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Wang Y, Huang X, Sun T, Fan G, Zhan Q, Weng L. Non-HIV-infected patients with Pneumocystis pneumonia in the intensive care unit: A bicentric, retrospective study focused on predictive factors of in-hospital mortality. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:152-161. [PMID: 35001555 PMCID: PMC9060091 DOI: 10.1111/crj.13463] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/06/2021] [Accepted: 11/07/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The incidence of Pneumocystis pneumonia (PCP) among patients without human immunodeficiency virus (HIV) infection continues to increase. Here, we identified potential risk factors for in-hospital mortality among HIV-negative patients with PCP admitted to the intensive care unit (ICU). METHODS We retrospectively analyzed medical records of 154 non-HIV-infected PCP patients admitted to the ICU at Peking Union Medical College Hospital (PUMCH) and China-Japan Friendship Hospital (CJFH) from October 2012 to July 2020. Clinical characteristics were examined, and factors related to in-hospital mortality were analyzed. RESULTS A total of 154 patients were enrolled in our study. Overall, the in-hospital mortality rate was 65.6%. The univariate analysis indicated that nonsurvivors were older (58 vs. 52 years, P = 0.021), were more likely to use high-dose steroids (≥1 mg/kg/day prednisone equivalent, 39.62% vs. 55.34%, P = 0.047), receive caspofungin during hospitalization (44.6% vs. 28.3%, P = 0.049), require invasive ventilation (83.2% vs. 47.2%, P < 0.001), develop shock during hospitalization (61.4% vs. 20.8%, P < 0.001), and develop pneumomediastinum (21.8% vs. 47.2%, P = 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores on ICU admission (20.32 vs. 17.39, P = 0.003), lower lymphocyte counts (430 vs. 570 cells/μl, P = 0.014), and lower PaO2/FiO2 values (mmHg) on admission (108 vs. 147, P = 0.001). Multivariate analysis showed that age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.00-1.06; P = 0.024), use of high-dose steroids (≥1 mg/kg/day prednisone equivalent) during hospitalization (OR 2.29; 95% CI 1.07-4.90; P = 0.034), and a low oxygenation index on admission (OR 0.99; 95% CI 0.99-1.00; P = 0.014) were associated with in-hospital mortality. CONCLUSIONS The mortality rate of non-HIV-infected patients with PCP was high, and predictive factors of a poor prognosis were advanced age, use of high-dose steroids (≥1 mg/kg/day prednisone equivalent) during hospitalization, and a low oxygenation index on admission. The use of caspofungin during hospitalization might have no contribution to the prognosis of non-HIV-infected patients with PCP in the ICU.
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Affiliation(s)
- Yuqiong Wang
- China-Japan Friendship School of Clinical Medicine, Peking University, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Xu Huang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Ting Sun
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,China-Japan Friendship School of Clinical Medicine, Capital Medical University, Beijing, China
| | - Guohui Fan
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Disease, Beijing, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Choi JS, Kwak SH, Kim MC, Seol CH, Kim SR, Park BH, Lee EH, Yong SH, Leem AY, Kim SY, Lee SH, Chung K, Kim EY, Jung JY, Kang YA, Park MS, Kim YS, Lee SH. Clinical impact of pneumothorax in patients with Pneumocystis jirovecii pneumonia and respiratory failure in an HIV-negative cohort. BMC Pulm Med 2022; 22:7. [PMID: 34996422 PMCID: PMC8742377 DOI: 10.1186/s12890-021-01812-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PCP) with acute respiratory failure can result in development of pneumothorax during treatment. This study aimed to identify the incidence and related factors of pneumothorax in patients with PCP and acute respiratory failure and to analyze their prognosis. Methods We retrospectively reviewed the occurrence of pneumothorax, including clinical characteristics and results of other examinations, in 119 non-human immunodeficiency virus patients with PCP and respiratory failure requiring mechanical ventilator treatment in a medical intensive care unit (ICU) at a tertiary-care center between July 2016 and April 2019. Results During follow up duration, twenty-two patients (18.5%) developed pneumothorax during ventilator treatment, with 45 (37.8%) eventually requiring a tracheostomy due to weaning failure. Cytomegalovirus co-infection (odds ratio 13.9; p = 0.013) was related with occurrence of pneumothorax in multivariate analysis. And development of pneumothorax was not associated with need for tracheostomy and mortality. Furthermore, analysis of survivor after 28 days in ICU, patients without pneumothorax were significantly more successful in weaning from mechanical ventilator than the patients with pneumothorax (44% vs. 13.3%, p = 0.037). PCP patients without pneumothorax showed successful home discharges compared to those who without pneumothorax (p = 0.010). Conclusions The development of pneumothorax increased in PCP patient with cytomegalovirus co-infection, pneumothorax might have difficulty in and prolonged weaning from mechanical ventilators, which clinicians should be aware of when planning treatment for such patients.
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Affiliation(s)
- Ji Soo Choi
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Se Hyun Kwak
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Min Chul Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Chang Hwan Seol
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Sung Ryeol Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Byung Hoon Park
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Eun Hye Lee
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Seung Hyun Yong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sang Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyungsoo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Eun Young Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Su Hwan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Chopra A, Al-Tarbsheh AH, Shah NJ, Yaqoob H, Hu K, Feustel PJ, Ortiz-Pacheco R, Patel KM, Oweis J, Kozlova N, Zouridis S, Ahmad S, Epelbaum O, Chong WH, Huggins JT, Saha BK, Conuel E, Chieng H, Mullins J, Bajaj D, Shkolnik B, Vancavage R, Madisi N, Judson MA. Pneumothorax in critically ill patients with COVID-19 infection: Incidence, clinical characteristics and outcomes in a case control multicenter study. Respir Med 2021; 184:106464. [PMID: 34044224 PMCID: PMC8116127 DOI: 10.1016/j.rmed.2021.106464] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 12/18/2022]
Abstract
Background The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax has not been rigorously described or compared to those who do not develop a pneumothorax. Purpose To determine the incidence, clinical characteristics, and outcomes of critically ill patients with COVID-19 infection who developed pneumothorax. In addition, we compared the clinical characteristics and outcomes of mechanically ventilated patients who developed a pneumothorax with those who did not develop a pneumothorax. Methods This study was a multicenter retrospective analysis of all adult critically ill patients with COVID-19 infection who were admitted to intensive care units in 4 tertiary care centers in the United States. Results A total of 842 critically ill patients with COVID-19 infection were analyzed, out of which 594 (71%) were mechanically ventilated. The overall incidence of pneumothorax was 85/842 (10%), and 80/594 (13%) in those who were mechanically ventilated. As compared to mechanically ventilated patients in the non-pneumothorax group, mechanically ventilated patients in the pneumothorax group had worse respiratory parameters at the time of intubation (mean PaO2:FiO2 ratio 105 vs 150, P<0.001 and static respiratory system compliance: 30ml/cmH2O vs 39ml/cmH2O, P = 0.01) and significantly higher in-hospital mortality (63% vs 49%, P = 0.04). Conclusion The overall incidence of pneumothorax in mechanically ventilated patients with COVID-19 infection was 13%. Mechanically ventilated patients with COVID-19 infection who developed pneumothorax had worse gas exchange and respiratory mechanics at the time of intubation and had a higher mortality compared to those who did not develop pneumothorax.
