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Qiu K, Lu J, Guo H, Du C, Liu J, Li A. Study on Respiratory Function and Hemodynamics of AIDS Patients with Respiratory Failure. Infect Drug Resist 2023; 16:6941-6950. [PMID: 37928608 PMCID: PMC10624180 DOI: 10.2147/idr.s376752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023] Open
Abstract
Objective We performed a comparative analysis of respiratory function and hemodynamics among patients with Acquired Immunodeficiency Syndrome (AIDS)-associated respiratory failure and those with non-AIDS-associated respiratory failure. Methods Data were collected from critically ill patients diagnosed with Acquired Immunodeficiency Syndrome who were admitted to the Intensive Care Unit (ICU) of Beijing Ditan Hospital, affiliated with Capital Medical University, between January 1, 2019, and December 31, 2019. We simultaneously gathered data from non-AIDS patients admitted to the ICU of Beijing Liangxiang Hospital within the same timeframe. A comparative study was performed to analyze clinical data from these two patient groups, encompassing parameters related to respiratory mechanics and hemodynamic indicators. Results A total of 12 patients diagnosed with Acquired Immunodeficiency Syndrome (AIDS) and experiencing respiratory failure, along with 23 patients with respiratory failure independent of AIDS, were included in our study. Subsequently, a comparative analysis of clinical information was conducted between the two patient cohorts. Our findings demonstrate non-statistically significant differences between the two patient groups when assessing various indicators, encompassing peak airway pressure, plateau pressure, mean pressure, compliance, oxygenation index, and arterial partial pressure of carbon dioxide (P>0.05). Additionally, the comparison of multiple indicators encompassing mean arterial pressure, central venous pressure, cardiac output index, intrathoracic blood volume index, global end-diastolic volume index, extravascular lung water content, and pulmonary vascular permeability index revealed no statistically significant differences between the two patient groups (P>0.05). Ultimately, the Galileo respiratory system was utilized to assess the pressure-volume (P-V) curve of the experimental cohort, revealing a consistent and seamless trajectory devoid of noticeable points of inflection. Conclusion No statistically significant differences were found in the respiratory function and hemodynamic profiles between patients diagnosed with AIDS presenting respiratory failure and those experiencing respiratory failure unrelated to AIDS. Additionally, the pressure-volume curve of individuals diagnosed with AIDS presenting respiratory failure displayed a seamless and uninterrupted trajectory devoid of discernible points of inflection. Hence, there might be constraints when utilizing P-V curve-based adjustments for positive end-expiratory pressure (PEEP) during mechanical ventilation in individuals diagnosed with AIDS presenting respiratory failure.
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Affiliation(s)
- Kai Qiu
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Department of Intensive Care Medicine, Liangxiang Hospital of Beijing Fangshan District, Beijing, People’s Republic of China
| | - Jiaqi Lu
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hebing Guo
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chunjing Du
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jingyuan Liu
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ang Li
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Szychowiak P, Boulain T, Timsit JF, Elabbadi A, Argaud L, Ehrmann S, Issa N, Canet E, Martino F, Bruneel F, Quenot JP, Wallet F, Azoulay É, Barbier F. Clinical spectrum and prognostic impact of cancer in critically ill patients with HIV: a multicentre cohort study. Ann Intensive Care 2023; 13:74. [PMID: 37608140 PMCID: PMC10444715 DOI: 10.1186/s13613-023-01171-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Both AIDS-defining and non-AIDS-defining cancers (ADC/NADC) predispose people living with HIV (PLHIV) to critical illnesses. The objective of this multicentre study was to investigate the prognostic impact of ADC and NADC in PLHIV admitted to the intensive care unit (ICU). METHODS All PLHIV admitted over the 2015-2020 period in 12 university-affiliated ICUs in France were included in the study cohort. The effect of ADC and NADC on in-hospital mortality (primary study endpoint) was measured through logistic regression with augmented backward elimination of potential independent variables. The association between ADC/NADC and treatment limitation decision (TLD) during the ICU stay (secondary study endpoint) was analysed. One-year mortality in patients discharged alive from the index hospital admission (exploratory study endpoint) was compared between those with ADC, NADC or no cancer. RESULTS Amongst the 939 included PLHIV (median age, 52 [43-59] years; combination antiretroviral therapy, 74.4%), 97 (10.3%) and 106 (11.3%) presented with an active NADC (mostly lung and intestinal neoplasms) and an active ADC (predominantly AIDS-defining non-Hodgkin lymphoma), respectively. Inaugural admissions were common. Bacterial sepsis and non-infectious neoplasm-related complications accounted for most of admissions in these subgroups. Hospital mortality was 12.4% in patients without cancer, 30.2% in ADC patients and 45.4% in NADC patients (P < 0.0001). NADC (adjusted odds ratio [aOR], 7.00; 95% confidence interval [CI], 4.07-12.05) and ADC (aOR, 3.11; 95% CI 1.76-5.51) were independently associated with in-hospital death after adjustment on severity and frailty markers. The prevalence of TLD was 8.0% in patients without cancer, 17.9% in ADC patients and 33.0% in NADC patients (P < 0.0001)-organ failures and non-neoplastic comorbidities were less often considered in patients with cancer. One-year mortality in survivors of the index hospital admission was 7.8% in patients without cancer, 17.0% in ADC patients and 33.3% in NADC patients (P < 0.0001). CONCLUSIONS NADC and ADC are equally prevalent, stand as a leading argument for TLD, and strongly predict in-hospital death in the current population of PLHIV requiring ICU admission.
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Affiliation(s)
- Piotr Szychowiak
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de L'Hôpital, 45100, Orléans, France
| | - Thierry Boulain
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de L'Hôpital, 45100, Orléans, France
| | - Jean-François Timsit
- Réanimation Médicale et des Maladies Infectieuses, Centre Hospitalier Universitaire Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre Elabbadi
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Argaud
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Nahema Issa
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Emmanuel Canet
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Frédéric Martino
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de La Guadeloupe, Pointe-À-Pitre, France
| | - Fabrice Bruneel
- Réanimation et Unité de Surveillance Continue, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Jean-Pierre Quenot
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Dijon-Bourgogne, Dijon, France
| | - Florent Wallet
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Élie Azoulay
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Barbier
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de L'Hôpital, 45100, Orléans, France.
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Hao J, Liu J, Pu L, Li C, Zhang M, Tan J, Wang H, Yin N, Sun Y, Liu Y, Guo H, Li A. High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation in AIDS Patients with Acute Respiratory Failure: A Randomized Controlled Trial. J Clin Med 2023; 12:jcm12041679. [PMID: 36836213 PMCID: PMC9967185 DOI: 10.3390/jcm12041679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/12/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Acute respiratory failure (ARF) remains the most common diagnosis for intensive care unit (ICU) admission in acquired immunodeficiency syndrome (AIDS) patients. METHODS We conducted a single-center, prospective, open-labeled, randomized controlled trial at the ICU, Beijing Ditan Hospital, China. AIDS patients with ARF were enrolled and randomly assigned in a 1:1 ratio to receive either high-flow nasal cannula (HFNC) oxygen therapy or non-invasive ventilation (NIV) immediately after randomization. The primary outcome was the need for endotracheal intubation on day 28. RESULTS 120 AIDS patients were enrolled and 56 patients in the HFNC group and 57 patients in the NIV group after secondary exclusion. Pneumocystis pneumonia (PCP) was the main etiology for ARF (94.7%). The intubation rates on day 28 were similar to HFNC and NIV (28.6% vs. 35.1%, p = 0.457). Kaplan-Meier curves showed no statistical difference in cumulative intubation rates between the two groups (log-rank test 0.401, p = 0.527). The number of airway care interventions in the HFNC group was fewer than in the NIV group (6 (5-7) vs. 8 (6-9), p < 0.001). The rate of intolerance in the HFNC group was lower than in the NIV group (1.8% vs. 14.0%, p = 0.032). The VAS scores of device discomfort in the HFNC group were lower than that in the NIV group at 2 h (4 (4-5) vs. 5 (4-7), p = 0.042) and at 24 h (4 (3-4) vs. 4 (3-6), p = 0.036). The respiratory rate in the HFNC group was lower than that in the NIV group at 24 h (25 ± 4/min vs. 27 ± 5/min, p = 0.041). CONCLUSIONS Among AIDS patients with ARF, there was no statistical significance of the intubation rate between HFNC and NIV. HFNC had better tolerance and device comfort, fewer airway care interventions, and a lower respiratory rate than NIV. CLINICAL TRIAL NUMBER Chictr.org (ChiCTR1900022241).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Ang Li
- Correspondence: (J.L.); (A.L.)
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Hao J, Liu J, Pu L, Li C, Yin N, Li A. Pulmonary Infections and Outcomes in AIDS Patients with Respiratory Failure: A 10-Year Retrospective Review. Infect Drug Resist 2023; 16:1049-1059. [PMID: 36845022 PMCID: PMC9951600 DOI: 10.2147/idr.s395658] [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: 10/31/2022] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
Background Respiratory failure in acquired immunodeficiency syndrome (AIDS) patients was the leading cause of intensive care unit (ICU) admission in our center. We aimed to describe the pulmonary infections and outcomes for respiratory failure in AIDS patients. Methods A retrospective study was conducted on AIDS adult patients with respiratory failure who were admitted to the ICU in Beijing Ditan hospital, China, from January 2012 to December 2021. We investigated pulmonary infections complicated by respiratory failure in AIDS patients. The primary outcome was ICU mortality, and a comparison between survivors and nonsurvivors was performed. Multiple logistic regression analysis was used to identify predictors of ICU mortality. The Kaplan-Meier curve and Log rank test were used for survival analysis. Results A total of 231 AIDS patients were admitted to ICU with respiratory failure over a 10-year period with a male predominance (95.7%). Pneumocystis jirovecii pneumonia was the main etiology of pulmonary infections (80.1%). The ICU mortality was 32.9%. In multivariate analysis, ICU mortality was independently associated with invasive mechanical ventilation (IMV) [odds ratio (OR), 27.910; 95% confidence interval (CI, 8.392-92.818; p = 0.000) and the time before ICU admission (OR, 0.959; 95% CI, 0.920-0.999; p = 0.046). In the survival analysis, patients with IMV and later admission to ICU had a higher probability of mortality. Conclusion Pneumocystis jirovecii pneumonia was the primary etiology for respiratory failure in AIDS patients admitted to the ICU. Respiratory failure remains a severe illness with high mortality, and ICU mortality was negatively associated with IMV and later admission to ICU.
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Affiliation(s)
- Jingjing Hao
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jingyuan Liu
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Lin Pu
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chuansheng Li
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ningning Yin
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ang Li
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China,Correspondence: Ang Li, Email
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5
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Hansen ME, Mangusan R, Lurain K, Odeny T, George J, Lu C, Manion M, Widell A, Ekwede I, Whitby D, Gulley JL, Kadri SS, Elinoff JM, Barochia A, Torabi-Parizi P, Uldrick TS, Yarchoan R, Ramaswami R. Characteristics of patients admitted to the ICU with Kaposi sarcoma herpesvirus-associated diseases. AIDS 2022; 36:1969-1978. [PMID: 35848586 PMCID: PMC9617765 DOI: 10.1097/qad.0000000000003333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There are four conditions caused by Kaposi sarcoma herpesvirus (KSHV): Kaposi sarcoma, KSHV-associated multicentric Castleman disease (MCD), primary effusion lymphoma (PEL), and KSHV inflammatory cytokine syndrome (KICS). These KSHV-associated disorders (KADs) often occur in people with HIV and can lead to multiorgan dysfunction requiring admission to the ICU. However, little is known about patient outcomes in this setting. METHODS A retrospective study of patients with KADs admitted to the ICU between 2010 and 2021 was conducted, examining KAD admission diagnoses, HIV characteristics, selected cytokine profiles, and ICU interventions. Primary outcomes were 60-day and median overall survival from ICU admission to death from any cause. RESULTS Forty-seven patients (all but one with HIV coinfection) were included. At ICU admission, 44 patients (94%) were on antiretroviral therapy with a median CD4 + count of 88 cells/μl and HIV viral load of 23 copies/ml. The most common presentation was respiratory failure alone (19%) or with hypotension (17%). Twenty-two (47%) patients had presumed KICS (with or without Kaposi sarcoma) at admission and an additional KAD was diagnosed in 36% of these patients. IL-6 levels did not vary across KAD subtype. Twenty (43%) patients received KAD-directed therapy in the ICU. Sixty-day survival was 70% and median overall survival was 9 months. CONCLUSION The majority of patients with HIV and KADs admitted to the ICU had well controlled HIV. Additional KAD were diagnosed during ICU admission in a proportion of patients who presented with presumed KICS. Critical illness did not preclude a subset of patients from receiving KAD-directed therapy in the ICU.
