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T R Sterling

Publications and source records attributed to T R Sterling.

34 records · Page 2Linked to original sources
PubMed1999

Relapse rates after short-course (6-month) treatment of tuberculosis in HIV-infected and uninfected persons.

OBJECTIVE: To determine the rate of tuberculosis relapse among HIV-seropositive and -seronegative persons treated for active tuberculosis with short-course (6-month) therapy. DESIGN: Consecutive cohort study. SETTING: City of Baltimore tuberculosis clinic. PATIENTS: Tuberculosis patients treated between 1 January 1993 and 31 December 1996. INTERVENTION: Patients received 2 months of isoniazid, rifampin, pyrazinamide and ethambutol followed by 4 months of isoniazid and rifampin. MAIN OUTCOME MEASURE: Passive follow-up for tuberculosis relapse was performed through September 30, 1998. RESULTS: There were 423 cases of tuberculosis during the study period; 280 patients completed a 6-month course of therapy. Therapy was directly-observed for 94% of patients. Of those who completed therapy, 47 (17%) were HIV-seropositive, 127 (45%) were HIV-seronegative, and 106 (38%) had unknown HIV status. HIV-infected patients required more time to complete therapy (median 225 versus 205 days; P = 0.04) but converted sputum culture to negative within the same time period (median 77 versus 72 days; P = 0.43) as HIV-seronegative or unknown patients. Relapse occurred in three out of 47 (6.4%) HIV-infected patients compared to seven out of 127 (5.5%) HIV-seronegative patients (P = 1.0). Relapse rates also did not differ when HIV-seropositive patients were compared with HIV-seronegative and patients with unknown HIV status (6.4% versus 3.0%; P = 0.38). Of the 10 patients with tuberculosis relapse, restriction fragment length polymorphism data were available for five; all five relapse isolates matched the initial isolate. CONCLUSIONS: These results support current recommendations to treat tuberculosis in HIV-infected patients with short-course (6-month) therapy.

AIDS-Related Opportunistic Infections↗
PubMed1999

Sex differences in longitudinal human immunodeficiency virus type 1 RNA levels among seroconverters.

Cross-sectional studies have demonstrated lower plasma human immunodeficiency virus type 1 (HIV-1) RNA virus levels (VLs) in women than in men, but it is unknown whether this sex difference is present at the time of seroconversion and throughout the course of infection. A nested case-control study was performed among HIV-1 seroconverters within a cohort of injection drug users. Plasma VL was determined longitudinally among both rapid progressors to AIDS (24 patients) and nonprogressors (47 controls). The initial median VL among female patients (n=10) was 14,918 copies/mL, compared with 148,354 copies/mL among male patients (n=14; P=.001); median plasma VL also tended to be lower among female (n=10) than among male controls (n=37; 11,917 vs. 61,311 copies/mL; P=.08). VL increased more rapidly over time in women than in men and subsequently converged in patients and controls, respectively. Understanding the mechanisms responsible for the sex difference in VL may provide insight into HIV-1 pathogenesis.

Acquired Immunodeficiency Syndrome↗
PubMed1999

Tuberculosis vaccination versus isoniazid preventive therapy: a decision analysis to determine the preferred strategy of tuberculosis prevention in HIV-infected adults in the developing world.

SETTING: The developing world. OBJECTIVE: To compare the strategy of TB vaccination with that of tuberculin skin-testing in conjunction with isoniazid (INH) in preventing tuberculosis in HIV-infected persons. For any clinical scenarios in which immunization would be more effective than INH preventive therapy, to determine the minimum necessary vaccine safety and effectiveness required. DESIGN: Decision analysis. A hypothetical cohort of 10000 HIV-infected persons, 65% of whom were tuberculin positive, living in the developing world, was studied. Probability estimates were based on BCG vaccine for the baseline analysis, and it was assumed that the vaccine cannot protect if given after infection. RESULTS: Under the probability estimates and assumptions of the analysis, tuberculin skin testing/INH preventive therapy would prevent 458 more cases of TB and 45 more deaths due to TB than TB vaccination. One- and two-way sensitivity analyses revealed no thresholds at which TB vaccination would be the preferred strategy. Vaccine safety did not impact the outcome of the analysis. Three-way sensitivity analysis revealed that if the prevalence of anergy were 35% and the risk of progression to active TB among anergic persons 12.2 cases per 100 person-years, a vaccine would have to be at least 87% effective to be preferred over INH preventive therapy. CONCLUSIONS: Under the conditions of the analysis, which did not account for cost or logistics, tuberculin skin testing/INH preventive therapy would be more effective than TB vaccination in preventing TB among HIV-infected persons. The hypothesized TB vaccine would prevent more TB than INH preventive therapy only in areas where the prevalence of anergy and risk of active TB if anergic were high, and vaccine effectiveness exceeded 87%.

