Outcome for hospitalized patients with fever and neutropenia who are infected with the human immunodeficiency virus

Use of Filgrastim (r-metHuG-CSF) in Human Immunodeficiency Virus Infection

In 2008, an estimated 33.4 million individuals worldwide were infected with the human immunodeficiency virus (HIV) [1]. Only a few years ago, infection with HIV almost invariably culminated in the development of the acquired immunodeficiency syndrome (AIDS), characterized by severe depletion of CD4⁺ lymphocytes leading to derangements predominantly affecting cell-mediated immunity, but affecting humoral immunity as well [2]. In the later stages of AIDS, neutropenia and neutrophil functional deficits were common sequelae of HIV infection, other opportunistic infections, or HIV- or opportunistic infection-related treatment [3]. The care of the HIV-infected patient was palliative in nature, and the possibility that use of filgrastim (rHuG-CSF) might extend survival in late-stage AIDS patients with severe neutropenia or severe opportunistic infections, or might be a treatment for HIV infection itself, was explored [4]. Subsequently, however, the development of protease inhibitors and the widespread adoption of their use in multidrug regimens of highly active antiretroviral therapy (HAART) revolutionized the care of HIV-infected patients, and the number of patients dying from HIV decreased dramatically [5].

The use of Filgrastim in AIDS-related neutropenia

Neutropenic individuals are at high risk for bacterial and fungal infections. Filgrastim (r-metHuG-CSF, NEUPOGEN) has been shown to improve chemotherapy-induced neutropenia significantly. Because a high incidence of HIV-infected patients have neutropenia, often associated with myelosuppressive antiretroviral medication, Filgrastim is frequently used as a treatment strategy for this HIV-associated neutropenia. This review summarizes published work related to the use of Filgrastim in HIV-infected patients. Literature bases (EMBASE, MEDLINE, Int. Pharm. Abs., SciSearch, and Aidsline) from 1970 to 1998 were searched for articles describing the relationship of Filgrastim and ANC to bacterial infection rates, bacterial infection outcome, and overall survival. Thirty-five related articles were identified during this search. Filgrastim appears to have a significant role in increasing peripheral ANC and enhancing neutrophil function in patients with HIV infection and AIDS. This may translate into a clinical benefit of delivery of full-dose myelosuppressive antiretroviral therapy and decreased susceptibility to infections and increased survival in this patient population.

Sepsis

OBJECTIVES

To review infection and sepsis in patients with cancer and to provide an overview of controversies and research-based practices of infectious complications and management strategies.

DATA SOURCES

Research studies, review articles, web sites, and consensus documents.

CONCLUSIONS

Traditional assumptions about infection and its optimal management are redefined by research regarding transfusion and catheter-related infections, prophylactic antibiotic administration, use of growth factors, and antimicrobial therapy regimens.

IMPLICATIONS FOR NURSING PRACTICE

Infection is still the most common source of morbidity and mortality among cancer patients. The importance of recognizing high-risk patients, implementing infection prevention practices, and prompt intervention for infection symptoms has been established.

Outcomes of granulocyte colony-stimulating factor or granulocyte-macrophage colony-stimulating factor use in neutropenic patients infected with human immunodeficiency virus

OBJECTIVE

To characterize the effects of granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) on clinical outcomes in neutropenic HIV-infected patients, by means of a retrospective cohort study at an urban teaching hospital.

METHOD

Data were reviewed from all patients discharged between January 1, 1996, and August 31, 1997, with human immunodeficiency virus and neutropenia (absolute neutrophil count (ANC) <1000 cells/mL), with outcome measures of length of stay, infectious complications, and survival to discharge.

RESULTS

Of the 228 discharged patients who met selection criteria, 71 had received G-CSF or GM-CSF; 157 controls had not. Cases had lower CD4+ cell counts (30 vs. 54 cells/mL; P = 0. 017) and lower nadir ANCs (372 vs. 579 cells/mL; P < 0.001). Granulocyte-CSF or GM-CSF usage was not associated with the frequency of site-related infections, fever, or sepsis (all P > 0. 20). No difference was found in duration of hospitalization (23 vs. 21 days; P > 0.20). In a logistic regression model for survival to discharge, higher nadir ANC and CSF use were independently associated with improved survival (P = 0.034 and P = 0.026, respectively).

CONCLUSION

Use of G-CSF or GM-CSF was associated with improved survival to discharge among hospitalized HIV-infected patients with neutropenia.

Frequency and risk factors of infectious complications in neutropenic patients infected with HIV

OBJECTIVE

To determine causes, incidence and factors associated with infections in neutropenic [polymorphonuclear neutrophil (PMN), 1000 x 10(6)/l] HIV-infected patients.

DESIGN

Prospective study.

SETTING

Infectious disease service of a 1000-bed university teaching hospital in Paris, France.

PATIENTS

HIV-infected patients with a PMN count of < 1000 x 10(6)/l confirmed on two occasions were included in the study. Baseline characteristics, cause of neutropenia and occurrence of infectious episodes were analysed.

RESULTS

The cause of neutropenia was lymphoma in four cases (6.5%), antineoplastic chemotherapy in seven (11.3%), zidovudine in 32 (51%), trimethoprim-sulphamethoxazole (TMP-SMX) in 28 (45%) and ganciclovir in 11 (18%). Fifteen patients (24%) developed infectious complications. Neutropenia induced by chemotherapy or lymphoma was more frequently complicate by infectious episodes (P = 0.02). Neutropenia in the previous 3 months (P = 0.05), presence of a central venous catheter (P = 0.05) and a trough PMN count (P = 0.02) were the three risk factors of infection retained in a logistic model.

CONCLUSION

Neutropenia induced by zidovudine, gangiclovir or TMP-SMX, are less complicated by infectious episodes than neutropenia induced by antineoplastic chemotherapy. Overall, infectious episodes in neutropenic HIV-infected patients appear lower than in patients with haemobiologic malignancies.

Infections in HIV-infected patients with malignancy

With the increasing prevalence of HIV, better combination treatment regimens, and preventive therapy for opportunistic infections, physicians will be caring for an ever-increasing number of survivors with an ever-dwindling immune function. Increasing this burden is the unfortunate patient who also develops cancer concurrent with HIV infection. The combined risk factors of these diseases make a worst-case scenario in evaluation and treatment of infections. This article reviews AIDS-defining tumors and other malignancies, risk factors for infection, opportunistic infections, and therapy strategies.