RESUMO
BACKGROUND AND AIMS: The prevalence of hepatitis B virus (HBV) infection in patients on renal replacement has been reduced in developed countries, but information from developing nations is currently scarce and high prevalence rates are suspected. We undertook this study to analyze the prevalence of HBV infection and identify risk factors associated with it in a sample of Mexican hemodialysis patients. METHODS: A cross-sectional study was performed in patients on hemodialysis in Mexico. Adult patients from 10 hemodialysis centers were randomly selected. Patients answered a questionnaire for risk factors for HB infection and a blood sample was taken for HBsAg determination. RESULTS: We included 368 patients, 197 (53.5%) male, with a median age of 52 years (range: 18-93 years). In 26 patients HBsAg was positive with a prevalence of 7.1% (95% CI 4.4-9.7). Hepatitis C (HCV) was also tested, and 31 patients were positive with a prevalence of 8.4% (95% CI 5.5-11.2). Two patients (0.5%) were co-infected. Patients infected with HBV had been on hemodialysis longer (median time 50.5 months in HB positive vs. 34 months in HB negative; p = 0.005) and had history of more transfusions (median number of transfusions 5.5 vs 2; p < 0.009) compared with patients without HBV infection. CONCLUSIONS: The prevalence of HBV infection in patients on maintenance hemodialysis in Mexico is about 7%, 35 times higher compared with the general population (0.2%).
Assuntos
Hepatite B/epidemiologia , Diálise Renal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Masculino , México , Pessoa de Meia-Idade , Prevalência , Adulto JovemRESUMO
The National Government HAART Program (NGP) for the provision of HAART to uninsured HIV-infected persons in Mexico began in 2001. The objective was to describe the virologic outcome of patients enrolled in the NGP in a large HIV treatment center in Mexico City. HIV-infected persons, naive or < or =6 months on HAART, who entered the NGP from 2001 to 2005 were included. Patients with virological suppression were compared to those with virologic failure (VF) during follow-up. Of 377 patients enrolled, 191 where eligible for analysis. The median age was 35.9 (18-75 years) and 85% were male. The median baseline CD4(+) T cell count was 183 cells/mm(3); 63.9% had <200 cells/mm(3) and/or an AIDS-defining event. During follow-up (median: 17.77 months), 55 patients (28.7%) changed their first regimen: 8.3% because of VF and the remaining due to toxicity. The probability of VF at 48 months was 20%. VF was associated with age <30 years (p = 0.003, RR 4.7, IC 95% 1.5-14.4). The use of NNRTI was associated with lower risk of VF (p = 0.042, RR 0.3, IC 95% 0.12-0.99). Nadir CD4(+) and AIDS-defining at baseline were not associated with VF. Implementation of NGP for HAART access in a specialized care setting in Mexico resulted in an excellent virologic response. Younger age was a significant risk factor for VF.
Assuntos
Terapia Antirretroviral de Alta Atividade , Infecções por HIV/tratamento farmacológico , HIV-1/efeitos dos fármacos , Adolescente , Adulto , Fatores Etários , Idoso , Feminino , Infecções por HIV/mortalidade , Infecções por HIV/virologia , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde , México/epidemiologia , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Fatores de Risco , Falha de Tratamento , Carga Viral/efeitos dos fármacosRESUMO
OBJECTIVE: To compare the efficacy of efavirenz (EFV) vs lopinavir/ritonavir (LPV/r) in combination with azidothymidine/lamivudine in antiretroviral therapy naive, HIV+ individuals presenting for care with CD4 counts <200/mm. METHODS: Prospective, randomized, open label, multicenter trial in Mexico. HIV-infected subjects with CD4 <200/mm were randomized to receive open label EFV or LPV/r plus azidothymidine/lamivudine (fixed-dose combination) for 48 weeks. Randomization was stratified by baseline CD4 cell count (< or =100 or >100/mm). The primary endpoint was the percentage of patients with plasma HIV-1 RNA <50 copies/mL at 48 weeks by intention-to-treat analysis. RESULTS: A total of 189 patients (85% men) were randomized to receive EFV (95) or LPV/r (94). Median baseline CD4 were 64 and 52/mm, respectively (P = not significant). At week 48, by intention-to-treat analysis, 70% of EFV and 53% of LPV/r patients achieved HIV-1 RNA <50 copies/mL [estimated difference 17% (95% confidence interval 3.5 to 31), P = 0.013]. The proportion with HIV-1 RNA <400 copies/mL was 73% with EFV and 65% with LPV/r (P = 0.25). Virologic failure occurred in 7 patients on EFV and 17 on LPV/r. Mean CD4 count increases (cells/mm) were 234 for EFV and 239 for LPV/r. Mean change in total cholesterol and triglyceride levels were 50 and 48 mg/dL in EFV and 63 and 116 mg/dL in LPV/r (P = 0.24 and P < 0.01). CONCLUSIONS: In these very advanced HIV-infected ARV-naive subjects, EFV-based highly active antiretroviral therapy had superior virologic efficacy than LPV/r-based highly active antiretroviral therapy, with a more favorable lipid profile.