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Affiliation(s)
- Amit Chopra
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY, USA.
| | | | - Nidhi J Shah
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA
| | - Hamid Yaqoob
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Kurt Hu
- Division of Pulmonary, Critical Care and Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul J Feustel
- Department of Neuroscience and Experimental Therapeutics, Albany Medical Center, NY, USA
| | - Ronaldo Ortiz-Pacheco
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Stony Brook Medicine, NY, USA
| | - Kinner M Patel
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Stony Brook Medicine, NY, USA
| | - Jozef Oweis
- Department of Medicine, Albany Medical Center, NY, USA
| | - Natalya Kozlova
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | | | - Sahar Ahmad
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Stony Brook Medicine, NY, USA
| | - Oleg Epelbaum
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Woon H Chong
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY, USA
| | - John T Huggins
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, MO, USA
| | - Edward Conuel
- Department of Medicine, Albany Medical Center, NY, USA
| | - Hau Chieng
- Department of Medicine, Albany Medical Center, NY, USA
| | - Jeannette Mullins
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY, USA
| | - Divyansh Bajaj
- Division of Pulmonary, Critical Care and Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Boris Shkolnik
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY, USA
| | - Rachel Vancavage
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY, USA.
| | - Nagendra Madisi
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY, USA
| | - Marc A Judson
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY, USA
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Nureki SI, Usagawa Y, Watanabe E, Takenaka R, Shigemitsu O, Abe T, Yasuda N, Goto K, Kitano T, Kadota JI. Veno-Venous Extracorporeal Membrane Oxygenation for Severe Pneumocystis jirovecii Pneumonia in an Immunocompromised Patient without HIV Infection. TOHOKU J EXP MED 2021; 250:215-221. [PMID: 32249237 DOI: 10.1620/tjem.250.215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) occurs in immunocompromised hosts and is classified as PJP with human immunodeficiency virus (HIV) infection (HIV-PJP) and PJP without HIV infection (non-HIV PJP). Non-HIV PJP rapidly progresses to respiratory failure compared with HIV-PJP possibly due to the difference in immune conditions; namely, the prognosis of non-HIV PJP is worse than that of HIV PJP. However, the diagnosis of non-HIV PJP at the early stage is difficult. Herein, we report a case of severe non-HIV PJP successfully managed with veno-venous extracorporeal membrane oxygenation (V-V ECMO). A 54-year-old woman with neuromyelitis optica was treated with oral corticosteroid, azathioprine, and methotrexate. She admitted to our hospital for fever, dry cough, and dyspnea which developed a week ago. On admission, she required endotracheal intubation and invasive ventilation for hypoxia. A chest computed tomography (CT) scan revealed ground-glass opacity and consolidation in the both lungs. Grocott staining and PCR analysis of bronchoalveolar lavage fluid indicated the presence of fungi and Pneumocystis jirovecii, respectively, whereas serum HIV-antibody was negative. The patient was thus diagnosed with non-HIV PJP and was treated with intravenous pentamidine and corticosteroid pulse therapy for PJP. However, hypoxia was worsened; consequently, V-V ECMO assistance was initiated on day 7. The abnormal chest CT findings and hypoxia were gradually improved. The V-V ECMO support was successfully discontinued on day 14 and mechanical ventilation was discontinued on day 15. V-V ECMO could be a useful choice for respiratory assistance in severe cases of PJP among patients without HIV infection.
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Affiliation(s)
- Shin-Ichi Nureki
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Yuko Usagawa
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Erina Watanabe
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Ryuichi Takenaka
- Department of Emergency Medicine, Oita University Faculty of Medicine
| | - Osamu Shigemitsu
- Department of Emergency Medicine, Oita University Faculty of Medicine
| | - Takakuni Abe
- Department of Anesthesiology and Intensive Care Medicine, Oita University Faculty of Medicine
| | - Norihisa Yasuda
- Department of Anesthesiology and Intensive Care Medicine, Oita University Faculty of Medicine
| | - Koji Goto
- Department of Anesthesiology and Intensive Care Medicine, Oita University Faculty of Medicine
| | - Takaaki Kitano
- Department of Anesthesiology and Intensive Care Medicine, Oita University Faculty of Medicine
| | - Jun-Ichi Kadota
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
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Orsini J, Gawlak H, Sabayev V, Shah K, Washburn L, McCarthy K, Courey A, Mouyeos E, Pangallo S. Pneumocystis jirovecii Pneumonia-Associated Acute Respiratory Distress Syndrome Complicated by Pneumomediastinum and Pneumopericardium in a Non-Human Immunodeficiency Virus-Infected Patient. J Clin Med Res 2020; 12:209-213. [PMID: 32231758 PMCID: PMC7092758 DOI: 10.14740/jocmr4074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 01/21/2020] [Indexed: 01/15/2023] Open
Abstract
Pneumocystis jirovecii pneumonia is widely known as a life-threatening opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). However, with the widespread use of highly active antiretroviral therapy (HAART) and effective anti-Pneumocystis antimicrobial prophylaxis, this entity has declined substantially in patients with human immunodeficiency virus (HIV) infection. Interestingly, the incidence of Pneumocystis jirovecii pneumonia has been increasing among patients without HIV infection, mainly as a consequence of the expanding use of chemotherapy and other immunosuppressive agents. Nevertheless, Pneumocystis jirovecii pneumonia remains an important cause of HIV- and non-HIV-related catastrophic complications. Pneumomediastinum and pneumopericardium are extremely uncommon events in patients with Pneumocystis jirovecii pneumonia. In this report, we described a unique case of Pneumocystis jirovecii pneumonia-associated acute respiratory distress syndrome (ARDS), complicated by pneumomediastinum and pneumopericardium in a non-HIV infected patient.
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Affiliation(s)
- Jose Orsini
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Hannah Gawlak
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Vladimir Sabayev
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Kumar Shah
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Leah Washburn
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Keira McCarthy
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Anthony Courey
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Erin Mouyeos
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Siblea Pangallo
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
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Chiliza N, Du Toit M, Wasserman S. Outcomes of HIV-associated pneumocystis pneumonia at a South African referral hospital. PLoS One 2018; 13:e0201733. [PMID: 30071089 PMCID: PMC6072084 DOI: 10.1371/journal.pone.0201733] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/21/2018] [Indexed: 11/18/2022] Open
Abstract
HIV-associated pneumocystis pneumonia (PCP) is increasingly recognized as an important cause of severe respiratory illness in sub-Saharan Africa. Outcomes of HIV-infected patients with PCP, especially those requiring intensive care unit (ICU) admission, have not been adequately studied in sub-Saharan Africa. The aim of this study was to describe the clinical phenotype and outcomes of HIV-associated PCP in a group of hospitalized South African patients, and to identify predictors of mortality. We conducted a retrospective record review at an academic referral center in Cape Town. HIV-infected patients over the age of 18 years with definite (any positive laboratory test) or probable PCP (defined according to the WHO/CDC clinical case definition) were included. The primary outcome measure was 90-day mortality. Logistic regression and Cox proportional hazards models were constructed to identify factors associated with mortality. We screened 562 test requests between 1 May 2004 and 31 April 2015; 124 PCP cases (68 confirmed and 56 probable) were included in the analysis. Median age was 34 years (interquartile range, IQR, 29 to 41), 89 (72%) were female, and median CD4 cell count was 26 cells/mm3 (IQR 12 to 70). Patients admitted to the ICU (n = 42) had more severe impairment of gas exchange (median ratio of arterial to inspired oxygen (PaO2:FiO2) 158 mmHg vs. 243 mmHg, p < 0.0001), and increased markers of systemic inflammation compared to those admitted to the ward (n = 82). Twenty-nine (23.6%) patients were newly-diagnosed with tuberculosis during their admission. Twenty-six (61.9%) patients admitted to ICU and 21 (25.9%) admitted to the ward had died at 90-days post-admission. Significant predictors of 90-day mortality included PaO2:FiO2 ratio (aOR 3.7; 95% CI, 1.1 to 12.9 for every 50 mgHg decrease), serum LDH (aOR 2.1; 95% CI, 1.1 to 4.1 for every 500 U/L increase), and concomitant antituberculosis therapy (aOR 82; 95% CI, 1.9 to 3525.4; P = 0.021). PaO2:FiO2 < 100 mmHg was significantly associated with inpatient death (aHR 3.8; 95% CI, 1.6 to 8.9; P = 0.003). HIV-associated PCP was associated with a severe clinical phenotype and high rates of tuberculosis co-infection. Mortality was high, particularly in patients admitted to the ICU, but was comparable to other settings. Prognostic indictors could be used to inform ICU admission policy for patients with this condition.