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Affiliation(s)
- Megan E Hansen
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Ralph Mangusan
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Kathryn Lurain
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Thomas Odeny
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Jomy George
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Crystal Lu
- Pharmacy Department, Clinical Center, National Institutes of Health
| | - Maura Manion
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases
| | - Anaida Widell
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Irene Ekwede
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory
| | - James L Gulley
- Center for Immuno-oncology, Center for Cancer Research, National Cancer Institute
| | | | | | - Amisha Barochia
- Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Thomas S Uldrick
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Robert Yarchoan
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
| | - Ramya Ramaswami
- HIV/AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute
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Ruiz GO, Herrera CFL, Bohórquez JAM, Betancur JE. Mortality in patients with acquired human immunodeficiency virus infection hospitalized in an intensive care unit during the period 2017-2019. Sci Rep 2022; 12:15644. [PMID: 36123430 PMCID: PMC9483872 DOI: 10.1038/s41598-022-19904-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Identify risk factors associated with mortality in HIV patients admitted to an ICU in the city of Bogotá. Retrospective cohort study of patients treated in an ICU during the years 2017–2019. The analysis included descriptive statistics, association tests, and a logistic regression model. A predictive model of mortality at the time of admission to the ICU was developed. 110 HIV patients were identified. Association was found between a Charlson index ≥ 6 and mortality (OR = 2.3, 95% CI 1.0–5.1) and an increase in mortality in the first 21 days of ICU stay (OR = 2.2, 95% CI 1.0–4.9). In the logistic regression analysis, the absence of highly active antiretroviral therapy (HAART) upon admission to the ICU (OR = 2.5 95% CI 1.0–6.1) and the first 21 days of ICU stay (OR = 2.3 95% CI 1.0–5.4) were associated with an increase in mortality. The predictive mortality model established that mortality was higher in patients admitted to the ICU without having previously received HAART than in those who did receive therapy at the time of admission to the ICU. In patients with HIV admitted to the ICU, the absence of HAART will negatively impact mortality during their hospital stay.
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Affiliation(s)
- Guillermo Ortiz Ruiz
- Critical Medicine and Intensive Care and Pulmonology, Universidad del Bosque, Bogotá, Colombia.,National Academy of Medicine, Hospital Santa Clara, Bogotá, Colombia
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7
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Sowah LA, George N, Doll M, Chiou C, Bhat P, Smith C, Palacio D, Nieweld C, Miller E, Oni I, Okwesili C, Mathur P, Saleeb PG, Buchwald UK. Predictors of in-hospital mortality in a cohort of people living with HIV (PLHIV) admitted to an academic medical intensive care unit from 2009 to 2014: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e29750. [PMID: 35839058 PMCID: PMC11132374 DOI: 10.1097/md.0000000000029750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/20/2022] [Indexed: 11/26/2022] Open
Abstract
Outcomes for critically ill people living with human immunodeficiency virus (PLHIV) have changed with the use of antiretroviral therapy (ART). To identify these outcomes and correlates of mortality in a contemporary critically ill cohort in an urban academic medical center in Baltimore, a city with a high burden of HIV, we conducted a retrospective cohort study of individuals admitted to a medical intensive care unit (MICU) at a tertiary care center between 2009 and 2014. PLHIV who were at least 18 years of age with an index MICU admission of ≥24 hours during the 5-year study period were included in this analysis. Data were obtained for participants from the time of MICU admission until hospital discharge and up to 180 days after MICU admission. Logistic regression was used to identify independent predictors of hospital mortality. Between June 2009 and June 2014, 318 PLHIV admitted to the MICU met inclusion criteria. Eighty-six percent of the patients were non-Hispanic Blacks. Poorly controlled HIV was very common with 70.2% of patients having a CD4 cell count <200 cells/mm3 within 3 months prior to admission and only 34% of patients having an undetectable HIV viral load. Hospital mortality for the cohort was 17%. In a univariate model, mortality did not differ by demographic variables, CD4 cell count, HIV viral load, or ART use. Regression analysis adjusted by relevant covariates revealed that MICU patients admitted from the hospital ward were 6.4 times more likely to die in hospital than those admitted from emergency department. Other positive predictors were a diagnosis of end-stage liver disease, cardiac arrest, ventilator-dependent respiratory failure, vasopressor requirement, non-Hodgkin lymphoma, and symptomatic cytomegalovirus disease. In conclusion, in this critically ill cohort with HIV infection, most predictors of mortality were not directly related to HIV and were similar to those for the general population.
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Affiliation(s)
- Leonard A. Sowah
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institute of Health, Department of Health and Human Services, Rockville, Maryland
| | - Nivya George
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michelle Doll
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Christine Chiou
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institute of Health, Department of Health and Human Services, Rockville, Maryland
| | - Pavan Bhat
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Christopher Smith
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Danica Palacio
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Carl Nieweld
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Eric Miller
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ibukunolupo Oni
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Christine Okwesili
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Poonam Mathur
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Paul G. Saleeb
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ulrike K. Buchwald
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland
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Performance of a Real Time PCR for Pneumocystis jirovecii Identification in Induced Sputum of AIDS Patients: Differentiation between Pneumonia and Colonization. J Fungi (Basel) 2022; 8:jof8030222. [PMID: 35330224 PMCID: PMC8950466 DOI: 10.3390/jof8030222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/23/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PcP) remains an important cause of morbimortality worldwide and a diagnostic challenge. Conventional methods have low accuracy, hardly discriminating colonization from infection, while some new high-cost or broncho-alveolar lavage-based methods have limited usefulness in developing countries. Quantitative PCR (qPCR) tests may overcome these limitations due to their high accuracy, possibility of automation, and decreasing cost. We evaluated an in-house qPCR targeting the fungus mtSSU gene using induced sputum. Sensitivity of the assay (ten target gene copies/assay) was determined using recombinant plasmids. We prospectively studied 86 AIDS patients with subacute respiratory symptoms in whom PcP was suspected. qPCR results were determined as quantification cycles (Cq) and compared with a qualitative PCR performed in the same IS, serum 1,3-β-D-Glucan assay, and a clinical/laboratory/radiology index for PcP. The qPCR clustered the patients in three groups: 32 with Cq ≤ 31 (qPCR+), 45 with Cq ≥ 33 (qPCR-), and nine with Cq between 31-33 (intermediary), which, combined with the other three analyses, enabled us to classify the groups as having PcP, not P. jirovecii-infected, and P. jirovecii-colonized, respectively. This molecular assay may contribute to improve PcP management, avoiding unnecessary treatments, and our knowledge of the natural history of this infection.
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Akgün KM, Krishnan S, Butt AA, Gibert CL, Graber CJ, Huang L, Pisani MA, Rodriguez-Barradas MC, Hoo GWS, Justice AC, Crothers K, Tate JP. CD4+ cell count and outcomes among HIV-infected compared with uninfected medical ICU survivors in a national cohort. AIDS 2021; 35:2355-2365. [PMID: 34261095 PMCID: PMC8563390 DOI: 10.1097/qad.0000000000003019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND People with HIV (PWH) with access to antiretroviral therapy (ART) experience excess morbidity and mortality compared with uninfected patients, particularly those with persistent viremia and without CD4+ cell recovery. We compared outcomes for medical intensive care unit (MICU) survivors with unsuppressed (>500 copies/ml) and suppressed (≤500 copies/ml) HIV-1 RNA and HIV-uninfected survivors, adjusting for CD4+ cell count. SETTING We studied 4537 PWH [unsuppressed = 38%; suppressed = 62%; 72% Veterans Affairs-based (VA) and 10 531 (64% VA) uninfected Veterans who survived MICU admission after entering the Veterans Aging Cohort Study (VACS) between fiscal years 2001 and 2015. METHODS Primary outcomes were all-cause 30-day and 6-month readmission and mortality, adjusted for demographics, CD4+ cell category (≥350 (reference); 200-349; 50-199; <50), comorbidity and prior healthcare utilization using proportional hazards models. We also adjusted for severity of illness using discharge VACS Index (VI) 2.0 among VA-based survivors. RESULTS In adjusted models, CD4+ categories <350 cells/μl were associated with increased risk for both outcomes up to 6 months, and risk increased with lower CD4+ categories (e.g. 6-month mortality CD4+ 200-349 hazard ratio [HR] = 1.35 [1.12-1.63]; CD4+ <50 HR = 2.14 [1.72-2.66]); unsuppressed status was not associated with outcomes. After adjusting for VI in models stratified by HIV, VI quintiles were strongly associated with both outcomes at both time points. CONCLUSION PWH who survive MICU admissions are at increased risk for worse outcomes compared with uninfected, especially those without CD4+ cell recovery. Severity of illness at discharge is the strongest predictor for outcomes regardless of HIV status. Strategies including intensive case management for HIV-specific and general organ dysfunction may improve outcomes for MICU survivors.
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Affiliation(s)
- Kathleen M Akgün
- Department of Medicine, VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine, Yale University School of Medicine, New Haven
| | - Supriya Krishnan
- Department of Medicine, VA Connecticut Healthcare System, West Haven
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Adeel A Butt
- Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Weill Cornell Medical College, Doha, Quatar and New York, New York, USA
- Hamad Medical Corporation, Doha, Qatar
| | | | - Christopher J Graber
- Infectious Diseases Section, and VA Greater Los Angeles Healthcare System and the Geffen School of Medicine at University of California, Los Angeles
| | - Laurence Huang
- Department of Medicine, Zuckerberg San Francisco, General Hospital and University of California, San Francisco, California
| | - Margaret A Pisani
- Department of Internal Medicine, Yale University School of Medicine, New Haven
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VAMC and Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Guy W Soo Hoo
- Pulmonary and Critical Care Section, VA Greater Los Angeles Healthcare System and Geffen School of Medicine at University of California, Los Angeles, California
| | - Amy C Justice
- Department of Medicine, VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine, Yale University School of Medicine, New Haven
- Yale School of Public Health, New Haven, Connecticut
| | - Kristina Crothers
- Department of Medicine, VA Puget Sound Healthcare System and University of Washington, Seattle, Washington, USA
| | - Janet P Tate
- Department of Internal Medicine, Yale University School of Medicine, New Haven
- VA Connecticut Healthcare System, West Haven, Connecticut
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10
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Funakoshi K, Morita T, Kumanogoh A. Longer Prehospitalization and Preintubation Periods in Intubated Non-survivors and ECMO Patients With COVID-19: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:727101. [PMID: 34722567 PMCID: PMC8554002 DOI: 10.3389/fmed.2021.727101] [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: 06/18/2021] [Accepted: 09/20/2021] [Indexed: 01/08/2023] Open
Abstract
Purpose: There is no clear consensus on the clinical course of critical COVID-19 patients. We examined the clinical course among intubated survivors, non-survivors, and extracorporeal membrane oxygenation (ECMO) patients to reveal the standard clinical course and the difference among critical COVID-19 patients. Methods: In this systematic review and meta-analysis, we searched PubMed, Web of Science, and Scopus for original studies published until December 11, 2020, including case accumulation and clinical course reporting. Pregnant patients and children were excluded. We followed PRISMA guidelines and registered them with PROSPERO (CRD42021235534). Results: Of the 11,716 studies identified, 94 met the selection criteria, and 2,549 cases were included in this meta-analysis. The times from intubation to extubation and death were 12.07 days (95% confidence interval 9.80–14.33 days) and 10.14 days (8.18–12.10 days), respectively, and the ECMO duration was 14.72 days (10.57–18.87 days). The time from symptom onset to hospitalization (prehospitalization period) of intubated survivors, non-survivors, and ECMO patients was 6.15 (4.61–7.69 days), 6.45 (4.55–8.34 days), and 7.15 days (6.48–7.81 days), and that from symptom onset to intubation (preintubation period) was 8.58 (7.36–9.80 days), 9.14 (7.26–11.01 days), and 10.54 days (9.18–11.90 days), respectively. Sensitivity analysis showed that the time from intubation to extubation and death was longer in the US and Europe than in East Asia. Conclusion: For COVID-19, we hypothesize that prehospitalization and preintubation periods are longer in intubated non-survivors and ECMO patients than in intubated survivors. These periods may serve as a predictor of disease severity or death and support therapeutic strategy determination.
