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Bacterial infections in people with HIV

Bacteria are tiny single-celled micro-organisms which are found everywhere in nature. They can cause infection even when a person's immune system is unaffected by HIV.

In an uninfected person, various parts of the immune system play different roles in protecting against bacteria. People with HIV may have abnormalities in their immune system which make them more vulnerable to bacterial infections: immunoglobulins (antibodies) are not secreted properly; monocytes do not work properly; the bone marrow may be damaged by drugs such as AZT (zidovudine, Retrovir), ganciclovir (Cymevene) or anti-cancer chemotherapy; and HIV itself may prevent the release of neutrophils.

Bacteria can cause a range of different problems in different parts of the body; the commonest among people with advanced HIV infection are sinusitis, pneumonia, diarrhoea, bronchitis and skin and soft tissue infections. Co-trimoxazole (Septrin) as Pneumocystis pneumonia (PCP) prophylaxis offers a good level of protection against bacterial infections.

Bacteria are tiny single-celled micro-organisms which are found everywhere in nature. They can cause infection even when a person's immune system is unaffected by HIV.

In an uninfected person, various parts of the immune system play different roles in protecting against bacteria. People with HIV may have abnormalities in their immune system which make them more vulnerable to bacterial infections: immunoglobulins (antibodies) are not secreted properly; monocytes do not work properly; the bone marrow may be damaged by drugs such as AZT (zidovudine, Retrovir), ganciclovir (Cymevene) or anti-cancer chemotherapy; and HIV itself may prevent the release of neutrophils.

Bacteria can cause a range of different problems in different parts of the body; the commonest among people with advanced HIV infection are sinusitis, pneumonia, diarrhoea, bronchitis and skin and soft tissue infections. Co-trimoxazole (Septrin) as Pneumocystis pneumonia (PCP) prophylaxis offers a good level of protection against bacterial infections.

The most common bacterial infections seen in people with advanced HIV infection are sinusitis, bacterial pneumonia, bronchitis and skin and soft tissue infections. The incidence of bacterial infections has declined with the introduction of potent antiretroviral therapy, but people with HIV still experience bacterial infections more frequently than their HIV-negative counterparts of a similar age. Bacterial infections remain a significant cause of illness in injecting drug users prior to the development of AIDS.

Sinusitis

Infection or inflammation of the sinuses is a relatively common problem among people with HIV. The sinuses are hollow cavities in the front of the skull, whose main purpose is to warm the air we breathe. They are lined with membranes that use a constant flow of mucus to capture bacteria and other foreign matter that we breathe in through the nasal passages, and drain out into the nose or lungs.

People with HIV are at increased risk of sinusitis, and its severity increases in people with lower CD4 cell counts. Sinusitis can be short-lived and time-limited (acute), or an ongoing long-term problem (chronic). Acute sinusitis is caused by infections, while chronic sinusitis is usually caused by a low-level inflammatory process and related to an allergy.

Symptoms of acute sinusitis can be similar to those of the common cold, including nasal congestion, headache, fever, runny nose, facial pressure, tenderness and pain in the cheeks and forehead, and discharges of thick mucus with a strong taste.

The most common bacterial infections which cause HIV-related sinusitis are Staphylococcus epidermis, S. aureus, S. pneumoniae, H. influenzae and Pseudomonas species. It can also be related to Mycobacterium avium intracellulare (MAI) infection. However, in many cases of sinusitis no infection can be identified.

A three-pronged attack is necessary in order to treat and prevent further sinus attacks. The first line of attack is to treat with an appropriate antibiotic for the organism. This often has to be guessed as it is difficult to isolate the bacteria. Amoxicillin is often used, sometimes with the addition of clavulanic acid or an antibiotic of the cephalosporin family. Antibiotics of the quinolone group have little effect on Staphylococcus bacteria which predominate in sinus infections, but are very useful for treating Pseudomonas, which can dominate in HIV infection. Treatment should be continued for several weeks to reduce the chances of recurrence.

The second prong of attack is to shrink the swollen sinus tissues with the daily application of a nasal corticosteroid spray such as beclometasone (Beconase) or budesonide (Rhinocort). Pseudoephedrine (Galpseud / Sudafed) tablets are useful in an acute attack to help shrink the tissue. It is important to avoid using topical decongestant sprays as these can cause problems with rebound congestion. It is important to continue to use the steroid spray as the tissue will invariably swell if this is stopped.