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Affiliation(s)
- Nondumiso Chiliza
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mariette Du Toit
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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7
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Risk Factors for the Mortality of Pneumocystis jirovecii Pneumonia in Non-HIV Patients Who Required Mechanical Ventilation: A Retrospective Case Series Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7452604. [PMID: 28567422 PMCID: PMC5439059 DOI: 10.1155/2017/7452604] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/09/2017] [Accepted: 04/20/2017] [Indexed: 01/15/2023]
Abstract
Background The risk factors for the mortality rate of Pneumocystis jirovecii pneumonia (PCP) who required mechanical ventilation (MV) remained unknown. Methods A retrospective chart review was performed of all PCP patients admitted to our intensive care unit and treated for acute hypoxemic respiratory failure to assess the risk factors for the high mortality. Results Twenty patients without human immunodeficiency virus infection required mechanical ventilation; 19 received noninvasive ventilation; and 11 were intubated. PEEP was incrementally increased and titrated to maintain FIO2 as low as possible. No mandatory ventilation was used. Sixteen patients (80%) survived. Pneumothorax developed in one patient with rheumatoid arthritis (RA). Median PEEP level in the first 5 days was 10.0 cmH2O and not associated with death. Multivariate analysis showed the association of incidence of interstitial lung disease and increase in serum KL-6 with 90-day mortality. Conclusions We found MV strategies to prevent pneumothorax including liberal use of noninvasive ventilation, and PEEP titration and disuse of mandatory ventilation may improve mortality in this setting. Underlying disease of interstitial lung disease was a risk factor and KL-6 may be a useful predictor associated with mortality in patients with RA. These findings will need to be validated in larger studies.
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Abstract
Pneumocystis carinii pneumonia (PCP) remains a serious infection in the immunocompromised host (in the absence of HIV infection) and presents significant management and diagnostic challenges to ICU physicians. Non-HIV PCP is generally abrupt in onset, and follows a fulminate course with high rates of hospitalization, ICT admission, respiratory failure, and requirement for intubation. Mortality is generally high, especially if mechanical ventilation is required. Non-invasive ventilatory support may be considered, although the rapid progression to respiratory failure often necessitates intubation at the time of presentation. Bronchoscopy is often required to establish the diagnosis, and empirical antimicrobial treatment specifically targeted to P. carinii should be initiated while awaiting confirmation. Adjunctive corticosteroids may accelerate recovery, although their use has not yet been established in non-HIV PCP. For the ICU physicians to diagnose PCP, the non-specific presentation of an acute febrile illness and respiratory distress with diffuse pulmonary infiltrates requires a high clinical index of suspician, familiarity with clinical conditions associated with increased risk for PCP, and a low threshold for bronchoscopy to establish the diagnosis.
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Affiliation(s)
- Geoffrey S. Gilmartin
- Division of Pulmonary and Critical Care, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Henry Koziel
- Division of Pulmonary and Critical Care, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.,
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9
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Lefebvre A, Rabbat A. Ventilation non invasive et patients immunodéprimés. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1096-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Esquinas AM. Noninvasive Positive-Pressure Ventilation in Patients with Acute Hypoxemic Respiratory Failure and HIV/AIDS. NONINVASIVE VENTILATION IN HIGH-RISK INFECTIONS AND MASS CASUALTY EVENTS 2014. [PMCID: PMC7122284 DOI: 10.1007/978-3-7091-1496-4_10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pulmonary complications, especially acute respiratory failure (ARF), contribute to morbidity and mortality in immunocompromised patients. The etiology, pathophysiology, and reversibility of lung injury and the severity of ARF are key to the therapeutic response and prognosis for these patients.
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Affiliation(s)
- Antonio M. Esquinas
- Intensive Care & Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain
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Wu YS, Lin NC, Chen IM, Chang SC, Wang FD, Huang YC, Wu TH, Loong CC. Extracorporeal membrane oxygenation as treatment for acute respiratory failure and subsequent pneumothorax caused by Pneumocystis jirovecii pneumonia in a kidney transplant recipient. Transpl Infect Dis 2012; 15:E5-8. [PMID: 23279741 DOI: 10.1111/tid.12039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 08/21/2012] [Accepted: 09/05/2012] [Indexed: 12/01/2022]
Abstract
Acute respiratory failure (ARF) accompanied by pneumothorax caused by Pneumocystis jirovecii pneumonia (PJP) is often fatal. We present our experience using extracorporeal membrane oxygenation as treatment for ARF and subsequent pneumothorax caused by PJP in a kidney transplant recipient.
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Affiliation(s)
- Y-S Wu
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
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Gil Cano A, Monge García M, Gracia Romero M, Díaz Monrové J. Incidencia, características y evolución del barotrauma durante la ventilación mecánica con apertura pulmonar. Med Intensiva 2012; 36:335-42. [DOI: 10.1016/j.medin.2011.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 10/17/2011] [Accepted: 10/30/2011] [Indexed: 10/14/2022]
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Braicks O, Anneken K, Reichelt D, Schäbitz WR, Dziewas R, Evers S, Husstedt IW. [Treatment of neuro-AIDS on a neurological intensive care unit: epidemiology and predictors of outcome]. DER NERVENARZT 2011; 82:1290-5. [PMID: 21567297 DOI: 10.1007/s00115-011-3298-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Investigations concerning the outcome for patients suffering from neuro-AIDS treated on a neurological intensive care unit and specific predictors indicating "dead" were analyzed. MATERIAL AND METHODS A total of 56 patients with a mean age of 39 ± 0.7 years, a mean CD4+ cell count of 130 ± 166 CD4+ cells/µl and viral load of 146,520 ± 198,059 copies/ml were treated on a neurological intensive care unit due to different forms of neuro-AIDS. RESULTS Of the patients, 34% were immigrants of whom 74% came from sub-Saharan regions. In 57% of the patients the diagnosis of HIV infection was made during therapy on the neurological intensive care unit. The median for the time between diagnosis of HIV infection and the treatment on the neurological intensive care unit was 8 days for immigrants and 10 years for residents. The most common manifestations of neuro-AIDS were cerebral toxoplasmosis, cryptococcosis and progressive multifocal leukoencephalopathy (PML). Fifty per cent of the patients (n=28) died during treatment on the neurological intensive care unit. Negative predictors for the outcome "dead" were (a) artificial ventilation, (b) antiretroviral naïve immigrant, (c) primary cerebral lymphoma and (d) missing antiretroviral therapy as a result of admission to the intensive care unit. DISCUSSION The rate of death during treatment of neuro-AIDS on a neurological intensive care unit is much higher than during treatment of internal medicine problems of HIV infection. Antiretroviral naïve immigrants show a much higher rate of death compared to residents in Germany. A lot of research and effort is necessary to improve the availability of the Highly Active Anti-Retroviral Therapy (HAART) worldwide in order to improve the outcome especially for immigrants with neuro-AIDS treated on a neurological intensive care unit.