Assuntos
Benzoxazinas/administração & dosagem , Infecções por HIV/tratamento farmacológico , HIV-1/imunologia , Pirimidinonas/administração & dosagem , Ritonavir/administração & dosagem , Adulto , Alcinos , Fármacos Anti-HIV/administração & dosagem , Terapia Antirretroviral de Alta Atividade/métodos , Contagem de Linfócito CD4 , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD4-Positivos/virologia , Ciclopropanos , Feminino , Infecções por HIV/imunologia , Infecções por HIV/virologia , HIV-1/genética , Humanos , Lopinavir , Masculino , México , Estudos Prospectivos , RNA Viral/sangueRESUMO
OBJECTIVE: The objective of the study was to evaluate the immune response to measles vaccine of HIV-infected adults in comparison to HIV non-infected adults. DESIGN: We conducted a cross-sectional study to identify adults lacking measles antibodies. 26 HIV-infected patients and 22 controls found to be measles seronegative in the cross-sectional study, received the MMR vaccine. We prospectively followed patients and measured measles antibodies, and cellular proliferative responses against measles antigens. We registered all adverse events at baseline, 3 and 12 months after vaccination. METHODS: We determined measles antibodies by ELISA and cellular proliferative response in PBMC's at baseline, and repeated measurements at 3 and 12 months after vaccination. RESULTS: The humoral immune response to the vaccine between HIV-infected adults and the HIV-uninfected group was not statistically different at 3 months (81% vs. 86% respectively). One year after vaccination, a higher proportion of HIV-infected adults had lost measles antibodies in contrast to controls. The cellular response was not statistically different between the groups at baseline, 3 and 12 months after immunization despite the waning of antibodies at 12 months. No severe adverse events were observed. Most patients were receiving HAART and had a mean CD4+ cell count of 496 cells/mL. CONCLUSIONS: The initial humoral immune response to measles vaccine was not different between HIV-infected adults and HIV-uninfected adults. However, HIV-infected adults have a rapid decline of measles antibodies despite their high CD4+ cell count and sustained cellular proliferative response.
Assuntos
Anticorpos Antivirais/sangue , Infecções por HIV/imunologia , Vacina contra Sarampo-Caxumba-Rubéola/imunologia , Sarampo/prevenção & controle , Adulto , Terapia Antirretroviral de Alta Atividade , Proliferação de Células , Estudos Transversais , Ensaio de Imunoadsorção Enzimática , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Imunidade Celular , Imunidade Humoral , Masculino , Sarampo/epidemiologia , Sarampo/imunologia , México/epidemiologia , Estudos Prospectivos , Estudos Soroepidemiológicos , Adulto JovemRESUMO
OBJECTIVES: To study the prevalence, risk factors, outcome, and molecular epidemiology in patients with bacteremia caused by extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae (Kp) (cases), in comparison with patients with bacteremia caused by a susceptible Kp (controls). METHODS: This was a retrospective case-control study including all episodes of Kp bacteremia for the period 1993 to 2002 at a referral hospital for adults in Mexico. ESBL production was tested for by E-test. All isolates were typed by pulsed field gel electrophoresis (PFGE). A subset of isolates underwent plasmid analysis, conjugal transfer of cefotaxime resistance to Escherichia coli J53-2, isoelectric focusing bioassay, colony-blot hybridization, PCR, and sequencing. RESULTS: Of the 121 patients with bacteremia due to Kp included in the study, 17 (14.0%) had an ESBL-Kp isolate (cases). Multivariate analysis identified prior use of cephalosporins (OR 7.6, 95% CI 1.1-53.5; p=0.039) and stay in the intensive care unit (ICU; OR 5.6, 95% CI 1.1-27.9; p=0.033) as significant risk factors. No differences were observed in hospital stay or mortality after the event. Multi-drug resistance was more frequent in ESBL-Kp. There was no clonal predominance. A distinct beta-lactamase profile was identified, which included a combination of TEM-1 (pI 5.4) and SHV-5 (pI 8.2) in 13/17 ESBL-Kp isolates. Cefotaxime resistance was transferred by conjugation in 14/17 isolates with a >120-kb plasmid encoding ESBL. CONCLUSIONS: The prevalence of ESBL-Kp was found to be lower than that previously reported in Latin America. ESBL-Kp bacteremia was not associated with a worse clinical outcome. We were able to identify a plasmid-mediated horizontal dissemination over the 10-year period.
