Bacterial/Mycobacterial Infections
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Bacterial/Mycobacterial Infections
People with HIV are particularly susceptible to a number of pyrogenic bacterial infections, including salmonellosis. Pneumonias resulting from Streptococcus pneumoniae, Haemophilus influenzae, and other streptococci; and enteritis caused by Shigella and Campylobacter are especially prevalent.
Sinusitis has been reported to occur frequently in HIV-infected people (Godofsky et al. and Zurlo et al.). Sinusitis is often recurrent or persistent, and may be asymptomatic. Thompson et al. report that many HIV-infected patients with sinusitis are infected with common bacteria (in particular staph epidermis). Most patients have at least a partial response to antibiotic treatment, although complete resolution of symptoms is difficult to achieve. Increasingly, in AIDS patients with advanced disease, Pseudomonas aeruginosa is the cause of chronic sinusitis.
Selwyn et al. report that in HIV-infected injection drug users, pyrogenic bacterial infections are both a substantial cause of pre-AIDS morbidity and mortality and a significant predictor of progression to AIDS. In this prospective study of a cohort of patients from a methadone clinic, 13/318 HIV-infected patients without a diagnosis of AIDS died of bacterial infections, while1/411 HIV-negative patients died of bacterial infections.
The United States Public Health Service and the Infectious Disease Society of America (1995) have published guidelines for the prevention of respiratory and enteric bacterial infections. To prevent certain respiratory bacterial infections, the guidelines state that adults should receive a single dose of 23-valent polysaccharide pneumococcal vaccine (along with annual influenza vaccination) as soon as possible after HIV infection has been diagnosed. H. influenzae vaccination should also be considered. Steinhoff et al. compared H. influenza type b polysaccharide (PRP) vaccine to the polysaccharide-mutant diphtheria toxoid conjugate vaccine (PRP-CRM. In symptomatic and early symptomatic HIV-positive men (and in HIV-negative men), the PRP-CRM vaccine caused a three-fold greater antibody response than the PRP vaccine.
However, in men with AIDS, the PRP vaccine induced a greater response. Standard antimicrobial therapies are generally effective for bacterial infections.
Two species of Rochalimaea (R.henselae and R.quintana) have been established as causes of cutaneous bacillary angiomatosis, peliosis hepatitis, and persistent fever and bacteremia (Bignall). Susceptibility to these opportunistic pathogens result primarily from defects in cell-mediated immunity. Erythromycin is the most commonly prescribed treatment, although one case report describes successful treatment of one patient with azithromycin (Guerra et al.).
Intravenous immunoglobulin (IVIG) reduces the incidence of serious bacterial infections (meningitis, bacteremia, osteomyelitis, septic arthritis, acute sinusitis, pneumonia, acute mastoiditis, or abscess of an internal organ) in HIV-infected children with CD4 count >200/mm3.
255 children with symptomatic HIV infection were enrolled in a double-blind placebo-controlled study (ACTG 051) comparing the combination of AZT and monthly infusions of IVIG 400 mg/kg with AZT alone (Spector et al.). After a median follow-up of 30 months, no significant benefit beyond that provided by AZT and PCP prophylaxis with TMP/SMX was observed.
The National Institute of Child Health and Development enrolled 372 symptomatic HIV-positive children in a double-blind placebo-controlled study of IVIG (Gamimune N, Cutter Biological) 400 mg/kg once a month. Equal numbers of patients in each group also received AZT (39% overall) and PCP prophylaxis (48% overall). After a median follow-up of 17 months, an interim analysis showed that among the 317 children who entered the study with CD4 cell counts >200/mm3, 12/162 (7%) IVIG recipients experienced a lab-proven serious bacterial infection, compared with 24/155 (15%) placebo recipients. For children with entry CD4 counts <200/mm3, there was no difference in the rate of these infections. Mortality rates were equal (31 deaths in each group).
In a post-hoc analysis of a randomized study comparing TMP/SMX and aerosolized pentamidine for secondary PCP prophylaxis (ACTG 021), fewer serious infections occurred in the TMP/SMX group. Hardy et al. report that 19 bacterial infections occurred in 154 TMP/SMX recipients, while 38 infections occurred in156 aerosolized pentamidine recipients. The time to a bacterial infection was also significantly longer in the TMP/SMX group (P = 0.017).
In children under 13 with documented HIV infection, recurrent or multiple cases of Streptococcus, Haemophilus or other pyrogenic bacteria establishes an AIDS diagnosis.
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Ongoing Prophylaxis Studies
A Phase II/III randomized trial (ACTG 254) of atovaquone and azithromycin compared to TMP/SMX in the prevention of bacterial infections in HIV-positive children between the ages of 2 and 8 years of age is currently underway.
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REFERENCES:
Center for Disease Control. USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus. MMWR 44:1-24,1995.
Godofsky EW et al. Sinusitis in HIV-infected patients: a clinical and radiographic review. Amer J Med 93:163-70,1992.
Guerra LG et al. Rapid response AIDS-related bacillary angiomatosis to azithromycin. Clin Inf Dis 17:264-6,1993.
Hardy WD et al. A controlled trial of trimethoprim-sulfamethoxazole or aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia patients with the acquired immunodeficiency syndrome. AIDS Clinical Trials Group Protocol 021. NEJM 237:1824-8, 1992.
Selwyn PA et al. Clinical manifestations and predictors of disease progression in drug users with human immunodeficiency virus infection. NEJM 327:1697-703, 1992.
Spector SA et al. A controlled trial of intravenous immune globulin for the prevention of serious bacterial infections in children receiving zidovudine for advanced human immunodeficiency virus infection. NEJM 331(18): 1181-7.
Steinhoff MC et al. Antibody responses to Haemophilus influenzae type B vaccines in men with HIV infection. NEJM 325:1837-42,1991.
Zurlo JJ et al. Sinusitis in HIV-1 infection. Amer J Med 93:157-62, 1992.
OTHER REPORTS:
Molina JM et al. Campylobacter infections in HIV-infected patients: clinical and bacteriological features. AIDS 9:881-885,1995.
Perkocha LA et al. Clinical and pathological features of bacillary peliosis hepatitis in association with human immunodeficiency virus infection. NEJM 323(23):
1581-86,1990.
Relman DA et al. The agent of bacillary angiomatosisÑan approach to the identification of uncultured pathogens. NEJM 323(23) 1573-80,1990.
Schrager LK et al. Bacterial infections in AIDS patients. AIDS, 2(Supp.1):
S183-9,1990.
Slater LN et al. A newly recognized fastidious gram-negative pathogen as a cause
of fever and bacteremia. NEJM 323(23): 1587-92,1990.
Steinhart R et al. Invasive Haemophilus influenzae infections in men with HIV infection. JAMA 268:3350-2,1992.
Bignall J. Rochalimaeas from cat-scratch to Kaposi. Lancet 342:359,1993.
Chaisson RE. Infections due to encapsulated bacteria, Salmonella, Shigella. and Campylobacter. Infect Dis Clin N Am 2(2): 475-84,1988.
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