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Affiliation(s)
- O Braicks
- Klinik für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Str. 33, 48129 Münster, Deutschland
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Fei MW, Kim EJ, Sant CA, Jarlsberg LG, Davis JL, Swartzman A, Huang L. Predicting mortality from HIV-associated Pneumocystis pneumonia at illness presentation: an observational cohort study. Thorax 2009; 64:1070-6. [PMID: 19825785 DOI: 10.1136/thx.2009.117846] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Although the use of antiretroviral therapy has led to dramatic declines in AIDS-associated mortality, Pneumocystis pneumonia (PCP) remains a leading cause of death in HIV-infected patients. OBJECTIVES To measure mortality, identify predictors of mortality at time of illness presentation and derive a PCP mortality prediction rule that stratifies patients by risk for mortality. METHODS An observational cohort study with case note review of all HIV-infected persons with a laboratory diagnosis of PCP at San Francisco General Hospital from 1997 to 2006. RESULTS 451 patients were diagnosed with PCP on 524 occasions. In-hospital mortality was 10.3%. Multivariate analysis identified five significant predictors of mortality: age (adjusted odds ratio (AOR) per 10-year increase, 1.69; 95% CI 1.08 to 2.65; p = 0.02); recent injection drug use (AOR 2.86; 95% CI 1.28 to 6.42; p = 0.01); total bilirubin >0.6 mg/dl (AOR 2.59; 95% CI 1.19 to 5.62; p = 0.02); serum albumin <3 g/dl (AOR 3.63; 95% CI 1.72-7.66; p = 0.001); and alveolar-arterial oxygen gradient >or=50 mm Hg (AOR 3.02; 95% CI 1.41 to 6.47; p = 0.004). Using these five predictors, a six-point PCP mortality prediction rule was derived that stratifies patients according to increasing risk of mortality: score 0-1, 4%; score 2-3, 12%; score 4-5, 48%. CONCLUSIONS The PCP mortality prediction rule stratifies patients by mortality risk at the time of illness presentation and should be validated as a clinical tool.
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Affiliation(s)
- M W Fei
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California 94110, USA.
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Bruneel F, Veziris N, Chevret S, Wolff M, Bedos JP. Retrospective review of Pneumocystis jirovecii pneumonia in a French intensive care unit (1994–2000). Int J STD AIDS 2009; 20:441-2. [DOI: 10.1258/ijsa.2009.009107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- F Bruneel
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay
- Intensive Care Unit, Bichat Claude-Bernard Hospital, Paris, France
| | - N Veziris
- Mycobacteria National Reference Center, Pitie Salpetriere Hospital
- Intensive Care Unit, Bichat Claude-Bernard Hospital, Paris, France
| | - S Chevret
- Biostatistics Department, Saint Louis Hospital
| | - M Wolff
- Intensive Care Unit, Bichat Claude-Bernard Hospital, Paris, France
| | - JP Bedos
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay
- Intensive Care Unit, Bichat Claude-Bernard Hospital, Paris, France
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Benefit of antiretroviral therapy on survival of human immunodeficiency virus-infected patients admitted to an intensive care unit. Crit Care Med 2009; 37:1605-11. [PMID: 19325488 DOI: 10.1097/ccm.0b013e31819da8c7] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate the impact of antiretroviral therapy (ART) and the prognostic factors for in-intensive care unit (ICU) and 6-month mortality in human immunodeficiency virus (HIV)-infected patients. DESIGN A retrospective cohort study was conducted in patients admitted to the ICU from 1996 through 2006. The follow-up period extended for 6 months after ICU admission. SETTING The ICU of a tertiary-care teaching hospital at the Universidade de São Paulo, Brazil. PARTICIPANTS A total of 278 HIV-infected patients admitted to the ICU were selected. We excluded ICU readmissions (37), ICU admissions who stayed less than 24 hours (44), and patients with unavailable medical charts (36). OUTCOME MEASURE In-ICU and 6-month mortality. MAIN RESULTS Multivariate logistic regression analysis and Cox proportional hazards models demonstrated that the variables associated with in-ICU and 6-month mortality were sepsis as the cause of admission (odds ratio [OR] = 3.16 [95% confidence interval [CI] 1.65-6.06]); hazards ratio [HR] = 1.37 [95% CI 1.01-1.88]), an Acute Physiology and Chronic Health Evaluation II score >19 [OR = 2.81 (95% CI 1.57-5.04); HR = 2.18 (95% CI 1.62-2.94)], mechanical ventilation during the first 24 hours [OR = 3.92 (95% CI 2.20-6.96); HR = 2.25 (95% CI 1.65-3.07)], and year of ICU admission [OR = 0.90 (95% CI 0.81-0.99); HR = 0.92 [95% CI 0.87-0.97)]. CD4 T-cell count <50 cells/mm(3) was only associated with ICU mortality [OR = 2.10 (95% CI 1.17-3.76)]. The use of ART in the ICU was negatively predictive of 6-month mortality in the Cox model [HR = 0.50 (95% CI 0.35-0.71)], especially if this therapy was introduced during the first 4 days of admission to the ICU [HR = 0.58 (95% CI 0.41-0.83)]. Regarding HIV-infected patients admitted to ICU without using ART, those who have started this treatment during ICU stay presented a better prognosis when time and potential confounding factors were adjusted for [HR 0.55 (95% CI 0.31-0.98)]. CONCLUSIONS The ICU outcome of HIV-infected patients seems to be dependent not only on acute illness severity, but also on the administration of antiretroviral treatment.
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Acute respiratory failure due to Pneumocystis pneumonia: outcome and prognostic factors. Int J Infect Dis 2009; 13:59-66. [DOI: 10.1016/j.ijid.2008.03.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Revised: 12/17/2007] [Accepted: 03/26/2008] [Indexed: 11/17/2022] Open
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Radhi S, Alexander T, Ukwu M, Saleh S, Morris A. Outcome of HIV-associated Pneumocystis pneumonia in hospitalized patients from 2000 through 2003. BMC Infect Dis 2008; 8:118. [PMID: 18796158 PMCID: PMC2551597 DOI: 10.1186/1471-2334-8-118] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Accepted: 09/16/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pneumocystis pneumonia (PCP) remains a leading cause of morbidity and mortality in HIV-infected persons. Epidemiology of PCP in the recent era of highly active antiretroviral therapy (HAART) is not well known and the impact of HAART on outcome of PCP has been debated. AIM To determine the epidemiology of PCP in HIV-infected patients and examine the impact of HAART on PCP outcome. METHODS We performed a retrospective cohort study of 262 patients diagnosed with PCP between January 2000 and December 2003 at a county hospital at an academic medical center. Death while in the hospital was the main outcome measure. Multivariate modeling was performed to determine predictors of mortality. RESULTS Overall hospital mortality was 11.6%. Mortality in patients requiring intensive care was 29.0%. The need for mechanical ventilation, development of a pneumothorax, and low serum albumin were independent predictors of increased mortality. One hundred and seven patients received HAART before hospitalization and 16 patients were started on HAART while in the hospital. HAART use either before or during hospitalization was not associated with mortality. CONCLUSION Overall hospital mortality and mortality predictors are similar to those reported earlier in the HAART era. PCP diagnoses in HAART users likely represented failing HAART regimens or non-compliance with HAART.
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Affiliation(s)
- Saba Radhi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine and the Will Rogers Institute Pulmonary Research Center, University of Southern California, Los Angeles, CA, USA.
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Alvarez-Martínez MJ, Moreno A, Miró JM, Valls ME, Rivas PV, de Lazzari E, Sued O, Benito N, Domingo P, Ribera E, Santín M, Sirera G, Segura F, Vidal F, Rodríguez F, Riera M, Cordero ME, Arribas JR, Jiménez de Anta MT, Gatell JM, Wilson PE, Meshnick SR. Pneumocystis jirovecii pneumonia in Spanish HIV-infected patients in the combined antiretroviral therapy era: prevalence of dihydropteroate synthase mutations and prognostic factors of mortality. Diagn Microbiol Infect Dis 2008; 62:34-43. [PMID: 18554841 DOI: 10.1016/j.diagmicrobio.2008.04.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 03/14/2008] [Accepted: 04/16/2008] [Indexed: 02/08/2023]
Abstract
The incidence of Pneumocystis jirovecii pneumonia (PCP) in HIV-infected patients has decreased thanks to sulfa prophylaxis and combined antiretroviral therapy. The influence of P. jirovecii dihydropteroate synthase (DHPS) gene mutations on survival is controversial and has not been reported in Spain. This prospective multicenter study enrolled 207 HIV-infected patients with PCP from 2000 to 2004. Molecular genotyping was performed on stored specimens. Risk factors for intensive care unit (ICU) admission and mortality were identified using a logistic regression model. Seven patients (3.7%; 95% confidence interval [CI], 1.5-7.5%) had DHPS mutations. Overall mortality was 15% (95% CI, 10-21%), rising to 80% (95% CI, 61-92%) in patients requiring mechanical ventilation. None of the patients with DHPS mutants died, nor did they need ICU admission or mechanical ventilation. PaO(2) <60 mm Hg at admission was a predictor of ICU admission (P = 0.01), and previous antiretroviral therapy predicted non-ICU admission (P = 0.009). PaO(2) <60 mm Hg at admission and ICU admission during the 1st week were predictors of mortality (P = 0.03 and P < 0.001, respectively). The prevalence of DHPS mutants in Spain is low and is not associated with a worse outcome. Severe respiratory failure at admission is the strongest predictor of PCP outcome.
