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Objective: To examine whether there have been recent changes in Australian antiretroviral treatment (ART) prescribers' perceptions and practices relating to early ART initiation, which was defined as commencing ART when a patient's CD4+ T-cell count approaches 500 cells/mm3 or immediately after a patient is diagnosed with HIV., Design, Participants and Setting: Self-completed, anonymous, cross-sectional surveys, targeting all ART prescribers in Australia, were conducted online in 2012 and 2013. The surveys included questions on prescriber factors, CD4+ T-cell count at which prescribers would most strongly recommend ART initiation, and perceived patient characteristics that could change prescribers' practices of early initiation of ART., Main Outcome Measures: Proportions of ART prescribers recommending early ART initiation., Results: We analysed responses from 108 participants in 2012 and 82 participants in 2013. In both years, more male than female prescribers participated. The median age of participants was 49 years in 2012 and 50 years in 2013. In both rounds, over 60% had more than 10 years' experience in treating HIV-positive patients. More prescribers in 2013 stated that they would most strongly recommend early ART initiation compared with those in 2012 (50.0% [95% CI, 38.7%-61.3%] v 26.9% [95% CI, 18.8%-36.2%]; P=0.001). The prescribers' primary concern was more about individual patient than public health benefit. Out of 824 patients for whom ART was initiated, as reported by prescribers in 2013, only 108 (13.1% [95% CI, 10.9%-15.6%]) were given ART primarily to prevent onward HIV transmission. The number of patients for whom ART was initiated was significantly associated with prescribers' HIV caseload even after adjusting for prescriber type (adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P<0.001); of the 37 who had initiated ART for 10 or more patients, 29 had a high HIV caseload. In 2013, 60 prescribers (73.2% [95% CI, 62.2%-82.4%]) reported that they routinely recommended ART to treatment-naive, asymptomatic patients with a CD4+ T-cell count of 350-500 cells/mm3., Conclusion: Our findings show increasing acceptance of and support for early ART initiation primarily as treatment and not as prevention.

Objective: To identify factors contributing to infective endocarditis at a major teaching hospital., Methods: Retrospective review of clinical records of patients diagnosed with endocarditis by standard case definitions with respect to causative organisms, clinical features and outcome., Results: One hundred and ninety-three episodes of endocarditis seen between 1979 and 1992 at Westmead Hospital, Sydney, were reviewed. In the 174 cases where the causative organism was isolated, 75 (43%) were Staphylococcus aureus and 50 (29%) were viridans streptococci. Nosocomial acquisition and/or inter-hospital transfer accounted for 83 episodes; 48 (58%) S. aureus (P < 0.001) and nine (11%) viridans streptococci (P < 0.001). In cases from the local community, viridans streptococci were more common than S. aureus (37% versus 25%); these included 18 episodes (14 S. aureus) in intravenous drug users., Conclusion: We conclude that, compared with community-acquired infections, the aetiology of endocarditis in a large teaching hospital is influenced strongly by the prevalence of nosocomial endocarditis and the need for interhospital transfer of complicated cases.

Clinical features, microbiology, therapy and outcome of 26 episodes of prosthetic valve endocarditis occurring at Westmead Hospital from 1979 to 1989 were examined retrospectively. Presentation with a new or changed cardiac murmur was associated with early onset infection (within 12 months of prosthetic valve insertion; P = 0.0033). Corynebacteria were the commonest cause of early onset endocarditis (4 of 11 episodes) and Streptococcus viridans of late onset endocarditis (4 of 15 episodes). Nine of 11 episodes responded to antimicrobial therapy and 12 of 15 to medical-surgical therapy. There was a trend towards increased mortality in patients with early onset endocarditis presenting with a new or changed cardiac murmur (4 of 9 v. 1 of 17, P = 0.068), suggesting early surgery should be considered in this group. Analysis of antibiograms and published reports indicated that vancomycin and an aminoglycoside should be recommended as empirical therapy for endocarditis occurring 12 to 18 months after prosthetic valve insertion.