experiences, (2) fully adopt competency-based evaluation and advancement, which will enhance training by focusing on individual learners' needs, (3) allow for increased, resident-centered education beyond the internal medicine core, because different types of practice require customized knowledge and skills, (4) improve ambulatory training by providing patient-centered longitudinal care that addresses the conflict between inpatient and outpatient responsibilities, (5) use new faculty models that emphasize the creation of a core faculty, and (6) align institutional and programmatic resources with the goals of redesign, balancing the clinical mission of the institution with the educational goals of residency training. Adoption of these recommendations will require significant efforts, including pilot projects, faculty development, changes in accreditation requirements, and modifications of GME funding systems. Opportunities are ample for individual programs to develop creative approaches based on the framework for educational redesign outlined in this article, and for these educational and clinical redesign initiatives to work hand-in-hand for the benefit of patients, faculty, trainees, and institutions.