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BACKGROUNDHospitalized patients with suspected tuberculosis (TB) are placed in airborne isolation until 3 sputum smear samples are negative for acid-fast bacilli (AFB). The Xpert MTB/RIF assay ("Xpert") nucleic acid amplification test (NAAT) to identify Mycobacterium tuberculosis DNA and resistance to rifampicin is superior to AFB sputum smear microscopy for the diagnosis of TB.OBJECTIVETo compare the performance of a single Xpert to AFB smear microscopy for time to airborne infection isolation (AII) discontinuation.METHODSConsecutive patients over 17 years of age in AII for suspected pulmonary TB between October 1, 2014, and March 31, 2016, with leftover respiratory AFB samples were enrolled in this study. A single Xpert was performed on the first available sample. Demographic, clinical, and microbiological data were recorded for each patient. We compared the duration of AII using a single Xpert to AFB smear microscopy under multiple theoretical scenarios using Kaplan-Meier cumulative incidence curves and the log-rank test.RESULTSIn total, 131 samples were included in our performance analysis of the Xpert, and 114 samples were included in our AII analysis. Overall, 81 patients (65%) were immunosuppressed, of whom 46 (37%) were positive for human immunodeficiency virus (HIV). The sensitivity and specificity of Xpert for diagnosis of M. tuberculosis infection were 67% and 100%, respectively. Xpert was negative in all cases of nontuberculous mycobacteria. Use of a single Xpert reduced AII duration from a median of 67 hours per patient to 42 hours with usual reporting, to 26 hours with direct communication, and to 12 hours with immediate testing.CONCLUSIONSA single negative Xpert result can reduce AII duration compared to the AFB smear microscopy technique under multiple theoretical scenarios.Infect Control Hosp Epidemiol 2018;39:590-595.

Objective: To determine mortality associated with a new cancer diagnosis in an urban, predominantly African-American, HIV-infected population., Design: Retrospective cohort study., Methods: All HIV-infected patients diagnosed with cancer between 1 January 2000 and 30 June 2010 were reviewed. Mortality was examined using Kaplan-Meier estimates and Cox proportional hazards models., Results: There were 470 cases of cancer among 447 patients. Patients were predominantly African-American (85%) and male (79%). Non-AIDS-defining cancers (NADCs, 69%) were more common than AIDS-defining cancers (ADCs, 31%). Cumulative cancer incidence increased significantly over the study period. The majority (55.9%) was taking antiretroviral therapy (ART) at cancer diagnosis or started afterward (26.9%); 17.2% never received ART. Stage 3 or 4 cancer was diagnosed in 67%. There were 226 deaths during 1096 person years of follow-up, yielding an overall mortality rate of 206 per 1000 person years. The cumulative mortality rate at 30 days, 1 year, and 2 years was 6.5, 32.2, and 41.4%, respectively. Mortality was similar between patients on ART whether they started before or after the cancer diagnosis but was higher in patients who never received ART. In patients with a known cause of death, 68% were related to progression of the underlying cancer., Conclusion: In a large cohort of urban, predominantly African-American patients with HIV and cancer, many patients presented with late-stage cancer. There was substantial 30-day and 2-year mortality, although ART had a significant mortality benefit. Deaths were most often caused by progression of cancer and not from another HIV-related or AIDS-related event.

Regimens containing abacavir (ABC), tenofovir (TDF), and lamivudine (3TC) have recently been demonstrated to have high failure rates. This poses a clinical dilemma of how to manage patients currently being treated with other regimens containing tenofovir/abacavir. We evaluated the outcomes of tenofovir/abacavir regimens in our clinical practice through a retrospective review of 2655 charts. Two hundred patients (7%) were on a tenofovir/abacavir-containing regimen. Fifty-nine patients met the criteria for analysis and were grouped into three groups: (1) antiretroviral naïve, (2) virally suppressed patients switched to TDF/ABC, and (3) patients with failure of their first antiretroviral regimen. Rates of viral suppression in the naïve, switch, and first-failure groups were 95%, 86%, and 46%, respectively. In the first-failure group, viral suppression was 66% without and 18% with a preexisting M184V. A composite analysis of the groups revealed a success rate of 86% when the regimen contained zidovudine (ZDV) and 62% when it did not. No K65R mutations were noted. These findings support continued caution in the use of TDF/ABC in combination. However, these data suggest that this combination may be successfully used in selected situations such as in combination with ZDV. In patients already virally suppressed on a TDF/ABC-containing regimen, considerations include continuing the regimen or adding zidovudine, in the attempt to protect against the development of a K65R mutation and/or virologic failure, versus changing a stable regimen.