The third prong is to remove the pooled secretions by nasal washouts using salt water. This is a rather unsavoury practice whereby warm salt water is sniffed up into the nose from a cup and then sneezed out into a basin. This washes out the accumulated mucus and should be carried out on a regular basis.

In severe cases surgery to clear the sinuses may be offered.

Infection or inflammation of the sinuses is a relatively common problem among people with HIV. The sinuses are hollow cavities in the front of the skull, whose main purpose is to warm the air we breathe. They are lined with membranes that use a constant flow of mucus to capture bacteria and other foreign matter that we breathe in through the nasal passages, and drain out into the nose or lungs.

People with HIV are at increased risk of sinusitis, and its severity increases in people with lower CD4 cell counts[1] [2] [3]. Sinusitis can be short-lived and time-limited (acute), or an ongoing long-term problem (chronic). Acute sinusitis is caused by infections, while chronic sinusitis is usually caused by a low-level inflammatory process and related to an allergy.

Symptoms of acute sinusitis can be similar to those of the common cold, including nasal congestion, headache, fever, runny nose, facial pressure, tenderness and pain in the cheeks and forehead, and discharges of thick mucus with a strong taste.

The most common bacterial infections which cause HIV-related sinusitis are Staphylococcus epidermis, S. aureus, S. pneumoniae, H. influenzae and Pseudomonas species. It can also be related to Mycobacterium avium intracellulare (MAI) infection. However, in many cases of sinusitis no infection can be identified.

A three-pronged attack is necessary in order to treat and prevent further sinus attacks. The first line of attack is to treat with an appropriate antibiotic for the organism. This often has to be guessed as it is difficult to isolate the bacteria. Amoxicillin is often used, sometimes with the addition of clavulanic acid or an antibiotic of the cephalosporin family. Antibiotics of the quinolone group have little effect on Staphylococcus bacteria which predominate in sinus infections, but are very useful for treating Pseudomonas, which can dominate in HIV infection. Treatment should be continued for several weeks to reduce the chances of recurrence.

The second prong of attack is to shrink the swollen sinus tissues with the daily application of a nasal corticosteroid spray such as beclometasone (Beconase) or budesonide (Rhinocort). Pseudoephedrine (Galpseud / Sudafed) tablets are useful in an acute attack to help shrink the tissue. It is important to avoid using topical decongestant sprays as these can cause problems with rebound congestion. It is important to continue to use the steroid spray as the tissue will invariably swell if this is stopped.

The third prong is to remove the pooled secretions by nasal washouts using salt water. This is a rather unsavoury practice whereby warm salt water is sniffed up into the nose from a cup and then sneezed out into a basin. This washes out the accumulated mucus and should be carried out on a regular basis.

In severe cases surgery to clear the sinuses may be offered.

Urinary tract infections

There is some evidence that men with HIV are more prone to bacterial infections of the urinary tract (bacteriuria), and that the occurrence of these infections may be related to the CD4 cell count. One study has found that nearly a third of men with CD4 cell counts below 200 cells/mm3 developed bacteriuria, compared with 11% with CD4 cell counts between 200 and 500 cells/mm3, and none with CD4 cell counts greater than 500 cells/mm3. Bacteriuria can cause back pain and fever, but it may not cause any symptoms at all and so go undiagnosed. However, it does respond to treatment with antibiotics.

There is some evidence that men with HIV are more prone to bacterial infections of the urinary tract (bacteriuria), and that the occurrence of these infections may be related to the CD4 cell count[4] [5]. One study has found that nearly a third of men with CD4 cell counts below 200 cells/mm3 developed bacteriuria, compared with 11% with CD4 cell counts between 200 and 500 cells/mm3, and none with CD4 cell counts greater than 500 cells/mm3. Bacteriuria can cause back pain and fever, but it may not cause any symptoms at all and so go undiagnosed. However, it does respond to treatment with antibiotics.

Gonorrhoea

Gonorrhoea is a sexually-transmitted bacterial infection which affects moist body linings, including the vagina, cervix, urethra, anus, mouth and throat. Any contact between these warm linings infected with gonorrhoea can lead to transmission. It is caused by infection with Neisseria gonorrhoeae. The risk of contracting gonorrhoea, along with other sexually transmitted infections, is elevated in HIV-positive people (McClelland 2005).

