Medical Discussions

Marshall Fordyce – October 19, 2006[Edit]

Our very own Dr. Judy Aberg (head of the NYU/Bellevue AIDS Clinical Trials Group) wrote the accompanying editorial to this study published in AIM. In it, she highlights several points: in the post HAART era, HOPS (HIV Outpatient Study) demonstrated a reduction in mortality attributed to both opportunistic prophylaxis and the introduction of HAART; that in contrast to the original clinical guidelines for HIV+ patients, vaccinations (pneumococcus and hepatitis) are currently recommended; and that this study of New Yorkers underscores the fact that mortality is higher in the population of HIV+ patients that we care for: poor people, people of color, and those with a history of IVDU. It is important for us to note that, despite the trend highlighted in this study of New Yorkers, 75% of deaths were HIV-related. Our efforts to screen everybody at Bellevue is critical to case finding and further treatment and prevention. Does anyone know what our current seropositvity rate is?

If you know the answer post it in the comments.  Thanks for your thoughts Marshall.

by Raj Khandwalla

Background

• With the introduction of HAART therapy and prophylaxis  against common opportunistic disease, the morbidity and mortality associated with HIV/AIDS has decreased dramatically
  • Between 1996 and 1998, HIV-related morbidity and mortality  decreased by 60 percent in the United States
• Over time, the portion of deaths among patients with HIV from non-HIV causes has increased
• This is a population based analysis of the causes of death among HIV positive patients from 1999 through 2004
  •  the study is made up of two registries – the New York City HIV/AIDS Reporting System and Vital Statistics Registry

Methods

• Inclusion criteria: age of 13 years old or older who recieved a diagnosis of AIDS and were alive between 1999 and 2004. 
  • Patients had to be reported to the New York City HIV/AIDS Reporting System as of Sept 30, 2005
  • Patients had to be residents of New York City at the time of diagnosis
  • Among those who died, patients needed a known underlying cause of death
• The registry – The New York City HIV/AIDS Reporting System is a population based registry who recieved a diagnosis of AIDS as defined by the CBC
  • The reporting system recieves reports of possible AIDS diagnosis through an electronic  laboratory reporting system or through physician report and chart review 
• Defining AIDS
  • CD4 < 0.200 x 10^9 cells/L or less than 14 percent of total lymphocytes or
  • 1 of more 26 opportunistic illnesses
• Patients were classified by zip code and by ethnicity including Hispanic, non Hispanic people of European origin, non Hispanic African American, or other
• HIV transmission categories
  • Injection drug use
  • Men who have sex with men
  • High-risk heterosexual sex
  • Sex with an HIV positive partner, IV drug user, or with a bisexual man
• Outcome – underlying cause of death.  Persons with an unknown cause of death (1.8% of the total) were excluded from the anaylsis.

Baseline Demographics

• Median age 46 yo
• Gender, Male – 69.9 %
• Ethnicity
  • African American 46.9 %
  • Hispanic 33.4 %
  • Non Hispanic people of European origin 18.2%
  • Other 1.5%
• HIV transmission category
  • Men who have sex with men 23.6 %
  • IV drug users 33.2 %
  • High-risk heterosexual 14.4 %
  • Other transmission risk 1.7 %
  • Unknown 27.2 %
  • Among men with a known transmission category, 44.8% had sex with other men and 44.5% used injection drugs.
  • Among women with a known transmission category, 48.3% used injection drugs and 47.4% had high risk heterosexual sex.
• Socioeconomic status by zip code
  • Poverty 60.3 %
  • Nonpoverty 35.7%
  • Unknown 4 %
• Time of AIDS diagnosis
  • Before 1996 32.4%
  • 1996-1998 24.6%
  • 1999-2004 43%

Results

• Deaths
  •  74.2 percent of patients with known AIDS and known causes of death in NYC between 1999 and 2004, died of HIV related causes
  • 24 percent of patients with known AIDS died of non-HIV related causes
    • 7.4 percent died of substance abuse related deaths
    • 5.7 percent died of cardiovascular disease
    • 5 percent died of cancer
    • Accidents, chronic lower respiratory airway disease, cancer, diabetes, suicide, kidney disease each made up less 0.8 percent of deaths
• Trends in Deaths
  • Both the rate of HIV related deaths and the rate of non HIV related death decreased each year of the study
    • 54.9 percent decrease in HIV related deaths from 1999 to 2004
    • 34.3 percent decrease in non HIV related deaths from 1999 to 2004
  • Mortality rate for HIV related causes of death increased with age
  • Rates of HIV related deaths were higher for
    • women compared to men
    • African American men followed by Hispanic, and non Hispanic people of European heritage or other in both the HIV related and non HIV related groups.
  • Mortality rates were lowest for men who have sex with men and highest for injection drug users for both HIV related and non HIV related causes of death
  • The strongest predictor of death was a CD4 count <50 x 10^6
  • IV drug use was the strongest nonclinical predictor of death for both HIV related or non HIV related causes of death

 Discussion

• Between 1999 and 2004 in New York City, the rate of HIV related and non HIV related deaths has declined in people with AIDS
• HIV related deaths continue to account for the vast majority (74%) of deaths, but the proportion of non HIV related causes of death increased by 33% during this five year time period.
• The paper recommends that physicians taking care of HIV/AIDS patients should treat patients with “standard practices appropriate  for their age and sex” in addition to their HIV status.