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Affiliation(s)
- Kenji Funakoshi
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Takayoshi Morita
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Suita, Japan.,Department of Immunopathology, WPI, Immunology Frontier Research Center (iFReC), Osaka University, Suita, Japan.,Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives (OTRI), Osaka University, Suita, Japan.,Center for Infectious Diseases for Education and Research (CiDER), Osaka University, Suita, Japan
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11
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Boniatti MM, Pellegrini JAS, Marques LS, John JF, Marin LG, Maito LRDM, Lisboa TC, Damiani LP, Falci DR. Early antiretroviral therapy for HIV-infected patients admitted to an intensive care unit (EARTH-ICU): A randomized clinical trial. PLoS One 2020; 15:e0239452. [PMID: 32956419 PMCID: PMC7505451 DOI: 10.1371/journal.pone.0239452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/04/2020] [Indexed: 12/30/2022] Open
Abstract
Background Highly active antiretroviral therapy (HAART) has reduced HIV-related morbidity and mortality at all stages of infection and reduced transmission of HIV. Currently, the immediate start of HAART is recommended for all HIV patients, regardless of the CD4 count. There are several concerns, however, about starting treatment in critically ill patients. Unpredictable absorption of medication by the gastrointestinal tract, drug toxicity, drug interactions, limited reserve to tolerate the dysfunction of other organs resulting from hypersensitivity to drugs or immune reconstitution syndrome, and the possibility that subtherapeutic levels of drug may lead to viral resistance are the main concerns. The objective of our study was to compare the early onset (up to 5 days) with late onset (after discharge from the ICU) of HAART in HIV-infected patients admitted to the ICU. Methods This was a randomized, open-label clinical trial enrolling HIV-infected patients admitted to the ICU of a public hospital in southern Brazil. Patients randomized to the intervention group had to start treatment with HAART within 5 days of ICU admission. For patients in the control group, treatment should begin after discharge from the ICU. The patients were followed up to determine mortality in the ICU, in the hospital and at 6 months. The primary outcome was hospital mortality. The secondary outcome was mortality at 6 months. Results The calculated sample size was 344 patients. Unfortunately, we decided to discontinue the study due to a progressively slower recruitment rate. A total of 115 patients were randomized. The majority of admissions were for AIDS-defining illnesses and low CD4. The main cause of admission was respiratory failure. Regarding the early and late study groups, there was no difference in hospital (66.7% and 63.8%, p = 0.75) or 6-month (68.4% and 79.2%, p = 0.20) mortality. After multivariate analysis, the only independent predictors of in-hospital mortality were shock and dialysis during the ICU stay. For the mortality outcome at 6 months, the independent variables were shock and dialysis during the ICU stay and tuberculosis at ICU admission. Conclusions Although the early termination of the study precludes definitive conclusions being made, early HAART administration for HIV-infected patients admitted to the ICU compared to late administration did not show benefit in hospital mortality or 6-month mortality. ClinicalTrials.gov, NCT01455688. Registered 20 October 2011, https://clinicaltrials.gov/show/NCT01455688
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Affiliation(s)
- Márcio M. Boniatti
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Universidade La Salle, Porto Alegre, Brazil
- * E-mail:
| | - José Augusto S. Pellegrini
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Universidade La Salle, Porto Alegre, Brazil
| | - Leonardo S. Marques
- Critical Care Department, Hospital Nossa Senhora da Conceição, Porto Alegre, Porto Alegre, Brazil
| | - Josiane F. John
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Universidade La Salle, Porto Alegre, Brazil
| | - Luiz G. Marin
- Critical Care Department, Hospital Nossa Senhora da Conceição, Porto Alegre, Porto Alegre, Brazil
| | - Lina R. D. M. Maito
- Critical Care Department, Hospital São Vicente de Paulo, Passo Fundo, Brazil
| | - Thiago C. Lisboa
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Instituto de Pesquisa HCor, Universidade La Salle, Porto Alegre, Brazil
| | | | - Diego R. Falci
- Infectious Disease Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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12
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Elabbadi A, Pichon J, Visseaux B, Schnuriger A, Bouadma L, Philippot Q, Patrier J, Labbé V, Ruckly S, Fartoukh M, Timsit JF, Voiriot G. Respiratory virus-associated infections in HIV-infected adults admitted to the intensive care unit for acute respiratory failure: a 6-year bicenter retrospective study ( HIV- VIR study). Ann Intensive Care 2020; 10:123. [PMID: 32953200 PMCID: PMC7488215 DOI: 10.1186/s13613-020-00738-9] [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: 04/30/2020] [Accepted: 09/06/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Acute respiratory failure is the main reason for admission to the intensive care unit (ICU) in HIV-infected adults. There is little data about the epidemiology of respiratory viruses in this population. Methods HIV-infected adults admitted to two intensive care units over a 6-year period for an acute respiratory failure and explored for respiratory viruses with multiplex polymerase chain reaction (mPCR) were retrospectively selected. Objectives were to describe the prevalence of respiratory viruses, coinfections with non-viral pathogens, and hospital outcome. Results A total of 123 episodes were included. An HIV infection was newly diagnosed in 9% of cases and 72% of the population were on antiretroviral therapy. Real-time mPCR tests identified at least one respiratory virus in the respiratory tract of 33 (27%) patients, but with a non-viral copathogen in two-thirds of cases. Rhinovirus was predominant, documented in 15 patients, followed by Influenza and Respiratory Syncytial Viruses (both n = 6). The prevalence of respiratory virus-associated infection did not vary along with the level of the CD4 T-cell deficiency, except for Rhinovirus which was more prevalent in patients with a CD4 lymphocyte count below 200 cells/µL (n = 13 (20%) vs. n = 2 (4%), p < 0.01). In multivariate analysis, respiratory virus-associated infection was not associated with a worse prognosis. Conclusions Viruses are frequently identified in the respiratory tract of HIV-infected patients with acute respiratory failure that requires ICU admission, but with a non-viral copathogen in two-thirds of cases. Rhinovirus is the predominant viral specie; its prevalence is highest in patients with a CD4 lymphocyte count below 200 cells/µL.
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Affiliation(s)
- Alexandre Elabbadi
- Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Jérémie Pichon
- Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Benoit Visseaux
- Assistance Publique - Hôpitaux de Paris, Service de virologie, Hôpital Bichat, Université de Paris, Paris, France.,UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care, INSERM, Université de Paris, Paris, France
| | - Aurélie Schnuriger
- INSERM, Saint-Antoine Research Center (CRSA), Assistance Publique - Hôpitaux de Paris, Département de virologie site Trousseau, Sorbonne Université, Paris, France
| | - Lila Bouadma
- UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care, INSERM, Université de Paris, Paris, France.,Assistance Publique - Hôpitaux de Paris, Service de réanimation médicale et infectieuse, Hôpital Bichat, Université de Paris, Paris, France
| | - Quentin Philippot
- Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Juliette Patrier
- Assistance Publique - Hôpitaux de Paris, Service de réanimation médicale et infectieuse, Hôpital Bichat, Université de Paris, Paris, France
| | - Vincent Labbé
- Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Sorbonne Université, Paris, France.,Groupe de Recherche Clinique GRC05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Université Paris Est, Créteil, France
| | - Stéphane Ruckly
- UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care, INSERM, Université de Paris, Paris, France
| | - Muriel Fartoukh
- Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Sorbonne Université, Paris, France.,Groupe de Recherche Clinique GRC05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Université Paris Est, Créteil, France
| | - Jean-François Timsit
- UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care, INSERM, Université de Paris, Paris, France.,Assistance Publique - Hôpitaux de Paris, Service de réanimation médicale et infectieuse, Hôpital Bichat, Université de Paris, Paris, France
| | - Guillaume Voiriot
- Assistance Publique - Hôpitaux de Paris, Service de médecine intensive réanimation, Hôpital Tenon, Sorbonne Université, Paris, France.,Groupe de Recherche Clinique GRC05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Université Paris Est, Créteil, France
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13
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Andrade HB, da Silva I, Ramos GV, Medeiros DM, Ho YL, de Carvalho FB, Bozza FA, Japiassú AM. Short- and medium-term prognosis of HIV-infected patients receiving intensive care: a Brazilian multicentre prospective cohort study. HIV Med 2020; 21:650-658. [PMID: 32876389 DOI: 10.1111/hiv.12939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 07/15/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The characteristics of critically ill HIV-positive patients and the causes of their admission to intensive care units (ICUs) are only known through retrospective and unicentric studies. This study aims to fill this knowledge gap. METHODS This is a prospective, multicentre cohort study of short- and medium-term prognostic factors. The setting consisted of ICUs of three tertiary referral hospitals from the three largest metropolitan areas in Brazil in the period January 2014 to November 2015. In all, 161 HIV patients over 18 years old were included. RESULTS The clinical data of the outcomes (ICU mortality, hospital mortality and 90-day survival) were extracted from medical records using the REDCap®️ web-based form and analysed with the MedCalc® ️ application. Median age was 41.7 [interquartile range (IQR): 34-50] years, the Simplified Acute Physiologic Score 3 (SAPS 3) was 64 (IQR: 56-74), and the Sequential Organ Failure Assessment Score (SOFA) was 6 (IQR: 4-9) points. The main causes of admission were sepsis (54.5%) and acute respiratory failure (13.7%). ICU and hospital mortality rates were 32.3% and 40.4%, respectively. In a multivariate analysis, time until ICU admission ≥ 3 days (P = 0.0013), performance status (Eastern Cooperative Oncology Group score, P = 0.0344), coma (Glasgow Coma Scale ≤ 8 points, P = 0.0213) and sepsis (P = 0.0003) were associated with increased hospital mortality. Coma (P = 0.0002) and sepsis (P = 0.0008) were independently associated with 90-day survival. CONCLUSIONS Delayed ICU admission and the severity of critical illness determine the short- and medium-term mortality rates of HIV-infected patients admitted to the ICU, rather than factors associated with HIV infection. These results suggest that prognostic factors of HIV-infected patients in the ICU are similar to those of non-HIV-infected populations.
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Affiliation(s)
- H B Andrade
- Intensive Care Unit of the Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.,Sexually Transmitted Diseases Sector, Biomedical Institute, Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil
| | - Irf da Silva
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - G V Ramos
- Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - D M Medeiros
- Intensive Care Unit of the Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Y L Ho
- Infectious Diseases Intensive Care Unit of Hospital das Clínicas, Medical School of the University of São Paulo, São Paulo, SP, Brazil
| | - F B de Carvalho
- Intensive Care Unit of Hospital Eduardo de Menezes, Hospital Foundation of the State of Minas Gerais, Belo Horizonte, MG, Brazil
| | - F A Bozza
- Intensive Care Unit of the Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.,Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - A M Japiassú
- Intensive Care Unit of the Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
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14
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Barbier F, Mer M, Szychowiak P, Miller RF, Mariotte É, Galicier L, Bouadma L, Tattevin P, Azoulay É. Management of HIV-infected patients in the intensive care unit. Intensive Care Med 2020; 46:329-342. [PMID: 32016535 PMCID: PMC7095039 DOI: 10.1007/s00134-020-05945-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
The widespread use of combination antiretroviral therapies (cART) has converted the prognosis of HIV infection from a rapidly progressive and ultimately fatal disease to a chronic condition with limited impact on life expectancy. Yet, HIV-infected patients remain at high risk for critical illness due to the occurrence of severe opportunistic infections in those with advanced immunosuppression (i.e., inaugural admissions or limited access to cART), a pronounced susceptibility to bacterial sepsis and tuberculosis at every stage of HIV infection, and a rising prevalence of underlying comorbidities such as chronic obstructive pulmonary diseases, atherosclerosis or non-AIDS-defining neoplasms in cART-treated patients aging with controlled viral replication. Several patterns of intensive care have markedly evolved in this patient population over the late cART era, including a steady decline in AIDS-related admissions, an opposite trend in admissions for exacerbated comorbidities, the emergence of additional drivers of immunosuppression (e.g., anti-neoplastic chemotherapy or solid organ transplantation), the management of cART in the acute phase of critical illness, and a dramatic progress in short-term survival that mainly results from general advances in intensive care practices. Besides, there is a lack of data regarding other features of ICU and post-ICU care in these patients, especially on the impact of sociological factors on clinical presentation and prognosis, the optimal timing of cART introduction in AIDS-related admissions, determinants of end-of-life decisions, long-term survival, and functional outcomes. In this narrative review, we sought to depict the current evidence regarding the management of HIV-infected patients admitted to the intensive care unit.
