Abstracts e73

accepting pandemic H1N1 vaccination, 34% received only 1of the 2 recommended doses.

Discussion

Vaccination with 2 doses of pandemic H1N1 influenzavaccine were recommended for use in immunocompro-mised patients due to concerns about immunogenicity ofsingle vaccine. A low proportion of our HIV positive in-dividuals were offered vaccination, although evidence ofthe severity of this infection in these individuals existed.Further, a low proportion of those vaccinated received twodoses. Evidence has recently emerged confirming suspicionsthat single dose vaccine in well-controlled HIV infectionleads to a sub-optimal immunological response. We canregard vaccination as a proxy for adequate provision ofpreventative health care in HIV, and through this studyillustrate a short-fall.

Conclusions

Pandemic H1N1 poses a potentially serious health threat toHIV infected individuals. The Department of Health haveprovided clear guidance on vaccination. Overall uptake ofpandemic flu vaccination was suboptimal both in terms ofoverall numbers and numbers receiving 2 doses despitea high degree of media attention. Good information topatients and good communication between patients, spe-cialists and GPs/primary care providers may improve futureuptake of seasonal flu vaccination and pandemic fluvaccination if advised.

LIVER FIBROSIS AND CIRRHOSIS IN HEPATITIS BAND SCHISTOSOMIASIS CO-INFECTIONCATEGORY:CLINICAL LESSON

Catherine Houlihan 1, Siobhan Duffy 3,Jayne Harwood 1, Sheila Waugh 1, MatthiasL Schmid 1,2

1Newcastle upon Tyne Hospitals NHS Trust, Newcastle uponTyne, United Kingdom2The University of Newcastle upon Tyne, Newcastle uponTyne, United Kingdom3The University of Glasgow, Glasgow, United Kingdom

Introduction

World-wide distribution of chronic viral hepatitis B (HBV)and non-haematobium schistosomiasis overlap, affectingsub-Saharan Africa ,South America and South-east Asiadisproportionately. These two infections individually canlead to liver fibrosis and cirrhosis. Conflicting evidenceexists to suggest that co-infection can increase the rate ofprogression of liver disease. We had noticed that someyoung patients with co-infection had presented with severeliver cirrhosis or even hepatocellular carcinoma. A retro-spective review of 3 groups of infected patients was carried

out obtaining results from case notes, a HBV database andschistosomiasis database. The three groups were: patientswith schistosomiasis/HBV co-infection, chronic HBV mono-infection and schistosomiasis mono-infection. We collecteddata on evidence of liver disease including data on liverfunction, FBC, ultrasound, fibroscan and liver biopsy as wellas treatment for schistosomiasis or HBV infection.

Scientific findings

We reviewed 7 co-infected patients: 6 male, all from sub-Saharan Africa; age range 20-40. All were HBs antigenpositive, HIV/HCV antibody negative, schistosomiasis ELISApositive. In, 3 s. mansoni ova were seen on microscopy. 6(86%) had evidence of either cirrhosis or fibrosis on ultra-sound. Only one had no evidence of cirrhosis or fibrosis.

Of the 210 chronic HBV patients, 100 were in similar agegroup as those co-infected. Of these 32% had eithercirrhosis (3) or fibrosis (29).

Of the 35 schistosomiasis infected patients, 8 were fromsub-Saharan Africa. One of those (12.5%) had evidence offibrosis on biopsy.

Discussion

Ahigh rate of severe liver disease in co-infectedpatients fromendemic countries was seen. Patients with only HBV or non-haematobium schistosomiasis revealed lower rates of liverfibrosis/cirrhosis. As other factors are associatedwith fibrosis(i.e. length of infection, ethnicity, HBV genotype, egg-burden, alcohol) the groups cannot be directly compared.

Although animal models suggest that HBV and s.mansoniinfection run parallel courses, a prospective cohort study inEthiopia identified HBV markers in schistosomiasis patientsas independent risk factor for peri-portal thickening/fibro-sis progression. Praziquantel leads to fibrosis regression inpatients with schistosomiasis, but its role in co-infectionhas not been investigated.

Conclusions

Although no statistical comparison could be made, therewas an unusually high proportion of patients with severeliver disease in those infected with both schistosomiasis andhepatitis B. We suggest the need for a large study in co-infected patients from endemic countries to evaluatepathological interaction as well as effect of treatment ofpraziquantel and antiviral agents in reduction of progres-sion to severe liver disease. Further, because of the over-lapping epidemiology of these diseases, screening for bothinfections in the presence of the other is advised. Patientswith co-infection should be actively investigated for evi-dence of chronic liver disease.