Assuntos
Bacteriemia/epidemiologia , Infecções por Klebsiella/epidemiologia , Klebsiella pneumoniae , Epidemiologia Molecular , beta-Lactamases/biossíntese , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/farmacologia , Bacteriemia/microbiologia , Bacteriemia/mortalidade , Estudos de Casos e Controles , Feminino , Humanos , Infecções por Klebsiella/microbiologia , Infecções por Klebsiella/mortalidade , Klebsiella pneumoniae/efeitos dos fármacos , Klebsiella pneumoniae/enzimologia , Klebsiella pneumoniae/genética , Klebsiella pneumoniae/isolamento & purificação , Masculino , México/epidemiologia , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Adulto Jovem , Resistência beta-Lactâmica/genética , beta-Lactamases/genéticaRESUMO
BACKGROUND: The use of fluoroquinolone prophylaxis in patients with cancer and neutropenia has failed to show a significant impact on mortality, despite its usefulness in reducing the incidence of gramnegative bacteremia. However, an increase in grampositive bacteremia and the emergence of resistant colonizing bacteria have consistently been noticed. OBJECTIVE: To determine the impact of prophylaxis with fluoroquinolones on the incidence of bacteremia and mortality in a hospital with high fluorquinolone resistance in Mexico City. PATIENTS: We conducted a retrospective and comparative study of patients with acute mieloid (AML) and hybrid (HL) leukemia who received or not prophylaxis with fluoroquinolones and who were attended from January 2000 to December 2003. We reviewed all pertinent clinical and laboratory data of the hematologic malignancies and the febrile episodes. RESULTS: A total of 108 febrile episodes of severe neutropenia occurred in 69 patients, with an incidence of 6.5 events/1000 day-patient with neutropenia. The median age was 35 +/- 18.3 years and 58% were men; 51 patients had AML (71.8%) and 20 (28.1%) HL. Prophylaxis had been given since the beginning of granulocytopenia in 46 (42.6%) febrile episodes (group 1), where as in 62 no prophylaxis was given (group 2). Of the 46 episodes with prophylaxis, 27 received ciprofloxacin 500 mg qd p.o. and 19, ciprofloxacin 500 mg qd po plus fluconazol 100 mg qd po. The median duration of prophylaxis was 8.5 days (range 1-90 days). Twenty-nine bacteremias (26.8%) were documented, with an incidence of 16.4 bacteremias/1000 day-patient with neutropenia, 12 (26%) in group 1 and 17 (27.5%) in group 2. Bacteremia was most frequently caused by gram negative organisms (18/29), being Escherichia coli (14) the most commonly isolated pathogen, with 7 episodes in each group. Eight (29.6%) of the 21 isolates in which fluoroquinolone susceptibility was tested were ciprofloxacin resistant, 3 in group 1 and 5 in group 2 (p = 0.58). Median survival of patients was 38 days in group 1 and 40 days in group 2. (p = 0.2); mortality was similar in both groups, 34% and 27%, respectively. CONCLUSIONS: In a hospital with a high prevalence of fluoroquinolone-resistance, prophylaxis in patients with acute leukemia and severe neutropenia did not prevent febrile episodes and did not have any impact on mortality. However, there was no increase in infections caused by resistant bacteria.