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Affiliation(s)
- François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France.
| | - Mervin Mer
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg University Hospital, Johannesburg, South Africa
| | - Piotr Szychowiak
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - Robert F Miller
- Research Department of Infection and Population Health, University College London, London, UK
| | - Éric Mariotte
- Medical Intensive Care Unit, Saint-Louis University Hospital, APHP, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Saint-Louis University Hospital, APHP, Paris, France
| | - Lila Bouadma
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, APHP, Paris, France.,Paris Diderot University, IAME-UMR 1137, INSERM, Paris, France
| | - Pierre Tattevin
- Infectious Diseases and Medical Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Élie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, APHP, Paris, France. .,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic, Sorbonne-Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France.
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15
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Neto NB, Marin LG, de Souza BG, Moro AL, Nedel WL. HIV treatment non-adherence is associated with ICU mortality in HIV-positive critically ill patients. J Intensive Care Soc 2020; 22:47-51. [PMID: 33643432 DOI: 10.1177/1751143719898977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction Combined antiretroviral therapy has led to significant decreases in morbidity and mortality in acquired immunodeficiency syndrome patients. Survival among these patients admitted to intensive care units has also improved in the last years. However, the prognostic predictors of human immunodeficiency vírus patients in intensive care units have not been adequately studied. The main objective of this study was to evaluate if non-adherence to antiretroviral therapy is a predictor of hospital mortality. Methods A unicentric, retrospective, cohort study composed of patients admitted to a 59-bed mixed intensive care unit including all patients with human immunodeficiency vírus infection. Patients were excluded if exclusive palliative care was established before completing 48 h of intensive care unit admission. Clinical and treatment data were obtained, including demographic records, underlying diseases, Simplified Acute Physiology III score at the time of intensive care unit admission, CD4 lymphocyte count, antiretroviral therapy adherence, admission diagnosis, human immunodeficiency vírus-related diseases, sepsis and use of mechanical ventilation and hemodialysis. The outcome analyzed was hospital mortality. Results Overall, 167 patients were included in the study, and intensive care unit mortality was 34.7%. Multivariate analysis indicated that antiretroviral therapy adherence and the Simplified Acute Physiology 3 score were independently related to hospital mortality. antiretroviral therapy adherence was a protective factor (OR 0.2; 95% CI 0.05-0.71; P = 0.01), and Simplified Acute Physiology 3 (OR 1.04; 95% CI 1.01-1.08; P < 0.01) was associated with increased hospital mortality. Conclusion Non-adherence to antiretroviral therapy is associated with hospital mortality in this population. Highly active antiretroviral therapy non-adherence may be associated with other comorbidities that may be associated with a worst prognosis in this scenario.
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Affiliation(s)
- Nelson Bf Neto
- Intensive Care Unit, Hospital Bruno Born, Lajeado/RS, Brazil
| | - Luiz G Marin
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre/RS, Brazil
| | - Bruna G de Souza
- Infectious Disease Department, Hospital Nossa Senhora da Conceição, Porto Alegre/RS, Brazil
| | - Ana Ld Moro
- Intensive Care Unit, Hospital Bruno Born, Lajeado/RS, Brazil
| | - Wagner L Nedel
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre/RS, Brazil.,Postgraduate Program in Biochemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre/RS, Brazil
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16
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Azoulay É, de Castro N, Barbier F. Critically Ill Patients With HIV: 40 Years Later. Chest 2019; 157:293-309. [PMID: 31421114 DOI: 10.1016/j.chest.2019.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/25/2019] [Accepted: 08/04/2019] [Indexed: 01/27/2023] Open
Abstract
The development of combination antiretroviral therapies (cARTs) in the mid-1990s has dramatically modified the clinical presentation of critically ill, HIV-infected patients. Most cART-treated patients aging with controlled HIV replication are currently admitted to the ICU for non-AIDS-related events, mostly bacterial pneumonia and exacerbation of comorbidities, variably affected by chronic HIV infection (COPD, cardiovascular diseases, or solid neoplasms). Today, Pneumocystis jirovecii pneumonia, cerebral toxoplasmosis, TB, and other severe opportunistic infections only occur in patients with unknown viral status, limited access to cART, viral resistance, or compliance issues. Acute respiratory failure, neurological disorders, and sepsis remain the main conditions that lead HIV-infected patients to the ICU, although admissions for liver diseases or acute kidney injury are increasing. Case fatality dropped substantially over the past decades, reaching figures of HIV-uninfected critically ill patients with similar demographic characteristics, comorbidities, and level of organ dysfunctions. Several other facets of critical care management have evolved in this population, including diagnostic procedures, cART management at the acute phase of critical illness, and ethical considerations. The goal of this narrative review was to depict the current evidence and emerging challenges for the management of critically ill, HIV-infected patients, almost 40 years following the onset of the AIDS epidemic.
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Affiliation(s)
- Élie Azoulay
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France; ECSTRA, SBIM, and the Saint-Louis Hospital, APHP, Paris, France.
| | - Nathalie de Castro
- Department of Infectious Diseases, Saint-Louis Hospital, APHP, Paris, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
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17
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Kulkarni, AP, Sengar, M, Chinnaswamy, G, Hegde, A, Rodrigues, C, Soman, R, Khilnani, GC, Ramasubban, S, Desai, M, Pandit, R, Khasne, R, Shetty, A, Gilada, T, Bhosale, S, Kothekar, A, Dixit, S, Zirpe, K, Mehta, Y, Pulinilkunnathil, JG, Bhagat, V, Khan, MS, Narkhede, AM, Baliga, N, Ammapalli, S, Bamne, S, Turkar, S, K, VB, Choudhary, J, Kumar, R, Divatia JV. Indian Antimicrobial Prescription Guidelines in Critically Ill Immunocompromised Patients. Indian J Crit Care Med 2019; 23:S64-S96. [PMID: 31516212 PMCID: PMC6734470 DOI: 10.5005/jp-journals-10071-23102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
How to cite this article: Kulkarni AP, Sengar M, Chinnaswamy G, Hegde A, Rodrigues C, Soman R, Khilnani GC, Ramasubban S, Desai M, Pandit R, Khasne R, Shetty A, Gilada T, Bhosale S, Kothekar A, Dixit S, Zirpe K, Mehta Y, Pulinilkunnathil JG, Bhagat V, Khan MS, Narkhede AM, Baliga N, Ammapalli S, Bamne S, Turkar S, Bhat KV, Choudhary J, Kumar R, Divatia JV. Indian Journal of Critical Care Medicine 2019;23(Suppl 1): S64-S96.
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Affiliation(s)
- Atul P Kulkarni,
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Manju Sengar,
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy,
- Department of Paediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Ashit Hegde,
- Consultant in Medicine and Critical Care, PD Hinduja National Hospital, Mahim, Mumbai, Maharashtra, India
| | - Camilla Rodrigues,
- Consultant Microbiologist and Chair Infection Control, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Rajeev Soman,
- Consultant ID Physician, Jupiter Hospital, Pune, DeenanathMangeshkar Hospital, Pune, BharatiVidyapeeth, Deemed University Hospital, Pune, Courtsey Visiting Consultant, Hinduja Hospital Mumbai, Maharashtra, India
| | - Gopi C Khilnani,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Suresh Ramasubban,
- Pulmomary and Critical Care Medicine, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata, West Bengal, India
| | - Mukesh Desai,
- Department of Immunology, Prof of Pediatric Hematology and Oncology, Bai Jerbaiwadia Hospital for Children, Consultant, Hematologist, Nanavati Superspeciality Hospital, Director of Pediatric Hematology, Surya Hospitals, Mumbai, Maharashtra, India
| | - Rahul Pandit,
- Intensive Care Unit, Fortis Hospital, Mulund Goregaon Link Road, Mulund (W), Mumbai, Maharashtra, India
| | - Ruchira Khasne,
- Critical Care Medicine, Ashoka - Medicover Hospital, Indira Nagar, Wadala Nashik, Maharashtra, India
| | - Anjali Shetty,
- Microbiology Section, 5th Floor, S1 Building, PD Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Trupti Gilada,
- Consultant Physician in Infectious Disease, Unison Medicare and Research Centre and Prince Aly Khan Hospital, Maharukh Mansion, Alibhai Premji Marg, Grant Road, Mumbai, Maharashtra, India
| | - Shilpushp Bhosale,
- Intensive Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Amol Kothekar,
- Division of Critical Care Medicine, Departemnt of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Subhal Dixit,
- Consultant in Critical Care, Director, ICU Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Kapil Zirpe,
- Neuro-Trauma Unit, Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Yatin Mehta,
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Jacob George Pulinilkunnathil,
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr E Borges Road, Mumbai, Maharashtra, India
| | - Vikas Bhagat,
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, HomiBhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Mohammad Saif Khan,
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Amit M Narkhede,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Nishanth Baliga,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Srilekha Ammapalli,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Shrirang Bamne,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Siddharth Turkar,
- Department of Medical Oncology, Tata Memorial Hospital, HomiBhabha National Institute, Mumbai, Maharashtra, India
| | - Vasudeva Bhat K,
- Department of Pediatric Oncology, Tata Memorial Hospital, HomiBhabha National Institute, Dr E. Borges Marg, Parel, Mumbai, Maharashtra, India
| | - Jitendra Choudhary,
- Critical Care, Fortis Hospital, 102, Nav Sai Shakti CHS, Near Bhoir Gymkhana, M Phule Road, Dombivali West Mumbai, Maharashtra, India
| | - Rishi Kumar,
- Critical Care Medicine, PD Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
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18
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Collett LW, Simpson T, Camporota L, Meadows CI, Ioannou N, Glover G, Kulasegaram R, Barrett NA. The use of extracorporeal membrane oxygenation in HIV-positive patients with severe respiratory failure: a retrospective observational case series. Int J STD AIDS 2018; 30:316-322. [PMID: 30421647 DOI: 10.1177/0956462418805606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective is to describe the outcomes of patients with human immunodeficiency virus (HIV) infection who received extracorporeal membrane oxygenation (ECMO) for severe respiratory failure (SRF). The design and setting was a single centre retrospective observational case series, from January 2012 to June 2017, at a tertiary university hospital and regional referral centre for ECMO in the United Kingdom. The participants were all patients referred with SRF and HIV infection. The main outcome measure was patient 90-day survival. Twenty-four patients were referred, of whom nine received ECMO. Six out of nine (67%) of patients were alive at 90 days. Median duration of ECMO was 18 days. There were no identified differences between survivors and non-survivors. ECMO can be used successfully in selected patients with HIV and SRF, including those with poor HIV control and high illness severity. HIV status alone should not exclude patients from treatment with extracorporeal therapy.
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Affiliation(s)
- Luke W Collett
- 1 Intensive Care Unit, Royal North Shore Hospital, St Leonards, Australia
| | - Thomas Simpson
- 2 Department of Respiratory Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- 3 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Chris Is Meadows
- 3 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Ioannou
- 3 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Guy Glover
- 3 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ranjababu Kulasegaram
- 4 Department of HIV/GU Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas A Barrett
- 3 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
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19
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Hernandez Conte AT, Ng D, Ramzy D, Dilibero D, LaBounty TM, Gaultier C, Behringer EC. Extracorporeal Membrane Oxygenation in a 29-Year-Old Man with Pneumocystis jirovecii Respiratory Failure and AIDS. Tex Heart Inst J 2018; 45:254-259. [PMID: 30374241 DOI: 10.14503/thij-16-6186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in patients who have acute respiratory distress syndrome has been generally beneficial. However, because of various concerns, ECMO has rarely been used in patients who have human immunodeficiency virus infection with or without acquired immune deficiency syndrome. We report our successful use of venovenous ECMO in a 29-year-old man who presented with severe respiratory distress secondary to Pneumocystis jirovecii pneumonia associated with undiagnosed infection with the human immunodeficiency virus and acquired immune deficiency syndrome. After highly active antiretroviral therapy was begun, acute immune reconstitution inflammatory syndrome developed. The patient's respiratory condition deteriorated rapidly; he was placed on venovenous ECMO for 19 days and remained intubated thereafter. After a 65-day hospital stay and inpatient pulmonary rehabilitation, he recovered fully. In addition to presenting this case, we review the few previous reports and note the multidisciplinary medical and surgical support necessary to treat similar patients.
