Objective: People with HIV (PWH) and co-infected with hepatitis C virus (PWH þ HCV) have increased risk of cardiovascular disease (CVD). Peri-coronary inflammation, measured by fat attenuation index (FAI) on coronary computed tomography angiography (CCTA), independently predicts cardiovascular risk in the general population but has not been studied in the PWH þ HCV population. We tested whether peri-coronary inflammation is increased in PWH or PWH þ HCV, and whether inflammation changes over time.Design: Cross-sectional analysis to determine FAI differences among groups. Longitudinal analysis in PWH to assess changes in inflammation over time.Methods: Age-matched and sex-matched seropositive groups (PWH and PWH þ HCV) virologically suppressed on antiretroviral therapy, HCV viremic, and without prior CVD and matched controls underwent CCTA. Peri-coronary FAI was measured around the proximal right coronary artery (RCA) and left anterior descending artery (LAD). Followup CCTA was performed in 22 PWH after 20.6-27.4 months.Results: A total of 101 participants (48 women) were studied (60 PWH, 19 PWH þ HCV and 22 controls). In adjusted analyses, peri-coronary FAI did not differ between seropositive groups and controls. Low attenuation coronary plaque was significantly less common in seropositive groups compared with controls (LAD, P ¼ 0.035; and RCA, P ¼ 0.017, respectively). Peri-coronary FAI values significantly progressed between baseline and follow-up in PWH (RCA: P ¼ 0.001, LAD: P ¼ <0.001). Conclusion:PWH and PWH þ HCV without history of CVD do not have significantly worse peri-coronary inflammation, assessed by FAI, compared with matched controls. However, peri-coronary inflammation in mono-infected PWH significantly increased over approximately 22 months. FAI measures may be an important imaging biomarker for tracking asymptomatic CVD progression in PWH.
Outcomes for critically ill people living with human immunodeficiency virus (PLHIV) have changed with the use of antiretroviral therapy (ART). To identify these outcomes and correlates of mortality in a contemporary critically ill cohort in an urban academic medical center in Baltimore, a city with a high burden of HIV, we conducted a retrospective cohort study of individuals admitted to a medical intensive care unit (MICU) at a tertiary care center between 2009 and 2014. PLHIV who were at least 18 years of age with an index MICU admission of ≥24 hours during the 5-year study period were included in this analysis. Data were obtained for participants from the time of MICU admission until hospital discharge and up to 180 days after MICU admission. Logistic regression was used to identify independent predictors of hospital mortality. Between June 2009 and June 2014, 318 PLHIV admitted to the MICU met inclusion criteria. Eighty-six percent of the patients were non-Hispanic Blacks. Poorly controlled HIV was very common with 70.2% of patients having a CD4 cell count <200 cells/mm3 within 3 months prior to admission and only 34% of patients having an undetectable HIV viral load. Hospital mortality for the cohort was 17%. In a univariate model, mortality did not differ by demographic variables, CD4 cell count, HIV viral load, or ART use. Regression analysis adjusted by relevant covariates revealed that MICU patients admitted from the hospital ward were 6.4 times more likely to die in hospital than those admitted from emergency department. Other positive predictors were a diagnosis of end-stage liver disease, cardiac arrest, ventilator-dependent respiratory failure, vasopressor requirement, non-Hodgkin lymphoma, and symptomatic cytomegalovirus disease. In conclusion, in this critically ill cohort with HIV infection, most predictors of mortality were not directly related to HIV and were similar to those for the general population.
Background Patients with substance use disorder (SUD) are frequently admitted to hospitals for invasive infections and may have poor infection outcomes including non-adherence and lack of completion of therapy. Methods In this retrospective cohort of 263 hospital encounters among 201 patients for invasive infections due to SUD to an urban tertiary care facility, we looked at characteristics of SUD to assess whether there were differences in infections, their management, SUD interventions and parenteral antibiotic outcomes between groups. Results Among people with SUD, 79% of antibiotic courses were completed in skilled nursing facilities. Most common infectious syndromes were osteoarticular infections (123, 47%), infective endocarditis (IE) (54, 20%) and non-IE endovascular infection (23, 9%). Among SUD specific interventions, 64% of episodes had documentation of a consultation by substance use services and 68% episodes had documentation of medication for opioid use disorder (MOUD) being prescribed at discharge. Overall, completion of therapy was documented in 163 (62%) of encounters. Overall, treatment non-adherence was seen in 63 encounters (24%). Non-adherence was documented 32% of episodes with documentation of injection drug use (IDU), 28% of encounters where active substance use was documented in the prior year and 33% of encounters where use of more than one substance was documented (P< 0.05 for all 3 groups). Drug or catheter related adverse events seemed to be significantly higher in the IDU group (3.64/1000 OPAT days) and catheter abuse was documented in 7 encounters of which 6 were with IDU or active SUD active documented. Cumulatively an unfavorable outcome (including failure, 30-day readmission, drug or PICC related adverse event, non-adherence or death) seemed to occur in 58% of IDU encounters as compared to non-IDU encounters (42.5%, P=0.011). Medication for opioid use disorder (MOUD) was prescribed at discharge in 68% of overall cohort and was not associated with improved outcomes for any of the above groups. Demographics, infection details and outcomes by type of SUD Conclusion In patients hospitalized with SUD-related infections, interventions need to be focused on those with high risk, unstable SUD through MOUD optimization along transitions of care and linkage to care to improve OPAT outcomes and overall health events Disclosures Shyam Kottilil, MD, PhD, Arbutus Pharmaceuticals: Grant/Research Support|Gilead: Grant/Research Support|Merck: Grant/Research Support|Regeneron Pharmaceuticals: Advisor/Consultant|Silverback Therapeutics: Advisor/Consultant|The Liver Company: Advisor/Consultant|Yufan Biotechnologies: Advisor/Consultant.
Background The management of invasive infections related to substance use disorder (SUD) needing parenteral antimicrobial therapy is challenging and may have poor infection outcomes including non-adherence and lack of completion of parenteral antimicrobial therapy. Methods In this retrospective cohort of 201 patients with invasive infections related to SUD, we looked at frequency and determinants of unfavorable outcomes including non-adherence. Results 79% of patients with SUD related infection completed parenteral antibiotic therapy in skilled nursing facilities (SNF). 21.5% of patient episodes had documentation of non-adherence. Non-adherence was higher in patients with active injection drug use (IDU) [28.5% vs 15% in non IDU, adjusted odds ratio (OR) 2.36, 95% CI 1.1-5.5 P = 0.024], patients with active SUD in the prior year (24.5% vs 11%, P = 0.047), patients with use of more than one illicit substance (30.3% vs 17%, P = 0.031), as well as in people experiencing homelessness (32.8% vs 15.7% in stably housed P = 0.005). In a multivariate model, nonadherence was significantly associated with IDU (OR 2.38, 95% CI 1.03-5.5), and homelessness (OR 2.25, 95% CI 1.01-4.8) Medication for opioid use disorder (MOUD) was prescribed at discharge in 68% of overall cohort and was not associated with improved outcomes for any of the above groups. Conclusions Non-adherence to parenteral antimicrobial therapy is high in the most vulnerable patients with unstable high-risk SUD and adverse social determinants of health. The design of the work has been approved by Institutional Review Board at the University of Maryland and was deemed exempt from full review and not requiring separate patient consent for purposes of this study.
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