Assuntos
Bacteriemia/prevenção & controle , Fluoroquinolonas/uso terapêutico , Leucemia Mieloide Aguda/tratamento farmacológico , Neutropenia/etiologia , Adulto , Idoso , Bacteriemia/epidemiologia , Bacteriemia/etiologia , Resistência Microbiana a Medicamentos , Feminino , Hospitais , Humanos , Masculino , México , Neutropenia/induzido quimicamente , Neutropenia/complicações , Prevalência , Estudos Retrospectivos , Índice de Gravidade de Doença , População UrbanaAssuntos
Humanos , Transplante de Medula Óssea , Infecções/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Infecções por Adenoviridae/tratamento farmacológico , Infecções por Adenoviridae/epidemiologia , Antifúngicos/uso terapêutico , Antivirais/uso terapêutico , Transplante de Medula Óssea/efeitos adversos , Infecções por Citomegalovirus/tratamento farmacológico , Infecções por Citomegalovirus/epidemiologia , Infecções por Citomegalovirus/transmissão , Citomegalovirus/fisiologia , Infecções por Vírus Epstein-Barr/tratamento farmacológico , Infecções por Vírus Epstein-Barr/epidemiologia , Infecções por Vírus Epstein-Barr/transmissão , /fisiologia , Hospedeiro Imunocomprometido , Terapia de Imunossupressão/efeitos adversos , Infecções/etiologia , Infecções/transmissão , Micoses/tratamento farmacológico , Micoses/epidemiologia , Micoses/etiologia , Período Pós-Operatório , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/microbiologia , Complicações Pós-Operatórias/virologia , Fatores de Risco , Transplante Autólogo , Condicionamento Pré-Transplante/efeitos adversos , Transplante Homólogo/efeitos adversos , Ativação ViralAssuntos
Transplante de Medula Óssea , Infecções/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Infecções por Adenoviridae/tratamento farmacológico , Infecções por Adenoviridae/epidemiologia , Antifúngicos/uso terapêutico , Antivirais/uso terapêutico , Transplante de Medula Óssea/efeitos adversos , Citomegalovirus/fisiologia , Infecções por Citomegalovirus/tratamento farmacológico , Infecções por Citomegalovirus/epidemiologia , Infecções por Citomegalovirus/transmissão , Infecções por Vírus Epstein-Barr/tratamento farmacológico , Infecções por Vírus Epstein-Barr/epidemiologia , Infecções por Vírus Epstein-Barr/transmissão , Herpesvirus Humano 4/fisiologia , Humanos , Hospedeiro Imunocomprometido , Terapia de Imunossupressão/efeitos adversos , Infecções/etiologia , Infecções/transmissão , Micoses/tratamento farmacológico , Micoses/epidemiologia , Micoses/etiologia , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/microbiologia , Complicações Pós-Operatórias/virologia , Período Pós-Operatório , Fatores de Risco , Condicionamento Pré-Transplante/efeitos adversos , Transplante Autólogo , Transplante Homólogo/efeitos adversos , Ativação ViralRESUMO
The goal of this presentation is the description of the epidemiologic evolution and changes in natural history of the human immunodeficiency virus infection (HIV) epidemic itself and its relation with the acquired immunodeficiency syndrome-related lymphoma (ARL). We have started with the description of the world's state of the HIV epidemic, its features since the first case report in the United States of America in 1981, through the peak of new diagnoses in 1993 until the event that changed the natural history of the disease: the era of the widespread use of the highly active antiretroviral therapy (HAART), introduced in 1995 in the world and in 1997 in our country. The widespread introduction of HAART led to dramatic reductions in AIDS related mortality and morbidity throughout the developed world with a marked fall in the incidence of the major opportunistic infections in AIDS. We describe the main risk factors for the development of ARL, and the prognostic factors for survival and response to treatment. There is no clear definition in the literature of the roll that has played the use of HAART in relation to survival and response to treatment in ARL, but there is evidence that the basal count of CD4 cells has increased with HAART, leading to a better survival and response in ARL. The debate regarding this issue is surely affected by factors such as degree of antiretroviral treatment compliance, antiretroviral therapy resistance and chemotherapy heterogeneity. Finally we present the preliminary results of the analysis of our experience in ARL from 1986 to 2003.