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20
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Rey MF, Mary C, Sanguinetti D, Ranque S, Bartoli C, L'Ollivier C. Successful Treatment of Pulmonary and Cerebral Toxoplasmosis Associated with Pneumocystis Pneumonia in an HIV Patient. Diseases 2017; 5:diseases5040035. [PMID: 29258242 PMCID: PMC5750546 DOI: 10.3390/diseases5040035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 01/15/2023] Open
Abstract
In both the post and pre combination antiretroviral therapy (cART) era, Pneumocystis jirovecii and Toxoplasma gondii remain common opportunistic infectious agents. The common manifestations are pneumonia for P. jirovecii and brain abscess for T. gondii. Nevertheless, co-infection remains rare, and pulmonary toxoplasmosis is scarce, or may be underestimated because of its similarity with Pneumocystis jirovecii pneumonia. We reported an uncommon case of an AIDS patient (6 CD4 + T cells/mm³) with both pulmonary and cerebral toxoplasmosis associated with pneumocystis pneumonia. The patient presented with general weakness, fever and dyspnea. Pulmonary toxoplasmosis and pneumocystis were confirmed by microscopic examination and DNA detection in the bronchoalveolar lavage. Computed tomography imaging of the brain revealed a single characteristic cerebral toxoplasmosis lesion of the left capsular area. He was successful treated by trimethoprim/sulfamethoxaxole in conjunction with an early reintroduction of cART, and without IRIS development. During a 3-year follow-up, HIV viral load remained undetectable, and the patient did not relapse for toxoplasmosis or Pneumocystis pneumonia.
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Affiliation(s)
- Marie-Françoise Rey
- Department of Interregional Secure Hospital, AP-HM, University Hospital, 13915 Marseille CEDEX, France.
| | - Charles Mary
- Université Aix Marseille, CNRS 7278, IRD 198, Inserm 1095, AP-HM, URMITE, IHU Méditerranée Infection, 13915 Marseille CEDEX, France.
| | - Diane Sanguinetti
- Université Aix Marseille, CNRS 7278, IRD 198, Inserm 1095, AP-HM, URMITE, IHU Méditerranée Infection, 13915 Marseille CEDEX, France.
| | - Stéphane Ranque
- Université Aix Marseille, CNRS 7278, IRD 198, Inserm 1095, AP-HM, URMITE, IHU Méditerranée Infection, 13915 Marseille CEDEX, France.
| | - Christophe Bartoli
- Department of Interregional Secure Hospital, AP-HM, University Hospital, 13915 Marseille CEDEX, France.
| | - Coralie L'Ollivier
- Université Aix Marseille, CNRS 7278, IRD 198, Inserm 1095, AP-HM, URMITE, IHU Méditerranée Infection, 13915 Marseille CEDEX, France.
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21
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Andrade HB, Shinotsuka CR, da Silva IRF, Donini CS, Yeh Li H, de Carvalho FB, Americano do Brasil PEA, Bozza FA, Miguel Japiassu A. Highly active antiretroviral therapy for critically ill HIV patients: A systematic review and meta-analysis. PLoS One 2017; 12:e0186968. [PMID: 29065165 PMCID: PMC5655356 DOI: 10.1371/journal.pone.0186968] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/11/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION It is unclear whether the treatment of an HIV infection with highly active antiretroviral therapy (HAART) affects intensive care unit (ICU) outcomes. In this paper, we report the results of a systematic review and meta-analysis performed to summarize the effects of HAART on the prognosis of critically ill HIV positive patients. MATERIALS AND METHODS A bibliographic search was performed in 3 databases (PubMed, Web of Science and Scopus) to identify articles that investigated the use of HAART during ICU admissions for short- and long-term mortality or survival. Eligible articles were selected in a staged process and were independently assessed by two investigators. The methodological quality of the selected articles was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS Twelve articles met the systematic review inclusion criteria and examined short-term mortality. Six of them also examined long-term mortality (≥90 days) after ICU discharge. The short-term mortality meta-analysis showed a significant beneficial effect of initiating or maintaining HAART during the ICU stay (random effects odds ratio 0.53, p = 0.02). The data analysis of long-term outcomes also suggested a reduced mortality when HAART was used, but the effect of HAART on long-term mortality of HIV positive critically ill patients remains uncertain. CONCLUSIONS This meta-analysis suggests improved survival rates for HIV positive patients who were treated with HAART during their ICU admission.
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Affiliation(s)
- Hugo Boechat Andrade
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
| | - Cassia Righy Shinotsuka
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
| | - Ivan Rocha Ferreira da Silva
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
| | - Camila Sunaitis Donini
- Infectious Diseases Intensive Care Unit of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Ho Yeh Li
- Infectious Diseases Intensive Care Unit of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Frederico Bruzzi de Carvalho
- Intensive Care Unit of Hospital Eduardo de Menezes da Fundação Hospitalar do Estado de Minas Gerais. Belo Horizonte, MG, Brazil
| | | | - Fernando Augusto Bozza
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
| | - Andre Miguel Japiassu
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
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22
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Luna LDS, Soares DDS, Junior GBDS, Cavalcante MG, Malveira LRC, Meneses GC, Pereira EDB, Daher EDF. CLINICAL CHARACTERISTICS, OUTCOMES AND RISK FACTORS FOR DEATH AMONG CRITICALLY ILL PATIENTS WITH HIV-RELATED ACUTE KIDNEY INJURY. Rev Inst Med Trop Sao Paulo 2017; 58:52. [PMID: 27410912 PMCID: PMC4964321 DOI: 10.1590/s1678-9946201658052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/15/2016] [Indexed: 12/23/2022] Open
Abstract
Background: The aim of this study is to describe clinical characteristics, outcomes and risk factors for death among patients with HIV-related acute kidney injury (AKI) admitted to an intensive care unit (ICU). Methods: A retrospective study was conducted with HIV-infected AKI patients admitted to the ICU of an infectious diseases hospital in Fortaleza, Brazil. All the patients with confirmed diagnosis of HIV and AKI admitted from January 2004 to December 2011 were included. A comparison between survivors and non-survivors was performed. Risk factors for death were investigated. Results: Among 256 AKI patients admitted to the ICU in the study period, 73 were identified as HIV-infected, with a predominance of male patients (83.6%), and the mean age was 41.2 ± 10.4 years. Non-survivor patients presented higher APACHE II scores (61.4 ± 19 vs. 38.6 ± 18, p = 0.004), used more vasoconstrictors (70.9 vs. 37.5%, p = 0.02) and needed more mechanical ventilation - MV (81.1 vs. 35.3%, p = 0.001). There were 55 deaths (75.3%), most of them (53.4%) due to septic shock. Independent risk factors for mortality were septic shock (OR = 14.2, 95% CI = 2.0-96.9, p = 0.007) and respiratory insufficiency with need of MV (OR = 27.6, 95% CI = 5.0-153.0, p < 0.001). Conclusion: Non-survivor HIV-infected patients with AKI admitted to the ICU presented higher severity APACHE II scores, more respiratory damage and hemodynamic impairment than survivors. Septic shock and respiratory insufficiency were independently associated to death.
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Affiliation(s)
- Leonardo Duarte Sobreira Luna
- Federal University of Ceará, School of Medicine, Division of Nephrology, Department of Internal Medicine. Fortaleza, CE, Brazil. E-mails: ; ; ;
| | - Douglas de Sousa Soares
- Federal University of Ceará, School of Medicine, Division of Nephrology, Department of Internal Medicine. Fortaleza, CE, Brazil. E-mails: ; ; ;
| | | | - Malena Gadelha Cavalcante
- Federal University of Ceará, School of Medicine, Medical Sciences and Pharmacology Graduate Program. Fortaleza, CE, Brazil. E-mails: ;
| | - Lara Raissa Cavalcante Malveira
- Federal University of Ceará, School of Medicine, Division of Nephrology, Department of Internal Medicine. Fortaleza, CE, Brazil. E-mails: ; ; ;
| | - Gdayllon Cavalcante Meneses
- Federal University of Ceará, School of Medicine, Medical Sciences and Pharmacology Graduate Program. Fortaleza, CE, Brazil. E-mails: ;
| | - Eanes Delgado Barros Pereira
- University of Fortaleza, School of Medicine, Public Health Graduate Program. Fortaleza, CE, Brazil. E-mails: ; ;
| | - Elizabeth De Francesco Daher
- Federal University of Ceará, School of Medicine, Division of Nephrology, Department of Internal Medicine. Fortaleza, CE, Brazil. E-mails: ; ; ; .,University of Fortaleza, School of Medicine, Public Health Graduate Program. Fortaleza, CE, Brazil. E-mails: ; ;
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23
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Pecego AC, Amancio RT, Ribeiro C, Mesquita EC, Medeiros DM, Cerbino J, Grinsztejn B, Bozza FA, Japiassu AM. Six-month survival of critically ill patients with HIV-related disease and tuberculosis: a retrospective study. BMC Infect Dis 2016; 16:270. [PMID: 27286652 PMCID: PMC4902956 DOI: 10.1186/s12879-016-1644-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 06/08/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Tuberculosis is one of the leading causes of death from infectious diseases worldwide, mainly after the human immunodeficiency virus (HIV) epidemics. Patient with HIV-related illness are more likely to present with severe TB due to immunosuppression. Very few studies have explored HIV/TB co-infection in critically ill patients. The goal of this study was to analyze factors associated with long-term mortality in critically ill patient with HIV-related disease coinfected with TB. METHODS We conducted a retrospective study in an infectious disease reference center in Brazil that included all patient with HIV-related illness admitted to the ICU with laboratory-confirmed tuberculosis from March 2007 until June 2012. Clinical and laboratory variables were analyzed based on six-month survival. RESULTS Forty-four patients with HIV-related illness with a confirmed diagnosis of tuberculosis were analyzed. The six-month mortality was 52 % (23 patients). The main causes of admission were respiratory failure (41 %), severe sepsis/septic shock (32 %) and coma/torpor (14 %). The median time between HIV diagnosis and ICU admission was 5 (1-60) months, and 41 % of patients received their HIV infection diagnosis ≤ 30 days before admission. The median CD4 count was 72 (IQR: 23-136) cells/mm(3). The clinical presentation was pulmonary tuberculosis in 22 patients (50 %) and disseminated TB in 20 patients (45.5 %). No aspect of TB diagnosis or treatment was different between survivors and nonsurvivors. Neurological dysfunction was more prevalent among nonsurvivors (43 % vs. 14 %, p = 0.04). The nadir CD4 cell count lower than 50 cells/mm(3) was independently associated with Six-month mortality (hazard ratio 4.58 [1.64-12.74], p < 0.01), while HIV diagnosis less than three months after positive serology was protective (hazard ratio 0.27, CI 95 % [0.10-0.72], p = 0.01). CONCLUSION The Six-month mortality of HIV critically ill patients with TB coinfection is high and strongly associated with the nadir CD4 cell count less than 50 cels/mm(3).
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Affiliation(s)
- Ana Carla Pecego
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Rodrigo T Amancio
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Camila Ribeiro
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Emersom C Mesquita
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Denise M Medeiros
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - José Cerbino
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Beatriz Grinsztejn
- STD/AIDS Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Fernando A Bozza
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil.,Instituto D'Or de Pesquisa e Ensino, Rua Diniz Cordeiro, n° 30, Botafogo, Rio de Janeiro, RJ, 22281-100, Brazil
| | - Andre M Japiassu
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil.