Very often gonorrhoea is completely unnoticed, although it can still be transmitted. Unusual genital discharge may be a sign of gonorrhoea. Other typical symptoms include pain when going to the toilet and a sore throat. If left unnoticed it can potentially cause serious problems including blindness, pelvic inflammatory disease, fertility problems or even death.

Sexual activity should be avoided by people with gonorrhoea until it has been treated and cleared. However, safer sex practices can usually protect against transmission. If a person with HIV contracts gonorrhoea, HIV viral load in sexual fluids or semen may rise, potentially increasing the risk of HIV infection (Taylor 2002).

Gonorrhoea is treated with antibiotics. Normally this consists of a single dose of ciprofloxacin (Ciproxin), or a large dose of penicillin. It is important to take all the tablets prescribed to ensure that the bacteria are eradicated from the body.

However, gonorrhoea is becoming resistant to standard treatments and some people may need a second dose of antibiotics, usually given by injection. Given the prevalence of drug-resistant gonorrhoea, it is important for patients to attend a follow-up appointment after treatment.

The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) has been monitoring trends in drug-resistant gonorrhoea diagnosed in the United Kingdom since 2000. In 2001, nearly 10% of cases of gonorrhoea involved infection with ciprofloxacin-resistant bacteria. Regions with the highest rates of ciprofloxacin-resistant gonorrhoea were Yorkshire and Humberside (18%), the East Midlands (17%), the South-east (14%), and the West Midlands (12%). In London, 7% of gonorrhoea was ciprofloxacin resistant. In heterosexual men, 12% cases of gonorrhoea were drug resistant, as were 7% in heterosexual women and 9% in gay men (Fenton 2003). As a result, current United Kingdom guidelines recommend ofloxacin (Tarivid) or ampicillin (Penbritin / Rimacillin) plus probenecid (Benuryl / Probecid) as alternative first-line options for treating gonorrhoea.

However, there is recent evidence that gonorrhoea may become resistant to these options. Several cases of multidrug-resistant gonorrhoea have been reported, including reduced sensitivity to cefixime (Suprax) - the drug currently recommended for use as first-line treatment for gonorrhoea in the United States (Wang 2003). Alternative drugs used in the United States include intramuscular injection of ceftriaxone (Rocephin) or spectinomycin (Ratelle 2004).

Gonorrhoea is a sexually-transmitted bacterial infection which affects moist body linings, including the vagina, cervix, urethra, anus, mouth and throat. Any contact between these warm linings infected with gonorrhoea can lead to transmission. It is caused by infection with Neisseria gonorrhoeae. The risk of contracting gonorrhoea, along with other sexually transmitted infections, is elevated in HIV-positive people[6].

Very often gonorrhoea is completely unnoticed, although it can still be transmitted. Unusual genital discharge may be a sign of gonorrhoea. Other typical symptoms include pain when going to the toilet and a sore throat. If left unnoticed it can potentially cause serious problems including blindness, pelvic inflammatory disease, fertility problems or even death.

Sexual activity should be avoided by people with gonorrhoea until it has been treated and cleared. However, safer sex practices can usually protect against transmission. If a person with HIV contracts gonorrhoea, HIV viral load in sexual fluids or semen may rise, potentially increasing the risk of HIV infection[7].

Gonorrhoea is treated with antibiotics. Normally this consists of a single dose of ciprofloxacin (Ciproxin), or a large dose of penicillin. It is important to take all the tablets prescribed to ensure that the bacteria are eradicated from the body.

However, gonorrhoea is becoming resistant to standard treatments and some people may need a second dose of antibiotics, usually given by injection. Given the prevalence of drug-resistant gonorrhoea, it is important for patients to attend a follow-up appointment after treatment.

In 2001, nearly 10% of cases of gonorrhoea in the UK involved infection with ciprofloxacin-resistant bacteria[8]. As a result, current United Kingdom guidelines recommend ofloxacin (Tarivid) or ampicillin (Penbritin / Rimacillin) plus probenecid (Benuryl / Probecid) as alternative first-line options for treating gonorrhoea.

However, there is recent evidence that gonorrhoea may become resistant to these options. Several cases of multidrug-resistant gonorrhoea have been reported, including reduced sensitivity to cefixime (Suprax) - the drug currently recommended for use as first-line treatment for gonorrhoea in the United States[9] (Wang 2003). Alternative drugs used in the United States include intramuscular injection of ceftriaxone (Rocephin) or spectinomycin [10].