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Davis JL, Morris A, Kallet RH, Powell K, Chi AS, Bensley M, Luce JM, Huang L. Low tidal volume ventilation is associated with reduced mortality in HIV-infected patients with acute lung injury. Thorax 2008; 63:988-93. [PMID: 18535118 DOI: 10.1136/thx.2008.095786] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Respiratory failure remains the leading indication for admission to the intensive care unit (ICU) and a leading cause of death for HIV-infected patients in spite of overall improvements in ICU mortality. It is unclear if these improvements are due to combination anti-retroviral therapy, low tidal volume ventilation for acute lung injury, or both. A study was undertaken to identify therapies and clinical factors associated with mortality in acute lung injury among HIV-infected patients with respiratory failure in the period 1996-2004. A secondary aim was to compare mortality before and after introduction of a low tidal volume ventilation protocol in 2000. METHODS A retrospective cohort study was performed of 148 consecutive HIV-infected adults admitted to the ICU at San Francisco General Hospital with acute lung injury requiring mechanical ventilation. Demographic and clinical information including data on mechanical ventilation was abstracted from medical records and analysed by multivariate analysis using logistic regression. RESULTS In-hospital mortality was similar before and after introduction of a low tidal volume ventilation protocol, although the study was not powered to exclude a clinically significant difference (risk difference -5.4%, 95% CI -21% to 11%, p = 0.51). Combination antiretroviral therapy was not clearly associated with mortality, except in patients with Pneumocystis pneumonia. Among all those with acute lung injury, lower tidal volume was associated with decreased mortality (adjusted odds ratio 0.76 per 1 ml/kg decrease, 95% CI 0.58 to 0.99, p = 0.043), after controlling for Pneumocystis pneumonia, serum albumin, illness severity, gas exchange impairment and plateau pressure. CONCLUSIONS Lower tidal volume ventilation is independently associated with reduced mortality in HIV-infected patients with acute lung injury and respiratory failure.
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Affiliation(s)
- J L Davis
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, California 94110, USA.
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21
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Monnet X, Vidal-Petiot E, Osman D, Hamzaoui O, Durrbach A, Goujard C, Miceli C, Bourée P, Richard C. Critical care management and outcome of severe Pneumocystis pneumonia in patients with and without HIV infection. Crit Care 2008; 12:R28. [PMID: 18304356 PMCID: PMC2374632 DOI: 10.1186/cc6806] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Revised: 12/17/2007] [Accepted: 01/25/2008] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Little is known about the most severe forms of Pneumocystis jiroveci pneumonia (PCP) in HIV-negative as compared with HIV-positive patients. Improved knowledge about the differential characteristics and management modalities could guide treatment based on HIV status. METHODS We retrospectively compared 72 patients (73 cases, 46 HIV-positive) admitted for PCP from 1993 to 2006 in the intensive care unit (ICU) of a university hospital. RESULTS The yearly incidence of ICU admissions for PCP in HIV-negative patients increased from 1993 (0%) to 2006 (6.5%). At admission, all but one non-HIV patient were receiving corticosteroids. Twenty-three (85%) HIV-negative patients were receiving an additional immunosuppressive treatment. At admission, HIV-negative patients were significantly older than HIV-positive patients (64 [18 to 82] versus 37 [28 to 56] years old) and had a significantly higher Simplified Acute Physiology Score (SAPS) II (38 [13 to 90] versus 27 [11 to 112]) but had a similar PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio (160 [61 to 322] versus 183 [38 to 380] mm Hg). Ventilatory support was required in a similar proportion of HIV-negative and HIV-positive cases (78% versus 61%), with a similar proportion of first-line non-invasive ventilation (NIV) (67% versus 54%). NIV failed in 71% of HIV-negative and in 13% of HIV-positive patients (p < 0.01). Mortality was significantly higher in HIV-negative than HIV-positive cases (48% versus 17%). The HIV-negative status (odds ratio 3.73, 95% confidence interval 1.10 to 12.60) and SAPS II (odds ratio 1.07, 95% confidence interval 1.02 to 1.12) were independently associated with mortality at multivariate analysis. CONCLUSION The yearly incidence of ICU admissions for PCP in HIV-negative patients in our unit increased from 1993 to 2006. The course of the disease and the outcome were worse in HIV-negative patients. NIV often failed in HIV-negative cases, suggesting that NIV must be watched closely in this population.
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Affiliation(s)
- Xavier Monnet
- AP-HP, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
- Univ Paris-Sud, Faculté de médecine Paris-Sud, EA 4046, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
| | - Emmanuelle Vidal-Petiot
- AP-HP, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
- Univ Paris-Sud, Faculté de médecine Paris-Sud, EA 4046, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
| | - David Osman
- AP-HP, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
- Univ Paris-Sud, Faculté de médecine Paris-Sud, EA 4046, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
| | - Olfa Hamzaoui
- AP-HP, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
- Univ Paris-Sud, Faculté de médecine Paris-Sud, EA 4046, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
| | - Antoine Durrbach
- AP-HP, Hôpital de Bicêtre, service de néphrologie, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
| | - Cécile Goujard
- AP-HP, Hôpital de Bicêtre, service de médecine interne, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
- Univ Paris-Sud, INSERM, UMR_S 802, 78, rue du Général Leclerc, Le Kremlin Bicêtre, F-94270, France
| | - Corinne Miceli
- Univ Paris-Sud, INSERM, UMR_S 802, 78, rue du Général Leclerc, Le Kremlin Bicêtre, F-94270, France
- AP-HP, Hôpital de Bicêtre, service de rhumatologie, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
| | - Patrice Bourée
- Univ Paris-Sud, Faculté de médecine Paris-Sud, EA 4046, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
- AP-HP, Hôpital de Bicêtre, unité des maladies parasitaires, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
| | - Christian Richard
- AP-HP, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
- Univ Paris-Sud, Faculté de médecine Paris-Sud, EA 4046, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France
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Scemama J, Amathieu R, Tual L, Fessenmeyer C, Stirnemann J, Dhonneur G. Échec de traitement d'une pneumocystose par le cotrimoxazole: rôle de la co-infection par le cytomégalovirus? ACTA ACUST UNITED AC 2007; 26:604-7. [PMID: 17433609 DOI: 10.1016/j.annfar.2007.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 02/21/2007] [Indexed: 11/19/2022]
Abstract
Pneumocystis jiroveci pneumonia is a classic opportunist infection affecting AIDS patients. However it is less frequent since systematic prophylaxis and antiretroviral therapies. Treatment resistance is rare in France. We report the case of a severe Pneumocystis jiroveci pneumonia with treatment resistance to standard treatment and fatal outcome. The different causes of treatment resistance, notably the role of CMV co-infection, were reviewed and discussed.