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Abstract
OBJECTIVE Knowledge on characteristics and outcome of ICU patients with AIDS is highly limited. We aimed to determine the main reasons for admission and outcome in ICU patients with AIDS and trends over time therein. DESIGN A retrospective study within the Dutch National Intensive Care Evaluation registry. SETTING Dutch ICUs. PATIENTS We used data collected between 1997 and 2014. Characteristics of patients with AIDS were compared with ICU patients without AIDS, matched for age, sex, admission type, and admission year. Joinpoint regression analysis was applied to study trends over time. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We included 1,127 patients with AIDS and 4,479 matched controls. The main admission diagnoses of patients with AIDS were respiratory infection (28.6%) and sepsis (16.9%), which were less common in controls (7.7% and 7.5%, respectively; both p < 0.0001). Patients with AIDS had increased severity of illness and in-hospital mortality (28.2% vs 17.8%; p < 0.0001) compared with controls, which was associated with a higher rate of infections at admission in patients with AIDS (58.4% vs 25.5%). Over time, the proportion of patients with AIDS admitted with an infection decreased (75% in 1999 to 56% in 2013). Mortality declined in patients with AIDS (39% in 1999 to 16% in 2013), both in patients with or without an infection. Mortality also declined in matched controls without AIDS, but to a lesser extent. CONCLUSION Infections are still the main reason for ICU admission in patients with AIDS, but their prevalence is declining. Outcome of patients with AIDS continued to improve during a time of widespread availability of combination antiretroviral therapy, and mortality is reaching levels similar to ICU patients without AIDS.
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25
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Park DW, Lim DH, Kim B, Yhi JY, Moon JY, Kim SH, Kim TH, Shon JW, Yoon HJ, Shin DH, Pai H. Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome following HAART Initiation in an HIV-infected Patient Being Treated for Severe Pneumocystis jiroveciiPneumonia: Case Report and Literature Review. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.2.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Dong Won Park
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Dae Hyun Lim
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Ji Young Yhi
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Ji-Yong Moon
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Tae-Hyung Kim
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Jang Won Shon
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Ho Joo Yoon
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Dong Ho Shin
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Hyunjoo Pai
- Department of Internal Medicine, College of Medicine, Hanyang University Hospital, Seoul, Korea
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26
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Tasaka S. Pneumocystis Pneumonia in Human Immunodeficiency Virus-infected Adults and Adolescents: Current Concepts and Future Directions. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:19-28. [PMID: 26327786 PMCID: PMC4536784 DOI: 10.4137/ccrpm.s23324] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/06/2015] [Accepted: 07/08/2015] [Indexed: 12/17/2022]
Abstract
Pneumocystis jirovecii pneumonia (PCP) is one of the most common opportunistic infections in human immunodeficiency virus–infected adults. Colonization of Pneumocystis is highly prevalent among the general population and could be associated with the transmission and development of PCP in immunocompromised individuals. Although the microscopic demonstration of the organisms in respiratory specimens is still the golden standard of its diagnosis, polymerase chain reaction has been shown to have a high sensitivity, detecting Pneumocystis DNA in induced sputum or oropharyngeal wash. Serum β-D-glucan is useful as an adjunctive tool for the diagnosis of PCP. High-resolution computed tomography, which typically shows diffuse ground-glass opacities, is informative for the evaluation of immunocompromised patients with suspected PCP and normal chest radiography. Trimethoprim–sulfamethoxazole (TMP-SMX) is the first-line agent for the treatment of mild to severe PCP, although it is often complicated with various side effects. Since TMP-SMX is widely used for the prophylaxis, the putative drug resistance is an emerging concern.
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Affiliation(s)
- Sadatomo Tasaka
- Division of Pulmonary Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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27
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Mongardon N, Geri G, Deye N, Sonneville R, Boissier F, Perbet S, Camous L, Lemiale V, Thirion M, Mathonnet A, Argaud L, Bodson L, Gaudry S, Kimmoun A, Legriel S, Lerolle N, Luis D, Luyt CE, Mayaux J, Guidet B, Pène F, Mira JP, Cariou A. Etiologies, clinical features and outcome of cardiac arrest in HIV-infected patients. Int J Cardiol 2015; 201:302-7. [PMID: 26301665 DOI: 10.1016/j.ijcard.2015.08.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 07/29/2015] [Accepted: 08/01/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Compared to many other cardiovascular diseases, there is a paucity of data on the characteristics of successfully resuscitated cardiac arrest (CA) patients with human immunodeficiency virus (HIV) infection. We investigated causes, clinical features and outcome of these patients, and assessed the specific burden of HIV on outcome. METHODS Retrospective analysis of HIV-infected patients admitted to 20 French ICUs for successfully resuscitated CA (2000-2012). Characteristics and outcome of HIV-infected patients were compared to those of a large cohort of HIV-uninfected patients admitted after CA in the Cochin Hospital ICU during the same period. RESULTS 99 patients were included (median CD4 lymphocyte count 233/mm(3), viral load 43 copies/ml). When compared with the control cohort of 1701 patients, HIV-infected patients were younger, with a predominance of male, a majority of in-hospital CA (52%), and non-shockable initial rhythm (80.8%). CA was mostly related to respiratory cause (n=36, including 23 pneumonia), cardiac cause (n=33, including 16 acute myocardial infarction), neurologic cause (n=8) and toxic cause (n=5). CA was deemed directly related to HIV infection in 18 cases. Seventy-one patients died in the ICU, mostly for care withdrawal after post-anoxic encephalopathy. After propensity score matching, ICU mortality was not significantly affected by HIV infection. Similarly, HIV disease characteristics had no impact on ICU outcome. CONCLUSIONS Etiologies of CA in HIV-infected patients are miscellaneous and mostly not related to HIV infection. Outcome remains bleak but is similar to outcome of HIV-negative patients.
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Affiliation(s)
- Nicolas Mongardon
- Medical Intensive Care Unit, Cochin University Hospital, Groupe Hospitalier Paris Centre, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Guillaume Geri
- Medical Intensive Care Unit, Cochin University Hospital, Groupe Hospitalier Paris Centre, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France; INSERM U970, Sudden Death Expertise Centre, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, France
| | - Nicolas Deye
- Medical Intensive Care Unit, Lariboisière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Romain Sonneville
- Medical Intensive Care Unit, Bichat University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Florence Boissier
- Medical Intensive Care Unit, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, France; Medical Intensive Care Unit, Georges Pompidou European University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Sébastien Perbet
- Intensive Care Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Laurent Camous
- Medical Intensive Care Unit, Bicêtre University Hospital, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Marina Thirion
- Intensive Care Unit, Victor Dupouy Hospital, Argenteuil, France
| | | | - Laurent Argaud
- Intensive Care Unit, Edouard Herriot University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laurent Bodson
- Intensive Care Unit, Ambroise Paré University Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne-Billancourt, France
| | - Stéphane Gaudry
- Medical Intensive Care Unit, Louis Mourier University Hospital, Assistance Publique - Hôpitaux de Paris, Colombes, France
| | - Antoine Kimmoun
- Medical Intensive Care Unit, Nancy-Brabois University Hospital, Nancy, France
| | | | - Nicolas Lerolle
- Medical Intensive Care Unit, Angers University Hospital, Angers, France
| | - David Luis
- Intensive Care Unit, Raymond Poincaré University Hospital, Assistance Publique - Hôpitaux de Paris, Garches, France
| | - Charles-Edouard Luyt
- Medical Intensive Care Unit, Pitié-Salpétrière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Julien Mayaux
- Pulmonary Medicine and Medical Intensive Care Unit, Pitié-Salpétrière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Bertrand Guidet
- Medical Intensive Care Unit, Saint-Antoine University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin University Hospital, Groupe Hospitalier Paris Centre, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin University Hospital, Groupe Hospitalier Paris Centre, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin University Hospital, Groupe Hospitalier Paris Centre, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France; INSERM U970, Sudden Death Expertise Centre, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, France.
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Roux A, Canet E, Valade S, Gangneux-Robert F, Hamane S, Lafabrie A, Maubon D, Debourgogne A, Le Gal S, Dalle F, Leterrier M, Toubas D, Pomares C, Bellanger AP, Bonhomme J, Berry A, Durand-Joly I, Magne D, Pons D, Hennequin C, Maury E, Roux P, Azoulay É. Pneumocystis jirovecii pneumonia in patients with or without AIDS, France. Emerg Infect Dis 2015; 20:1490-7. [PMID: 25148074 PMCID: PMC4178412 DOI: 10.3201/eid2009.131668] [Citation(s) in RCA: 199] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Immunosuppressed patients without AIDS had longer time to treatment and a higher rate of death than did patients with AIDS. Pneumocystis jirovecii pneumonia (PCP) in patients without AIDS is increasingly common. We conducted a prospective cohort study of consecutive patients with proven PCP; of 544 patients, 223 (41%) had AIDS (AIDS patients) and 321 (59%) had other immunosuppressive disorders (non-AIDS patients). Fewer AIDS than non-AIDS patients required intensive care or ventilation, and the rate of hospital deaths—17.4% overall—was significantly lower for AIDS versus non-AIDS patients (4% vs. 27%; p<0.0001). Multivariable analysis showed the odds of hospital death increased with older age, receipt of allogeneic bone marrow transplant, immediate use of oxygen, need for mechanical ventilation, and longer time to treatment; HIV-positive status or receipt of a solid organ transplant decreased odds for death. PCP is more often fatal in non-AIDS patients, but time to diagnosis affects survival and is longer for non-AIDS patients. Clinicians must maintain a high index of suspicion for PCP in immunocompromised patients who do not have AIDS.
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The use of ECMO in HIV/AIDS with Pneumocystis jirovecii Pneumonia: a case report and review of the literature. ASAIO J 2015; 60:606-8. [PMID: 25166733 DOI: 10.1097/mat.0000000000000112] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
There are few reports of extracorporeal membrane oxygenation (ECMO) therapy for respiratory failure because of Pneumocystis jirovecii pneumonia (PJP) in patients with acquired immunodeficiency syndrome (AIDS). None of the cases reported involvement of immune reconstitution inflammatory syndrome (IRIS), a paradoxical clinical worsening after the initiation of antiretroviral therapy (ART) in ART-naïve patients because of an exaggerated systemic inflammation with cell count recovery. We present a patient with newly diagnosed AIDS and PJP pneumonia that progressed to acute respiratory distress syndrome (ARDS) secondary to probable IRIS for which veno-venous ECMO was initiated. He transitioned to conventional ventilator after 57 days of ECMO therapy. However, he did not survive to hospital discharge. Combined with four previously reported cases of ARDS in human immunodeficiency virus patients secondary to PJP treated with ECMO, three of the five patients survived to ECMO decannulation. Extracorporeal membrane oxygenation is considered an accepted modality for adult patients with respiratory and/or cardiac failure refractory to maximal medical therapy. As ECMO becomes increasingly utilized in clinical practice, there is ongoing controversy regarding the appropriate selection of patients. In the past, contraindications to ECMO included immunocompromised states and conditions with known poor prognosis. The cases herein suggest the indications and contraindications warrant further discussion and research.
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Characteristics and outcomes of HIV-1-infected patients with acute respiratory distress syndrome. J Crit Care 2014; 30:60-4. [PMID: 25466320 DOI: 10.1016/j.jcrc.2014.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 10/01/2014] [Accepted: 10/19/2014] [Indexed: 02/01/2023]
Abstract
PURPOSE We determined the prevalence of risk factors for the development of acute respiratory distress syndrome (ARDS), outcomes of critical illness, and the impact of highly active antiretroviral therapy in HIV-1-infected patients. We hypothesized that in an urban county hospital, HIV-1-infected patients with ARDS would have a higher mortality than their HIV-1-uninfected counterparts. MATERIALS AND METHODS Subjects were enrolled between 2006 and 2012. Baseline patient demographics, comorbidities, illness severity, causes of ARDS, and clinical outcomes were obtained. The primary end point was hospital mortality. RESULTS A total of 178 subjects with ARDS were enrolled in the study; 40 (22%) were infected with HIV-1. The median CD4 count was 75 (15.3-198.3), and 25% were on highly active antiretroviral therapy. HIV-1-infected subjects were significantly younger (44 vs 52 years; P < .01) and had higher rates of asthma, chronic obstructive pulmonary disease, pneumonia, history of hospital-acquired infections, and prior sepsis. HIV-1-infected subjects had greater illness severity by Acute Physiology and Chronic Health Evaluation II scores (29 [24-31] vs 24 [22-25]; P < .01). Hospital mortality was not higher among HIV-1-infected subjects compared with HIV-1-uninfected subjects (50.0% vs 38.4%; P = .19). CONCLUSIONS In patients with ARDS, HIV-1 infection was associated with greater illness severity but was not associated with higher mortality in ARDS. Future studies need to be done to evaluate the factors that contribute to high morbidity and mortality in medically vulnerable populations who develop ARDS.