Adult↗
PubMed1998

Mycobacterium tuberculosis infection and disease are not associated with protection against subsequent disseminated M. avium complex disease.

OBJECTIVE: To determine the relationship between Mycobacterium tuberculosis infection and disease and subsequent disseminated M. avium complex (MAC) disease in HIV-infected persons. DESIGN: A prospective observational cohort study. SETTING: The AIDS Linked to the Intravenous Experience (ALIVE) cohort of injecting drug users and the Johns Hopkins Hospital Adult HIV Clinic (JHHAHC). PARTICIPANTS: HIV-infected persons aged > 18 years with CD4 lymphocytes < 100 x 10(6)/l were followed between July 1989 and 31 October 1996. There were 182 persons in the ALIVE cohort and 1129 persons in JHHAHC who met these criteria. MAIN OUTCOME MEASURE: The relative risk of disseminated MAC was determined according to a history of prior opportunistic infection, MAC prophylaxis, antiretroviral therapy, M. tuberculosis infection or disease, race, sex, and injecting drug use. RESULTS: Amongst the 30 patients with active tuberculosis, eight developed disseminated MAC, compared with 208 cases of disseminated MAC amongst 1148 patients without prior M. tuberculosis infection or disease [relative risk (RR), 1.5; 95% confidence interval (CI), 0.8-2.7; P=0.2]. Amongst the 10 patients with extrapulmonary tuberculosis, five developed disseminated MAC (RR, 2.8; 95% CI, 1.5-5.2; P=0.02). Injecting drug use was associated with a decreased risk of disseminated MAC (RR, 0.7; 95% CI, 0.6-0.9; P=0.007). In a logistic regression analysis, disseminated MAC was significantly associated with extrapulmonary tuberculosis and other opportunistic disease, whereas antibiotic prophylaxis and injecting drug use were protective. CONCLUSIONS: A history of M. tuberculosis infection or disease was not associated with protection against subsequent disseminated MAC disease in HIV-infected persons. However, persons with extrapulmonary tuberculosis were at increased risk for disseminated MAC, particularly at low CD4 cell levels.

AIDS-Related Opportunistic Infections↗
PubMed1998

Resistance to amphotericin B: emerging clinical and microbiological patterns.

There has been an increasing number of reports of clinically significant amphotericin B (AmB) resistance in fungal pathogens, including Candida albicans. Concomitantly, advances in antifungal susceptibility testing have led to an improved correlation between microbiologic and clinical failure. Reports of AmB resistance, correlation of results and in vitro/in vivo correlations, mechanisms of resistance, and the transmission of resistant isolates within confined environments are reviewed. Recommendations are given regarding the clinical settings in which AmB susceptibility testing should be considered.

Journal Article↗
PubMed1996

The relationship between delayed or incomplete treatment and all-cause mortality in patients with tuberculosis.

OBJECTIVE: To analyze the factors associated with survival in patients with pulmonary and extrapulmonary tuberculosis in New York City. DESIGN: Observational study of a citywide cohort of tuberculosis cases. SETTING: New York City, April 1991, before the strengthening of its control program. PATIENTS: All 229 newly diagnosed cases of tuberculosis documented by culture in April 1991. Most patients (74%) were male, and the median age was 37 years (range, 1-89 years). In all, 89% belonged to minority groups. Human immunodeficiency virus (HIV) infection was present in 50% and multidrug resistance in 7% of the cases. Twenty-one patients (9%) were not treated. MAIN OUTCOME MEASURES: Follow-up information was collected through the New York City tuberculosis registry; death from any cause was verified through the National Death Index. RESULTS: Cumulative all-cause mortality by October 1994 was 44%; the median survival for those who died was 6.3 months (range, 0 days to 3 years). The most important baseline predictors of mortality, adjusted for baseline clinical and demographic factors, were acquired immunodeficiency syndrome (AIDS) (91% vs 11% in HIV-seronegative patients; Cox relative risk [RR], 7.8; 95% confidence interval [CI], 2.1-29.1), multidrug resistance (87% vs 39% in pansensitive cases; adjusted RR, 5.8; 95% CI, 2.3-14.5), and lack of treatment (81% vs 40%; adjusted RR, 3.1; 95% CI, 1.0-9.7). Also, 11 of 13 HIV-infected patients who started treatment after a 1-month delay died. Among 173 patients surviving the recommended treatment period, those who completed therapy (66%) had a lower subsequent mortality (20% vs 37%; RR, 0.5; 95% CI, 0.3-0.9). CONCLUSIONS: Mortality from tuberculosis was high, even among patients without multidrug resistance who were not known to be infected with HIV. Most HIV-seropositive patients with delayed therapy died. Multidrug resistance predicted higher mortality, and treatment completion was associated with improved subsequent patient survival.