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Affiliation(s)
- J Scemama
- Service d'anesthésie et de réanimation, CHU Jean-Verdier, APHP, Bondy, France
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De Castro N, Pavie J, Lagrange-Xélot M, Molina JM. Pneumocystose chez les patients d’onco-hématologie : est-ce inévitable ? Rev Mal Respir 2007; 24:741-50. [PMID: 17632433 DOI: 10.1016/s0761-8425(07)91148-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Although the use of prophylactic medication has reduced the incidence of Pneumocystis jiroveci pneumonia (PCP), it still occurs in cancer patients and is associated with a high morbidity and mortality. STATE OF THE ART Patients with haematological malignancies are at high risk for PCP because of chemotherapy and steroid-induced immunosuppression. Despite highly active prophylactic regimens, most cases occur in patients who are not receiving any prophylactic treatment even though the risk factors are well described. PCR techniques have been used for PCP diagnosis but these highly sensitive methods may not be able to discriminate between airway colonisation and infection. PERSPECTIVES Prophylaxis should be widely recommended for patients receiving prolonged steroid therapy or other immunosuppressive drugs. A low CD4+-T cell count (less than 200/microl) may be a useful marker to identify high risk patients who should not discontinue prophylaxis. CONCLUSION Because PCP is very severe in cancer patients, higher risk patients must be identified and long-term prophylaxis should be maintained as long as immunosuppression persists.
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Affiliation(s)
- N De Castro
- Service de Maladies Infectieuses et Tropicales, AP-HP, Hôpital Saint-Louis, Paris, France.
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Rabbat A. Détresse respiratoire aiguë chez un patient immunodéprimé. Rev Mal Respir 2007. [DOI: 10.1016/s0761-8425(07)91586-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE To describe critical illnesses that occur commonly in patients with human immunodeficiency virus (HIV) infection. METHODS We reviewed and summarized the literature on critical illness in HIV infection using a computerized MEDLINE search. SUMMARY In the last 10 yrs, our perception of HIV infection and acquired immune deficiency syndrome (AIDS) has changed from an almost uniformly fatal disease into a manageable chronic illness. Even patients with advanced immunosuppression may have prolonged survival, although usually with exacerbations and remissions, complicated by therapy-related toxicity and medical and psychiatric co-morbidity. The prevalence of opportunistic infections and the mortality have decreased considerably since early in the epidemic. The most common reason for intensive care unit admission in patients with AIDS is respiratory failure, but they are less likely to be admitted for Pneumocystis pneumonia and other HIV-associated opportunistic infections. HIV-infected persons are more likely to receive intensive care unit care for complications of end-stage liver disease and sepsis. Hepatitis C has emerged as a common cause of morbidity and mortality in patients with HIV infection. In addition, some develop life-threatening complications from antiretroviral drug toxicity and the immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Mark J Rosen
- Division of Pulmonary and Critical Care Medicine, Beth Israel Medical Center, New York, NY, USA
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Miller RF, Allen E, Copas A, Singer M, Edwards SG. Improved survival for HIV infected patients with severe Pneumocystis jirovecii pneumonia is independent of highly active antiretroviral therapy. Thorax 2006; 61:716-21. [PMID: 16601092 PMCID: PMC2104703 DOI: 10.1136/thx.2005.055905] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite a decline in incidence of Pneumocystis jirovecii pneumonia (PCP), severe PCP continues to be a common cause of admission to the intensive care unit (ICU) where mortality remains high. A study was undertaken to examine the outcome from intensive care for patients with PCP and to identify prognostic factors. METHODS A retrospective cohort study was conducted of HIV infected adults admitted to a university affiliated hospital ICU between November 1990 and October 2005. Case note review collected information on demographic variables, use of prophylaxis and highly active antiretroviral therapy (HAART), and hospital course. The main outcome was 1 month mortality, either on the ICU or in hospital. RESULTS Fifty nine patients were admitted to the ICU on 60 occasions. Thirty four patients (57%) required mechanical ventilation. Overall mortality was 53%. No patient received HAART before or during ICU admission. Multivariate analysis showed that the factors associated with mortality were the year of diagnosis (before mid 1996 (mortality 71%) compared with later (mortality 34%; p = 0.008)), age (p = 0.016), and the need for mechanical ventilation and/or development of pneumothorax (p = 0.031). Mortality was not associated with sex, ethnicity, prior receipt of sulpha prophylaxis, haemoglobin, serum albumin, CD4 count, PaO2, A-aO2 gradient, co-pathology in bronchoscopic lavage fluid, medical co-morbidity, APACHE II score, or duration of mechanical ventilation. CONCLUSIONS Observed improved outcomes from severe PCP for patients admitted to the ICU occurred in the absence of intervention with HAART and probably reflect general improvements in ICU management of respiratory failure and ARDS rather than improvements in the management of PCP.
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Affiliation(s)
- R F Miller
- Centre for Sexual Health and HIV Research, University College London, Mortimer Market Centre, London WC1E 6AU, UK.
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Morris A, Masur H, Huang L. Current issues in critical care of the human immunodeficiency virus-infected patient. Crit Care Med 2006; 34:42-9. [PMID: 16374154 DOI: 10.1097/01.ccm.0000194539.50905.81] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide current information on the epidemiology of human immunodeficiency virus (HIV)-infected patients admitted to the intensive care unit during the era of combination antiretroviral therapy and to review issues related to the administration of antiretroviral therapy that are relevant to the intensivist. DESIGN Review of literature related to intensive care of HIV-infected patients. RESULTS Overall mortality of HIV-infected patients in the intensive care unit has decreased in the era of combination antiretroviral therapy, and patients are more commonly admitted with non-HIV-related illnesses. Use of antiretroviral therapy in the intensive care unit is difficult but may be associated with improved outcomes. CONCLUSIONS HIV-infected patients are less likely to be admitted to the intensive care unit with opportunistic infections but more likely to be admitted with problems unrelated to HIV infection or with conditions related to antiretroviral therapy. With current management strategies, more patients survive intensive care unit admission. Intensivists need to be familiar with antiretroviral therapy to recognize life-threatening toxicities unique to these drugs; to avoid drug interactions, which are extremely common and potentially life-threatening; and to avoid enhancing HIV drug resistance, an occurrence that could have devastating consequences for the patient following intensive care unit discharge.
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Affiliation(s)
- Alison Morris
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Festic E, Gajic O, Limper AH, Aksamit TR. Acute respiratory failure due to pneumocystis pneumonia in patients without human immunodeficiency virus infection: outcome and associated features. Chest 2005; 128:573-9. [PMID: 16100140 DOI: 10.1378/chest.128.2.573] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To examine outcome and associated factors of acute respiratory failure (ARF) in non-HIV-related Pneumocystis pneumonia (PCP) in patients admitted to a medical ICU between 1995 and 2002. DESIGN A retrospective review of medical records and an APACHE (acute physiology and chronic health evaluation) III database. SETTING Academic tertiary medical center. RESULTS We identified 30 patients with non-HIV-related PCP and ARF. In-hospital, 6-month, and 1-year mortality rates were 67%, 77%, and 80%, respectively. Median age was 63.5 years. Median APACHE III score on day 1 was 65.5. Median ICU and hospital lengths of stay were 13 days and 21 days, respectively. All seven patients having a pneumothorax died. All but one patient had an elevated lactate dehydrogenase level (median, 563 U/L). The diagnosis was made using BAL in 28 patients and by transbronchial biopsy in the remaining 2 patients. All patients were immunosuppressed (eight were receiving corticosteroids, seven were receiving chemotherapy, and the remainder received both). Median immunosuppressive prednisone-equivalent dose was 40 mg (median length of treatment, 4.5 months). Not a single patient received PCP prophylaxis. All but one patient required intubation and invasive positive pressure ventilation (PPV). Hospital mortality was associated with high APACHE III scores on day 1 (p = 0.05), intubation delay (p = 0.03), length of PPV (p = 0.003), and development of pneumothorax (p = 0.033). Logistic regression analysis demonstrated that association of intubation delay with hospital mortality persisted after adjusting for severity of illness (p = 0.03). CONCLUSIONS Among patients with ARF secondary to non-HIV-related PCP, poor prognostic factors include high APACHE III scores, intubation delay, longer duration of PPV, and development of pneumothorax. None of the patients in this series received PCP prophylaxis prior to the development of pneumonia.