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Sanchez JF, Ghamande SA, Midturi JK, Arroliga AC. Invasive diagnostic strategies in immunosuppressed patients with acute respiratory distress syndrome. Clin Chest Med 2014; 35:697-712. [PMID: 25453419 DOI: 10.1016/j.ccm.2014.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Immunosuppression predisposes the host to development of pulmonary infections, which can lead to respiratory failure and the development of acute respiratory distress syndrome (ARDS). There are multiple mechanisms by which a host can be immunosuppressed and each is associated with specific infectious pathogens. Early invasive diagnostic modalities such as fiber-optic bronchoscopy with bronchoalveolar lavage, transbronchial biopsy, and open lung biopsy are complementary to serologic and noninvasive studies and assist in rapidly establishing an accurate diagnosis, which allows initiation of appropriate therapy and may improve outcomes with relative safety.
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Affiliation(s)
- Juan F Sanchez
- Pulmonary and Critical Care Medicine Division, Baylor Scott and White Healthcare, 2401 South 31st street, Temple, TX 76508, USA
| | - Shekhar A Ghamande
- Pulmonary and Critical Care Medicine Division, Baylor Scott and White Healthcare, 2401 South 31st street, Temple, TX 76508, USA
| | - John K Midturi
- Pulmonary and Critical Care Medicine Division, Baylor Scott and White Healthcare, 2401 South 31st street, Temple, TX 76508, USA
| | - Alejandro C Arroliga
- Pulmonary and Critical Care Medicine Division, Baylor Scott and White Healthcare, 2401 South 31st street, Temple, TX 76508, USA.
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Temporal trends in critical events complicating HIV infection: 1999-2010 multicentre cohort study in France. Intensive Care Med 2014; 40:1906-15. [PMID: 25236542 DOI: 10.1007/s00134-014-3481-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 09/01/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE Multicentre data are limited to appraise the management and prognosis of critically ill human immunodeficiency virus (HIV)-infected patients. We sought to describe temporal trends in demographic and clinical characteristics, indications for intensive care and outcome in this patient population. METHODS We conducted a cohort study of unselected HIV-infected patients admitted between 1999 and 2010 to 34 French ICUs contributing to the CUB-Réa prospective database. RESULTS We included 6,373 consecutive patients. Over the 12-year period, increases occurred in median age (39 years in 1999-2001; 47 years in 2008-2010, p < 0.0001) and prevalence of comorbidities (notably malignancies, from 6.7 to 16.4%, p < 0.0001). Admissions for respiratory failure (39.8% overall), shock (8.1%) and coma (22.7%) decreased (p < 0.0001), while those for sepsis (19.3%) remained stable. The main final diagnoses were bacterial sepsis (24.6%) and non-bacterial acquired immune deficiency syndrome (AIDS)-defining diseases (steady decline from 26.0 to 17.5%, p < 0.0001). Patients increasingly received mechanical ventilation (from 42.9 to 54.0%) and renal replacement therapy (from 9.6 to 16.8%) (p < 0.0001), whereas vasopressor use remained stable (27.4%). ICU readmissions increased after 2004 (p < 0.0001). ICU and hospital mortality (17.6 and 26.9%, respectively) dropped markedly in the most severely ill patients requiring multiple life-sustaining therapies. Malignancies and chronic liver disease were heavily associated with hospital mortality by multivariate analysis, while the most common AIDS-defining complications (Pneumocystis jirovecii pneumonia, cerebral toxoplasmosis and tuberculosis) had no independent impact. CONCLUSIONS Progressive ageing, increasing prevalence of comorbidities (mainly malignancies), a steady decline in AIDS-related illnesses and improved benefits from life-sustaining therapies were the main temporal trends in HIV-infected patients requiring ICU admission.
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Ferrand H, Crockett F, Naccache JM, Rioux C, Mayaud C, Yazdanpanah Y, Cadranel J. [Pulmonary manifestations in HIV-infected patients: a diagnostic approach]. Rev Mal Respir 2014; 31:903-15. [PMID: 25496788 DOI: 10.1016/j.rmr.2014.04.106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 04/25/2014] [Indexed: 01/12/2023]
Abstract
The spectrum of pulmonary diseases that can affect human immunodeficiency virus (HIV)-infected patients is wide and includes both HIV and non-HIV-related conditions. Opportunistic infections and neoplasms remain a major concern even in the current era of combination antiretroviral therapy. Although these diseases have characteristic clinical and radiological features, there can be considerable variation in these depending on the patient's CD4 lymphocyte count. The patient's history, physical examination, CD4 count and chest radiograph features must be considered in establishing an appropriate diagnostic algorithm. In this article, we propose different diagnostic approaches HIV infected to patients with respiratory symptoms depending on their clinico-radiological pattern.
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Affiliation(s)
- H Ferrand
- Service de pneumologie, hôpital Tenon, université P&M Curie, AP-HP, 4, rue de la Chine, 75970 Paris, France; Service de maladies infectieuses et tropicales, hôpital Bichat-Claude-Bernard, université Denis-Diderot, AP-HP, Paris, France
| | - F Crockett
- Service de pneumologie, hôpital Tenon, université P&M Curie, AP-HP, 4, rue de la Chine, 75970 Paris, France
| | - J-M Naccache
- Service de pneumologie, hôpital Tenon, université P&M Curie, AP-HP, 4, rue de la Chine, 75970 Paris, France
| | - C Rioux
- Service de maladies infectieuses et tropicales, hôpital Bichat-Claude-Bernard, université Denis-Diderot, AP-HP, Paris, France
| | - C Mayaud
- Service de pneumologie, hôpital Tenon, université P&M Curie, AP-HP, 4, rue de la Chine, 75970 Paris, France
| | - Y Yazdanpanah
- Service de maladies infectieuses et tropicales, hôpital Bichat-Claude-Bernard, université Denis-Diderot, AP-HP, Paris, France
| | - J Cadranel
- Service de pneumologie, hôpital Tenon, université P&M Curie, AP-HP, 4, rue de la Chine, 75970 Paris, France.
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Medrano J, Álvaro-Meca A, Boyer A, Jiménez-Sousa MA, Resino S. Mortality of patients infected with HIV in the intensive care unit (2005 through 2010): significant role of chronic hepatitis C and severe sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:475. [PMID: 25159592 PMCID: PMC4176576 DOI: 10.1186/s13054-014-0475-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/23/2014] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The combination antiretroviral therapy (cART) has led to decreased opportunistic infections and hospital admissions in human immunodeficiency virus (HIV)-infected patients, but the intensive care unit (ICU) admission rate remains constant (or even increased in some instances) during the cART era. Hepatitis C virus (HCV) infection is associated with an increased risk for hospital admission and/or mortality (particularly those related to severe liver disease) compared with the general population. The aim of this study was to assess the mortality among HIV-infected patients in ICU, and to evaluate the impact of HIV/HCV coinfection and severe sepsis on ICU mortality. METHODS We carried out a retrospective study based on patients admitted to ICU who were recorded in the Minimum Basic Data Set (2005 through 2010) in Spain. HIV-infected patients (All-HIV-group (n = 1,891)) were divided into two groups: HIV-monoinfected patients (HIV group (n = 1,191)) and HIV/HCV-coinfected patients (HIV/HCV group (n = 700)). A control group (HIV(-)/HCV(-)) was also included (n = 7,496). RESULTS All-HIV group had higher frequencies of severe sepsis (57.7% versus 39.4%; P < 0.001) than did the control group. Overall, ICU mortality in patients with severe sepsis was much more frequent than that in patients without severe sepsis (other causes) at days 30 and 90 in HIV-infected patients and the control group (P < 0.001). Moreover, the all-HIV group in the presence or absence of severe sepsis had a higher percentage of death than did the control group at days 7 (P < 0.001), 30 (P < 0.001) and 90 (P < 0.001). Besides, the HIV/HCV group had a higher percentage of death, both in patients with severe sepsis and in patients without severe sepsis compared with the HIV group at days 7 (P < 0.001) and 30 (P < 0.001), whereas no differences were found at day 90. In a bayesian competing-risk model, the HIV/HCV group had a higher mortality risk (adjusted hazard ratio (aHR) = 1.44 (95% CI = 1.30 to 1.59) and aHR = 1.57 (95% CI = 1.38 to 1.78) for patients with and without severe sepsis, respectively). CONCLUSIONS HIV infection was related to a higher frequency of severe sepsis and death among patients admitted to the ICU. Besides, HIV/HCV coinfection contributed to an increased risk of death in both the presence and the absence of severe sepsis.
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Moreira J. The burden of sepsis in critically ill human immunodeficiency virus-infected patients--a brief review. Braz J Infect Dis 2014; 19:77-81. [PMID: 25022567 PMCID: PMC9425204 DOI: 10.1016/j.bjid.2014.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/05/2014] [Accepted: 05/19/2014] [Indexed: 02/02/2023] Open
Abstract
Since the advent of highly active antiretroviral therapy in 1996, we have seen dramatic changes in morbi-mortality rates from human immunodeficiency virus-positive patients. If on the one hand, the immunologic preservation-associated with the use of current antiretroviral therapy markedly diminishes the incidence of opportunistic infections, on the other hand it extended life expectancy of human immunodeficiency virus-infected individuals similarly to the general population. However, the management of critically ill human immunodeficiency virus-infected patients remains challenging and troublesome for practicing clinician. Sepsis - a complex systemic inflammatory syndrome in response to infection - is the second leading cause of intensive care unit admission in both human immunodeficiency virus-infected and uninfected populations. Recent data have emerged describing a substantial burden of sepsis in the infected population, in addition, to a much poorer prognosis in this group. Many factors contribute to this outcome, including specific etiologies, patterns of inflammation, underlying immune dysregulation related to chronic human immunodeficiency virus infection and delays in prompt diagnosis and treatment. This brief review explores the impact of sepsis in the context of human immunodeficiency virus infection, and proposes future directions for better management and prevention of human immunodeficiency virus-associated sepsis.
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Affiliation(s)
- José Moreira
- Instituto Nacional de Infectologia Evandro Chagas, Hospital Evandro Chagas, Rio de Janeiro, RJ, Brazil.
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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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Etiology and Outcome of Patients with HIV Infection and Respiratory Failure Admitted to the Intensive Care Unit. Interdiscip Perspect Infect Dis 2013; 2013:732421. [PMID: 24065988 PMCID: PMC3771454 DOI: 10.1155/2013/732421] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 07/25/2013] [Indexed: 12/15/2022] Open
Abstract
Background. Although access to HAART has prolonged survival and improved quality of life, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support. Our objective is to evaluate the etiology of respiratory failure in patients with HIV infection admitted to the ICU, its relationship with the T-lymphocytes cell count as well as the use of HAART, and its impact on outcome. Methods. A single-center, prospective, and observational study among all patients with HIV-infection and respiratory failure admitted to the ICU from December 1, 2011, to February 28, 2013, was conducted. Results. A total of 42 patients were admitted during the study period. Their median CD4 cell count was 123 cells/ μ L (mean 205.7, range 2.0-694.0), with a median HIV viral load of 203.5 copies/mL (mean 58,676, range <20-367,649). At the time of admission, 23 patients (54.8%) were receiving HAART. Use of antiretroviral therapy at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts and lower HIV viral loads. Twenty-five patients (59.5%) had respiratory failure secondary to non-HIV-related diseases. Mechanical ventilation was required in 36 patients (85.1%). Thirteen patients (31.0%) died. Conclusions. Noninfectious etiologies of respiratory failure account for majority of HIV-infected patients admitted to ICU. Increased mortality was observed among patients with sepsis as etiology of respiratory failure (HIV related and non-AIDS related), in those receiving mechanical ventilation, and in patients with decreased CD4 cell count. Survival was not associated with the use of HAART. Complementary studies are warranted to address the impact of HAART on outcomes of HIV-infected patients with respiratory failure admitted to ICU.