Adolescent↗
PubMed1996

Diagnosis and treatment of ventilator-associated pneumonia--impact on survival. A decision analysis.

STUDY OBJECTIVE: To determine the impact of antibiotic treatment of ventilator-associated pneumonia (VAP) on survival. DESIGN: Decision analysis. PATIENTS: A hypothetical cohort of immunocompetent patients receiving mechanical ventilation who have suspected bacterial pneumonia. The analysis was performed separately for the following diagnostic techniques: clinical criteria, bronchoscopic protected specimen brush (PSB), and nonbronchoscopic protected BAL (pBAL). Additional factors accounted for in the analysis included the presence or absence of prior antibiotic use, mortality of antibiotic-treated and untreated pneumonia, mortality attributable to VAP, development of antibiotic resistance, and mortality due to adverse drug reactions. MEASUREMENTS AND RESULTS: The overall survival of patients who receive antibiotic therapy was compared to survival if antibiotic therapy had been withheld. Antibiotic treatment of clinically diagnosed VAP was associated with lower overall survival than withholding treatment. Antibiotic treatment of VAP diagnosed by invasive (PSB) or semi-invasive (pBAL) techniques was associated with better survival than withholding treatment, although withholding antibiotic therapy was favored as the mortality rate of antibiotic-treated VAP approached 70%. CONCLUSIONS: Invasive or semi-invasive diagnostic techniques should be used to diagnose VAP, guide therapy, and thereby potentially improve survival. A prospective, randomized trial assessing outcome according to diagnostic technique is needed.

Anti-Bacterial Agents↗
PubMedDate not supplied

Isoniazid preventive therapy in areas of high isoniazid resistance.

BACKGROUND: Previous decision analyses of isoniazid preventive therapy for low-risk tuberculin reactors aged 20 to 34 years have not accounted for the recently increased isoniazid resistance rate. Drug resistance trends could also affect the decision to use isoniazid preventive therapy for patients with recent conversion of tuberculin skin tests who are seronegative for human immunodeficiency virus. METHODS: A decision analysis was performed with a Markov simulation to assess the difference in life expectancy between those who receive isoniazid preventive therapy and those who do not. Probability estimates were determined from a review of the literature. RESULTS: For tuberculin reactors aged 20 to 34 years living in areas with 26% isoniazid resistance, isoniazid preventive therapy increases life expectancy by 2 days. Withholding isoniazid is clearly favored if the isoniazid hepatitis rate is 1.1% and the hepatitis fatality rate exceeds 2.8%. For recent tuberculin converters, isoniazid preventive therapy increases life expectancy by 14 to 17 days, depending on patient age. Withholding isoniazid from converters is favored only if the isoniazid resistance rate exceeds 90% to 98%, according to patient age. Two-way sensitivity analysis of isoniazid-associated hepatitis and hepatitis-related fatality rate did not affect the decision to use isoniazid for recent converters. CONCLUSIONS: For tuberculin reactors aged 20 to 34 years who are seronegative for human immunodeficiency virus and living in areas with high isoniazid resistance, there is minimal net benefit of isoniazid preventive therapy. The current recommendation to provide isoniazid preventive therapy to this patient population should be reexamined. For recent tuberculin converters aged 20 to 64 years who are seronegative for human immunodeficiency virus, isoniazid preventive therapy provides a small increase in life expectancy. Withholding isoniazid preventive therapy for human immunodeficiency virus-seronegative skin test converters at high risk for isoniazid-induced hepatitis may be considered; preventive therapy is advisable for all other recent converters.

Adult↗