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Affiliation(s)
- Emir Festic
- Division of Primary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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Gunduz M, Unlugenc H, Ozalevli M, Inanoglu K, Akman H. A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J 2005; 22:325-9. [PMID: 15843697 PMCID: PMC1726766 DOI: 10.1136/emj.2004.019786] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The role of non-invasive positive pressure ventilation delivered through a face mask in patients with flail chest is uncertain. We conducted a prospective, randomised study of continuous positive airway pressure (CPAP) given via a face mask to spontaneously breathing patients compared with intermittent positive pressure ventilation (IPPV) with endotracheal intubation (ETI) in 52 patients with flail chest who required mechanical ventilation. METHOD The 52 mechanically ventilated patients were randomly divided into two treatment groups: the ET group (n = 27) received mechanical ventilation with ETI, whereas patients in the CPAP group (n = 25) received CPAP via a face mask with patient controlled analgesia (PCA). Major complications, arterial blood gas levels, length of intensive care unit (ICU) stay and ICU survival rate were recorded. RESULTS Nosocomial infection was diagnosed in 10 of 21 patients in the ET group, but only in 4 of 22 in the CPAP group (p = 0.001). Mean PO(2) was significantly higher in the ET group in the first 2 days (p<0.05). There were no significant differences in length of ICU stay between groups. Twenty CPAP patients survived, but only 14 of 21 intubated patients who received IPPV (p<0.01). CONCLUSION Non-invasive CPAP with PCA led to lower mortality and a lower nosocomial infection rate, but similar oxygenation and length of ICU stay. The study supports the application of CPAP at least as a first line of treatment for flail chest caused by blunt thoracic trauma.
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Affiliation(s)
- M Gunduz
- Cukurova University Faculty of Medicine, Department of Anaesthesiology Balcali, Adana, Turkey.
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Crothers K, Beard CB, Turner J, Groner G, Fox M, Morris A, Eiser S, Huang L. Severity and outcome of HIV-associated Pneumocystis pneumonia containing Pneumocystis jirovecii dihydropteroate synthase gene mutations. AIDS 2005; 19:801-5. [PMID: 15867494 DOI: 10.1097/01.aids.0000168974.67090.70] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The impact of Pneumocystis jirovecii (formerly P. carinii) dihydropteroate synthase (DHPS) gene mutations on morbidity and mortality of Pneumocystis pneumonia (PCP) in HIV-positive patients is unclear. OBJECTIVE To determine whether severity and outcome of HIV-associated PCP differs according to DHPS genotype. SETTING A prospective, observational study in a university-affiliated county hospital. PATIENTS The study included 197 patients with 215 microscopically confirmed PCP episodes and successfully sequenced DHPS genotypes; 175 (81%) episodes displayed mutant genotypes. MAIN OUTCOME MEASURE All-cause mortality within 60 days. RESULTS The majority of patients (86%) with PCP containing Pneumocystis DHPS mutations survived. Although severity of PCP was comparable, there was a trend for more patients with mutant genotypes than patients with wild-type to require mechanical ventilation (14.3% versus 2.5%; P = 0.056) and to die (14.3% versus 7.5%, P = 0.31). Independent predictors of mortality at baseline were low serum albumin levels [odds ratio (OR), 4.62; 95% confidence interval (CI), 1.63-13.1; P = 0.004] and requiring intensive care within 72 h of hospitalization (OR, 5.06; 95% CI, 1.43-18.0; P = 0.012). CONCLUSION The majority of HIV-infected patients with PCP containing mutant Pneumocystis DHPS genotypes survived. Mortality was related primarily to the underlying severity of illness. However, a trend towards increased mortality in episodes of PCP containing mutant DHPS genotypes was observed and this warrants further study.
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Affiliation(s)
- Kristina Crothers
- Positive Health Program and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA.
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Casalino E, Wolff M, Ravaud P, Choquet C, Bruneel F, Regnier B. Impact of HAART advent on admission patterns and survival in HIV-infected patients admitted to an intensive care unit. AIDS 2004; 18:1429-33. [PMID: 15199319 DOI: 10.1097/01.aids.0000131301.55204.a7] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies found increased survival times and decreased hospitalization rates since the introduction of highly active antiretroviral therapy (HAART). OBJECTIVE To examine the impact of HAART on admission patterns and survival of HIV-infected patients admitted to an intensive care unit (ICU). DESIGN Prospective observational cohort study. SETTING AND SUBJECTS All HIV-infected patients admitted from 1 January 1995 to 30 June 1999, to an infectious diseases ICU located in Paris. MAIN OUTCOME MEASURES ICU utilization and admission patterns, and survival. RESULTS A total of 426 HIV-related admissions were included. Sepsis increased from 16.3% to 22.6% from the pre- to the post-HAART era, whereas AIDS-related admissions decreased from 57.7% to 37% (P < 0.05). No significant difference in ICU utilization was found. In both periods, half of the patients were not on antiretroviral treatment at ICU admission. In-ICU mortality was 23%, without significant difference between the study periods. By multivariable analysis, in-ICU mortality was significantly associated with SAPS II > 40, Omega score > 75 and mechanical ventilation; and long-term survival with admission in the HAART era and AIDS at ICU admission. Cumulative survival rates after ICU discharge were 85.3% and 70.8% after 12 and 24 months, respectively. CONCLUSIONS HAART had little impact on ICU utilization by HIV-infected patients. After the introduction of HAART AIDS-related conditions decreased and sepsis increased as reasons for ICU admission. Whereas ICU survival was dependent on usual prognostic markers, long-term survival was clearly dependent on HIV disease stage and HAART availability. In both study periods, at least a half of the HIV infected patients were not on anti-retroviral treatment at the time of ICU admission.
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Affiliation(s)
- Enrique Casalino
- Infectious Diseases Intensive Care Unit and the Epidemiology and Biostatistics Department, Bichat-Claude Bernard University Hospital, Paris, France
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Vincent B, Timsit JF, Auburtin M, Schortgen F, Bouadma L, Wolff M, Regnier B. Characteristics and outcomes of HIV-infected patients in the ICU: impact of the highly active antiretroviral treatment era. Intensive Care Med 2004; 30:859-66. [PMID: 14767592 DOI: 10.1007/s00134-004-2158-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2003] [Accepted: 12/22/2003] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine whether the introduction of highly active antiretroviral therapy (HAART) has changed the rate of admission, the clinical spectrum, and the mortality of HIV-infected ICU patients. DESIGN Observational study. SETTING Infectious diseases ICU in a teaching hospital, Paris, France. PATIENTS All HIV-infected patients admitted during a pre-HAART era (1995-1996; n=189) and a HAART era (1998-2000; n=236). INTERVENTIONS None. MEASUREMENTS AND RESULTS At the HAART era, 79% of patients had derived no or little benefit from the availability of HAART at ICU admission: 44% had no history of antiretroviral (ARV) medications and 35% had failed to respond to ARV. As compared with the pre-HAART era, the rate of hospitalized HIV-infected patients requiring the ICU stay increased (HAART, 5.9% vs pre-HAART, 4.4%; p=0.004). The admission was more likely to occur through the emergency room (45 vs 29%, p=0.0004), and the patients to be foreigners (38.1 vs 28.6%; p=0.04). After adjustment for significant prognostic covariates (AIDS-related tumors at admission, CD4 count <50/mm(3), poor functional status (Knaus score C or D), SAPSII, and need for mechanical ventilation), ICU survival was unchanged (adjusted OR=0.613, 95% CI=0.312-1.206), but 3-month survival was significantly improved (adjusted OR=0.57; 95% CI=0.32-0.99; p=0.045). CONCLUSION The number of HIV-infected patients admitted to the ICU remained high in the HAART era. Underutilization of HAART and limited access to health care are possible explanations. The ICU mortality has remained unchanged, but 3-month mortality has decreased.