MANAGEMENT OF INFECTIVE ENDOCARDITIS INTHE OPAT SETTING; A DESCRIPTIVEANALYSISCATEGORY: SCIENTIFIC FREE PAPER

e74 Abstracts

Christopher Duncan 1, Claire Mackintosh 1,Antonia Ho 1, Keith Robertson 2, Andrew Seaton 1

1Brownlee Centre for Infectious Diseases, TropicalMedicine and Counselling, Gartnavel Hospital, Glasgow,United Kingdom2Department of Cardiovascular Medicine, Golden JubilleeNational Hospital, Glasgow, United Kingdom

Introduction

Out-patient parenteral antimicrobial therapy (OPAT) isappealing because it reduces hospitalisation, lowershealthcare costs and limits nosocomial infection. Modelsof OPAT delivery include hospital clinic-based infusion, self-administration, or home-infusion services. OPAT has beenused to manage serious infections such as infective endo-carditis (IE) for several years.

Guidelines exist on the selection of patients with IE forOPAT. The use of OPAT in patients with prosthetic valve IE isnot advised in some published guidelines. However smallobservational trials outside Europe have reported goodoutcomes of OPAT in selected high-risk cases. No studieshave specifically described OPAT IE management in theUnited Kingdom (UK).

Since 2000, we have accepted IE referrals to ourhospital-clinic/self-administered OPAT service. This serviceis facilitated by close links with local cardiology services.Demographic, clinical, microbiological and outcome dataare collected prospectively on all OPAT patients usinga standardised proforma.

The primary objective of this study was to describe theOPAT management of endocarditis in this cohort. A second-ary objective was to identify factors associated with failureof OPAT management using logistic regression. Failure ofOPAT was defined as a composite of the following eventsduring OPAT for proven IE: congestive heart failure (sus-pected or proven), sepsis, unplanned surgery or readmissionfor any reason without re-referral to OPAT. Prospectivelycollected OPAT data were linked to clinical microbiology andechocardiography databases for analysis. Independent case-note review was performed for a proportion of episodes toensure accuracy of the prospective data collection and toprovide additional data where necessary.

Scientific findings

63 episodes for 59 patients (median age 60) were identified(2234 bed-days). 42/59 patients were male and co-morbiddisorders such as cardiovascular disease (21/59) werefrequent. Prosthetic or device-related IE (28/63 episodes)was frequent and staphylococci (12/24 S. aureus) were thecommonest organisms isolated. Right-sided IE was unusual(4/63). Modified Duke criteria was assessable in 53/63 epi-sodes (definite 32/53 possible 14/53).

Therapy was self/carer-administered in 31/63 episodes.Unplanned readmission occurred in 21% of episodes andfailure of OPAT in 8/46 proven-IE episodes.

Although several risk-factors were associated with fail-ure of OPAT in univariate analysis, none were significant bylogistic regression.

Discussion

IE accounts for approximately 1-2% of OPAT courses in theUK. However, few published data are available, and OPAThas not been compared to in-patient management ina prospective randomised controlled trial (RCT). This studywas designed to describe our experience of management ofIE with OPAT. Bias involved in retrospective reviews waslimited by the use of prospectively collected data.

Although not directly comparable, the rate of readmis-sion here was similar to other observational studies, despitehigher rates of prosthetic-valve IE. Risk-factors for OPATfailure on univariate analysis related to co-morbidities andthe pre-OPAT period.

Conclusions

This is the largest single centre description of OPAT IEmanagement in the UK. OPAT has been used in our centrefor the management of left-sided IE caused by high-riskpathogens in patients with significant co-morbidity and oftencomplex prosthetic valve or device-related disease. Carefuland appropriate clinical selection of IE patients for OPATremains critical, and management of prosthetic or device-related IE should occur in close collaborationwith cardiology.

DUPLICATE HIV-1 VIRAL LOAD TESTING IN HAART-TREATED PATIENTS WITH LOW LEVEL VIRAEMIAON THE ROCHE COBAS AMPLIPREP TAQMANASSAYCATEGORY: SCIENTIFIC FREE PAPER

John Widdrington 1, Brendan Payne 1,3,Manoj Valappil 2, Matthias L Schmid 1

1Royal Victoria Infirmary, Newcastle-upon-Tyne, UnitedKingdom2Health Protection Agency, Newcastle-upon-Tyne, UnitedKingdom3 Institute for Ageing and Health, Newcastle University,Newcastle-upon-Tyne, United Kingdom

Introduction

The aim of highly-active antiretroviral therapy (HAART) isto suppress HIV-1 viral load (VL) to undetectable levels. Allpatients on HAART should have a VL measured at regularintervals in order to monitor the success of therapy. InOctober 2006 the Newcastle Health Protection Agency(HPA) laboratory replaced the Roche COBAS HIV-1 Ampli-prep Amplicor Monitor (CAP/CA) assay with the more-sensitive Roche COBAS Ampliprep Taqman HIV-1 (CAP/CTM1) assay. Both locally and internationally the introduc-tion of the CAP/CTM1 assay was associated with a significantunexplained increase in the detection of low level HIV-1viraemia (VL 50 to 1000 copies/ml).

In an attempt to determine the validity and significanceof newly detected low level viraemia (LLV) with the CAP/CTM1 assay, duplicate VL testing of serum samples wascarried out in all patients with HIV-1 VL between 50 and