THE BOTTOM LINE: People with AIDS are living longer.  While HIV related causes of deaths, still make up a majority mortalities in this population, non HIV related causes of death are quickly increasing among AIDS patients.  The advent of HAART is clearly helping people live longer.  As such, physicians should treat their patients for common causes of death among the general population.

by Raj Khandwalla

Background

• Methicillin-resistant staphylococcus aureus (MRSA) emerged in the 1960 primarily in hospitilized patients
• More recently, community acquired MRSA has been identified in prisoners, IV drug users, athletes, military trainees, and men who have sex with men
• It is usually associated with skin and soft tissue  infections, but it has also been associated with sepsis and necrotizing pneumonia
• Compared hospitlized MRSA, community acquired MRSA is less resistant, produces different toxins, and has a different gene complex that confers methicillin resistant, named staphylococcus cassette chromosome mec (SCCmec)
• This study set out to determine the prevelance of skin infection caused by MRSA in several geographically diverse, metropolitan areas in the United States

Methods

• A prospective prevalance study involving adult patients with skin and soft tissue infections to emergency departments in Albuquerque, Atlanta, Charlotte, Kansas City, Los Angeles, Minneapolis New Orleans, New York, Philadephia, Phenoix, and Portland
• Inclusion criteria:  18 years or older presenting in August 2004 with purulent skin and soft tissue infections of less than one week’s duration
• Pt’s with perirectal abscesses were excluded
• Management decisions were left up to the physicians taking care of the patients
• Follow-up data were obained by telephone approx. two to three weeks after enrollment
• Specimens were obtained from the single largest area of infection with the use of sterile swabs

Results

• A total of 422 patients with skin and soft tissue infections wer enrolled
• Baseline Characteristics
  • Race
    • 49 percent of pts were non Hispanic African Americans
    • 25 percent were non Hispanic individuals of European origin
    • 22 percent were Hispanic
    • 4 percent belonged to other groups
  • Infections were located
    • upper extremities – 29 percent 
    • lower extremities – 27 percent
    • torso – 17 percent
    • perineum - 14 percent
    • head and neck – 13 percent
  • Infections were classfied as an abscess in 81 percent of patients, an infected wound in 11 percent, and as a cellulitis with purulent exudate in 8 percent
• S aureus was isolated from skin and soft tissue infections in 320 patients (76 percent) and of these 249 pts (78 percent) were MRSA
• The prevelance of MRSA ranged from 15 to 74 percent, and MRSA was the most common identifiable cause of skin and soft tissue infections in 10 of 11 emergency departments
• MRSA isolated in
  • 61 percent of abscesses
  • 53 percent of purulent wounds
  • 47 percent of cases of cellulutis with purulent exudate
• Seventeen percent of isolates were meticillin sensitive staph aureus (MSSA)
• Seven percent of isolates were streptococcal species
• MRSA susceptibilities
  • 100 percent to Bactrim and Rifampin
  • 95 percent clindamycin
  • 92 percent to tetracycline
  • 60 percent to fluroquinolones
  • 6 percent to erythromycin
• People with MRSA were more likely to
  • have used antibiotics in the month before enrollment
  • had an abscess
  • lesion attributed to a spider bite at enrollment
  • history of MRSA infection
  • recent history of close contact with someone with a similar skin infection
• Treatment
  • 19 percent were treated with incision and drainage
  • 10 percent received antibiotics alone
  • 66 percent were treated with I&D and antibiotics
  • 21 percent underwent neither I&D nor antibiotics
  • Of 422 patients 59 percent were contacted 15 to 21 days after their visit to the er
    • Of these,  96 percent reported that their infectionhad resolved or improved
    • There was no significant difference in the outcome between patients infected with MRSA, MSSA, or any other isolate

Discussion

• MRSA is the most common skin and soft tissue infection in the hospital centers studied
• Eighty percent of patients with MRSA received antimicrobial therapy for their infection
  • Interestingly, the isolated bacteria was resistant to the prescribed antibiotics in 57 percent of patients
  • Perhaps empiric treatment of infection needs to be reconsidered
• Despite the lack of susceptibility in the majority of cases , there was no difference in outcomes when comparing patients prescribe antibiotics that were or were not effective in killing the cultured bacteria
• • This is consistent with the known literature and suggests that simple skin abscesses can be treated with simple drainage
• The findings of this study show that there has been a dramatic increase in the incidence of MRSA
• Prescribing antibiotics that are not indicated will only decrease their effectiveness in the future
• Clinicians should consider culturing MRSA isolates and modifying standard empirical therapy when indicated