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Affiliation(s)
- Benoît Vincent
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, 48 rue Henri Huchard, 75877 Paris cedex 18, France
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Richard N, Stamm D, Floret D. Pneumocystoses graves en réanimation pédiatrique étude rétrospective 1980–2002. Arch Pediatr 2003; 10 Suppl 5:539s-544s. [PMID: 15022778 DOI: 10.1016/s0929-693x(03)90034-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this study was to ascertain the clinical and epidemiological characteristics of Pneumocystis carinii pneumonia (PCP) cases admitted to the Pediatric Intensive Care Unit (PICU). PATIENTS AND METHODS A retrospective study was carried out for the 10 PCP cases admitted to the PICU from 1980 to 2002. The variables studied were: age, sex, PRISM, underlying diseases, immunological status, clinical manifestations, radiology, response to therapy and clinical follow up. RESULTS Age of the patients varied between 5 months and 15 years and 4 months and there were 7 females and 3 males. Underlying diseases included: AIDS (3 cases), renal transplant (2 cases), West syndrome (1 case), cancer (4 cases). All presented an acute respiratory failure and 8/10 needed mechanical ventilation (mean duration: 14 days). All were treated by trimethoprim-sulfamethoxazole and 6/10 received steroids. Only one child died. CONCLUSION PCP is rare and affects mainly immunocompromised children who exhibit ARDS. Steroids treatment is now considered as an useful therapeutic adjuvant. A preventive treatment should be administered to children at risk.
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Affiliation(s)
- N Richard
- Service de réanimation pédiatrique polyvalente, hôpital Edouard-Herriot, Lyon, France.
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Boyton RJ, Mitchell DM, Kon OM. The pulmonary physician in critical care * Illustrative case 5: HIV associated pneumonia. Thorax 2003; 58:721-5. [PMID: 12885994 PMCID: PMC1746787 DOI: 10.1136/thorax.58.8.721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- R J Boyton
- Chest and Allergy Department, St Mary's Hospital NHS Trust, London W2 1NY, UK.
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Morris A, Wachter RM, Luce J, Turner J, Huang L. Improved survival with highly active antiretroviral therapy in HIV-infected patients with severe Pneumocystis carinii pneumonia. AIDS 2003; 17:73-80. [PMID: 12478071 DOI: 10.1097/00002030-200301030-00010] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although the incidence of pneumonia (PCP) has declined, mortality of patients who require intensive care for this disease remains high. Highly active antiretroviral therapy (HAART) might alter the course of PCP either via effects on the immune system or through anti- actions; however, HAART has not been studied in patients acutely ill with PCP. OBJECTIVE To assess the effects of HAART on outcome of patients admitted to the intensive care unit (ICU) with PCP. DESIGN AND SETTING Retrospective cohort study carried out at a University-affiliated county hospital. PARTICIPANTS Fifty-eight HIV-infected adults with PCP admitted to an ICU from 1996 to 2001. MEASUREMENTS A standardized chart review was performed to collect information on demographic variables, hospital course, and use of antiretroviral therapy. Outcome measured was death while in the ICU or hospital. RESULTS A total of 20.7% of patients were either receiving HAART or were started on therapy while hospitalized. Mortality in this group was 25%, whereas mortality in those not receiving therapy was 63% (P = 0.03). Multiple logistic regression analyses adjusting for potential confounders showed that HAART started either before or during hospitalization was associated with a lower mortality [odds ratio (OR), 0.14; 95% confidence interval (95% CI), 0.02-0.84; = 0.03). The need for mechanical ventilation and/or development of a pneumothorax (OR, 20.9; 95% CI, 1.9-227.2; = 0.01) and delayed ICU admission (OR, 9.7; 95% CI, 2.2-42.1; = 0.002) were associated with increased mortality. CONCLUSIONS Use of HAART is an independent predictor of decreased mortality in severe PCP and may represent a potential therapy to improve outcome in this disease.
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Affiliation(s)
- Alison Morris
- Department of Medicine, San Francisco General Hospital, San Francisco, California, USA.
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Zahar JR, Robin M, Azoulay E, Fieux F, Nitenberg G, Schlemmer B. Pneumocystis carinii pneumonia in critically ill patients with malignancy: a descriptive study. Clin Infect Dis 2002; 35:929-34. [PMID: 12355379 DOI: 10.1086/342338] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2002] [Revised: 05/06/2002] [Indexed: 11/04/2022] Open
Abstract
There are few data on Pneumocystis carinii pneumonia (PCP) in critically ill human immunodeficiency virus (HIV)-negative patients. Improved knowledge of the presenting symptoms of and prognostic factors for PCP may help to reduce the high mortality rate associated with PCP in such patients. We retrospectively studied 39 consecutive patients with acute PCP-related respiratory failure and malignancy who were treated at 2 intensive care units (ICUs) during a 10-year period. Univariate logistic regression identified the following 8 predictors of mortality at 30 days after patient admission to the ICU (30-day mortality rate, 33%): complete remission of the malignancy (odds ratio [OR], 0.18), receipt of >1 course of antimalignancy chemotherapy (OR, 17.2), involvement of 4 lobes noted on a chest radiograph (OR, 5), >15% neutrophils in bronchoalveolar lavage [BAL] fluid specimens (OR, 6), Organ System Failure score (OR, 7.33), Simplified Acute Physiology Score II (OR, 1.12), and the need for either mechanical ventilation (OR, 63) or vasopressors (OR, 25.9). Studies are needed to determine whether aggressive monitoring and treatment of patients with >15% neutrophils in BAL fluid specimens can improve the outcome of critically ill patients with malignancy and PCP.
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Affiliation(s)
- J R Zahar
- Intensive Care Department, Institut Gustave-Roussy, Paris, France.
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Abstract
Pneumothorax occurs in 1 to 2% of hospitalized patients with HIV and is associated with 34% mortality. Pneumocystis carinii pneumonia and chest radiographic evidence of cysts, pneumatoceles, or bullae are risk factors for spontaneous pneumothorax. Tube thoracostomy, pleurodesis, and surgical treatment are usually needed to manage spontaneous pneumothorax in AIDS. Pleural effusion is seen in 7 to 27% of hospitalized patients with HIV infection. Its three leading causes are parapneumonic effusions, tuberculosis, and Kaposi sarcoma. Pleural effusions occur in 15 to 89% of cases of pulmonary Kaposi sarcoma and in 68% of cases of thoracic non-Hodgkin lymphoma in patients with AIDS. Primary effusion lymphoma accounts for 1 to 2% of non-Hodgkin lymphomas. Kaposi sarcoma and primary effusion lymphoma are associated with human herpesvirus 8. The prognosis of patients with pleural Kaposi sarcoma and non-Hodgkin lymphoma in AIDS is poor, and the major goal of treatment is palliation.
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Affiliation(s)
- B Afessa
- Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Barry SM, Johnson MA. Pneumocystis carinii pneumonia: a review of current issues in diagnosis and management. HIV Med 2001; 2:123-32. [PMID: 11737389 DOI: 10.1046/j.1468-1293.2001.00062.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- S M Barry
- Department of Thoracic and HIV Medicine, Royal Free Hospital, London, UK.
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The HIV-infected patient in the intensive care unit. Curr Opin Crit Care 2000. [DOI: 10.1097/00075198-200010000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Schein RM, Quartin AA. Severe chronic disease with acute physiologic disturbance: a role for intensive care. Crit Care Med 2000; 28:3099-100. [PMID: 10966312 DOI: 10.1097/00003246-200008000-00080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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