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Medical ICU admission diagnoses and outcomes in human immunodeficiency virus-infected and virus-uninfected veterans in the combination antiretroviral era. Crit Care Med 2013; 41:1458-67. [PMID: 23507717 DOI: 10.1097/ccm.0b013e31827caa46] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Human immunodeficiency virus (HIV)-infected (HIV+) patients on combination antiretroviral therapy are living longer but have increased risk for aging-associated disease which may lead to increasing critical care requirements. We compare medical ICU admission characteristics and outcomes among HIV infected and demographically similar uninfected patients (uninfected) and considered whether an index which combines routine clinical biomarkers (the Veterans Aging Cohort Study Index) predicts 30-day medical ICU mortality. DESIGN Observational data analyses (Veterans Aging Cohort Study). SETTING Eight Veterans Affairs medical centers nationwide. PATIENTS HIV infected and uninfected with a medical ICU admission between 2002 and 2010. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Medical ICU admission was determined using bedsection (Veterans Affairs) and revenue center codes (Medicare). For Veterans Affairs admissions, we used clinical data to calculate Veterans Aging Cohort Study Index scores and multivariable logistic regression to determine factors associated with 30-day mortality. Overall, 539 of 3,620 (15%) HIV infected and 375 of 3,639 (10%) uninfected had a medical ICU admission; 72% and 78%, respectively, were Veterans Affairs based. HIV+ patients were younger at admission (p < 0.0001). Although most HIV+ patients were on antiretroviral therapy (71%) with undetectable HIV-1 RNA (54%), compared with uninfected they were more commonly admitted with respiratory diagnoses or infections (21% vs. 12%), were more likely to require mechanical ventilation (17% vs. 9%; p = 0.001), and had a higher mortality rate (18.6% vs. 11.2%, p = 0.003). Cardiovascular diagnoses were less common among HIV infected (18% vs. 29%; p < 0.0001). In logistic regression (c-statistic 0.87), a 5-point increment in Veterans Aging Cohort Study Index was associated with an odds ratio of death of 1.22 (95% confidence interval 1.14-1.30) among HIV infected and of 1.50 (95% confidence interval 1.29-1.76) among uninfected; infection/sepsis and respiratory diagnoses were also associated with mortality. CONCLUSIONS Medical ICU admission was frequent, 30-day mortality higher, and mechanical ventilation more common in HIV infected compared with uninfected. The Veterans Aging Cohort Study Index calculated at medical ICU admission predicted 30-day mortality for HIV infected and uninfected. As more individuals age with HIV, their requirements for medical ICU care may be greater than demographically similar uninfected individuals.
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Sarkar P, Rasheed HF. Clinical review: Respiratory failure in HIV-infected patients--a changing picture. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:228. [PMID: 23806117 PMCID: PMC3706935 DOI: 10.1186/cc12552] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Respiratory failure in HIV-infected patients is a relatively common presentation to ICU. The debate on ICU treatment of HIV-infected patients goes on despite an overall decline in mortality amongst these patients since the AIDS epidemic. Many intensive care physicians feel that ICU treatment of critically ill HIV patients is likely to be futile. This is mainly due to the unfavourable outcome of HIV patients with Pneumocystis jirovecii pneumonia who need mechanical ventilation. However, the changing spectrum of respiratory illness in HIV-infected patients and improved outcome from critical illness remain under-recognised. Also, the awareness of certain factors that can affect their outcome remains low. As there are important ethical and practical implications for intensive care clinicians while making decisions to provide ICU support to HIV-infected patients, a review of literature was undertaken. It is notable that the respiratory illnesses that are not directly related to underlying HIV disease are now commonly encountered in the highly active antiretroviral therapy (HAART) era. The overall incidence of P. jirovecii as a cause of respiratory failure has declined since the AIDS epidemic and sepsis including bacterial pneumonia has emerged as a frequent cause of hospital and ICU admission amongst HIV patients. The improved overall outcome of HIV patients needing ICU admission is related to advancement in general ICU care, including adoption of improved ventilation strategies. An awareness of respiratory illnesses in HIV-infected patients along with an appropriate diagnostic and treatment strategy may obviate the need for invasive ventilation and improve outcome further. HIV-infected patients presenting with respiratory failure will benefit from early admission to critical care for treatment and support. There is evidence to suggest that continuing or starting HAART in critically ill HIV patients is beneficial and hence should be considered after multidisciplinary discussion. As a very high percentage (up to 40%) of HIV patients are not known to be HIV infected at the time of ICU admission, the clinicians should keep a low threshold for requesting HIV testing for patients with recurrent pneumonia.
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Extracorporeal Membrane Oxygenation as Adjunctive Therapy for Refractory Hypoxemic Respiratory Failure in HIV-positive Patients With Severe Pneumocystis jirovecii Pneumonia. ACTA ACUST UNITED AC 2013. [DOI: 10.1097/cpm.0b013e31828fc487] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Ganesan A, Masur H. Critical care of persons infected with the human immunodeficiency virus. Clin Chest Med 2013; 34:307-23. [PMID: 23702179 DOI: 10.1016/j.ccm.2013.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Antiretroviral therapy (ART) has transformed the prognosis for patients infected with the human immunodeficiency virus (HIV). With effective ART, these individuals can expect to live almost as long as their HIV-negative counterparts. Given that more than a million people infected with HIV currently live in the United States, the likelihood that the practicing intensivist will manage a patient infected with HIV is high. This review discusses the challenges associated with management of critically ill patients infected with HIV, including the immune reconstitution inflammatory syndrome (a complication associated with ART initiation), ART-related toxicities, and the management of some common opportunistic infections.
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Affiliation(s)
- Anuradha Ganesan
- Department of Medicine, Division of Infectious Diseases, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA.
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Abstract
Antiretroviral therapy has improved longevity for HIV-infected persons, but long-term HIV infection is now complicated by increased rates of chronic medical conditions including pulmonary disorders. Chronic obstructive pulmonary disease, lung cancer, asthma, and pulmonary hypertension are becoming common comorbidities of HIV infection, and these diseases may develop as a result of HIV-related risk factors, such as antiretroviral drug toxicities, colonization by infectious organisms, HIV viremia, immune activation, or immune dysfunction. It also appears that the ability to control HIV infection does not completely eliminate the risk for infectious complications, such as bacterial pneumonia and tuberculosis. The effect of HIV infection on lung-specific immune responses is being elucidated to help develop better prevention and treatment strategies in HIV-infected persons.
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Affiliation(s)
- Matthew R. Gingo
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison Morris
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Risk factors for hospitalization and medical intensive care unit (MICU) admission among HIV-infected Veterans. J Acquir Immune Defic Syndr 2013; 62:52-9. [PMID: 23111572 DOI: 10.1097/qai.0b013e318278f3fa] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE With improved survival of HIV-infected persons on antiretroviral therapy and growing prevalence of non-AIDS diseases, we asked whether the VACS Index, a composite measure of HIV-associated and general organ dysfunction predictive of all-cause mortality, predicts hospitalization and medical intensive care unit (MICU) admission. We also asked whether AIDS and non-AIDS conditions increased risk after accounting for VACS Index score. METHODS We analyzed data from the Veterans Aging Cohort Study (VACS), a prospective study of HIV-infected Veterans receiving care between 2002 and 2008. Data were obtained from the electronic medical record, VA administrative databases, and patient questionnaires and were used to identify comorbidities and calculate baseline VACS Index scores. The primary outcome was first hospitalization within 2 years of VACS enrollment. We used multivariable Cox regression to determine risk factors associated with hospitalization and logistic regression to determine risk factors for MICU admission, given hospitalization. RESULTS Of 3410 patients, 1141 were hospitalized within 2 years; 203 (17.8%)/1141 patients included an MICU admission. Median VACS Index scores were 25 (no hospitalization), 34 (hospitalization only), and 51 (MICU). In adjusted analyses, a 5-point increment in VACS Index score was associated with 10% higher risk of hospitalization and MICU admission. In addition to VACS Index score, Hispanic ethnicity, current smoking, hazardous alcohol use, chronic obstructive pulmonary disease, hypertension, diabetes, and prior AIDS-defining event predicted hospitalization. Among those hospitalized, VACS Index score, cardiac disease, and prior cancer predicted MICU admission. CONCLUSIONS The VACS Index predicted hospitalization and MICU admission as did current smoking, hazardous alcohol use, and AIDS and certain non-AIDS diagnoses.
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Godet C, Beraud G, Cadranel J. [Bacterial pneumonia in HIV-infected patients (excluding mycobacterial infection)]. Rev Mal Respir 2012; 29:1058-66. [PMID: 23101646 DOI: 10.1016/j.rmr.2012.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 11/19/2011] [Indexed: 11/17/2022]
Abstract
Respiratory infections are the most common complications in HIV patients, regardless of the degree of immunosuppression. Even though antiretroviral therapy has a protective effect on the risk of bacterial pneumonia, this still remains high (including those with CD(4)>500/mm(3)). The most frequently isolated bacteria are Streptococcus pneumoniae and Haemophilus influenzae. The clinical and radiological presentations of lower respiratory tract infections in HIV patients are quite variable. The clinical presentation is more severe and the radiological presentation is more atypical if the immunosuppression is severe. The first-line antibiotic therapy is an injectable third-generation cephalosporin (ceftriaxone or cefotaxime) or co-amoxiclav. Pneumococcal vaccination (as well as influenza vaccine) is recommended. Although rare, Nocardia spp. and Rhodococcus equi seem more common among AIDS patients.
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Affiliation(s)
- C Godet
- Service de maladies infectieuses et de médecine interne, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers cedex, France.
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[Salmonella enteritidis bacteraemia as clinical onset of acquired immune deficiency syndrome]. ACTA ACUST UNITED AC 2012; 60:103-5. [PMID: 22657351 DOI: 10.1016/j.redar.2012.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 04/04/2012] [Indexed: 11/20/2022]
Abstract
The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48 hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient.
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Critical illness in HIV-infected patients in the era of combination antiretroviral therapy. Ann Am Thorac Soc 2011; 8:301-7. [PMID: 21653532 DOI: 10.1513/pats.201009-060wr] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
As HIV-infected persons on combination antiretroviral therapy (ART) are living longer and rates of opportunistic infections have declined, serious non-AIDS-related diseases account for an increasing proportion of deaths. Consistent with these changes, non-AIDS-related illnesses account for the majority of ICU admissions in more recent studies, in contrast to earlier eras of the AIDS epidemic. Although mortality after ICU admission has improved significantly since the earliest HIV era, it remains substantial. In this article, we discuss the current state of knowledge regarding the impact of ART on incidence, etiology, and outcomes of critical illness among HIV-infected patients. In addition, we consider issues related to administration of ART in the ICU and identify important areas of future research.
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Chiang HH, Hung CC, Lee CM, Chen HY, Chen MY, Sheng WH, Hsieh SM, Sun HY, Ho CC, Yu CJ. Admissions to intensive care unit of HIV-infected patients in the era of highly active antiretroviral therapy: etiology and prognostic factors. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R202. [PMID: 21871086 PMCID: PMC3387644 DOI: 10.1186/cc10419] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 07/21/2011] [Accepted: 08/26/2011] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Although access to highly active antiretroviral therapy (HAART) has prolonged survival and improved life quality, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support in intensive care units (ICU). This study aimed to describe the etiology and analyze the prognostic factors of HIV-infected Taiwanese patients in the HAART era. METHODS Medical records of all HIV-infected adults who were admitted to ICU at a university hospital in Taiwan from 2001 to 2010 were reviewed to record information on patient demographics, receipt of HAART, and reason for ICU admission. Factors associated with hospital mortality were analyzed. RESULTS During the 10-year study period, there were 145 ICU admissions for 135 patients, with respiratory failure being the most common cause (44.4%), followed by sepsis (33.3%) and neurological disease (11.9%). Receipt of HAART was not associated with survival. However, CD4 count was independently predictive of hospital mortality (adjusted odds ratio [AOR], per-10 cells/mm3 decrease, 1.036; 95% confidence interval [CI], 1.003 to 1.069). Admission diagnosis of sepsis was independently associated with hospital mortality (AOR, 2.91; 95% CI, 1.11 to 7.62). A hospital-to-ICU interval of more than 24 hours and serum albumin level (per 1-g/dl decrease) were associated with increased hospital mortality, but did not reach statistical significance in multivariable analysis. CONCLUSIONS Respiratory failure was the leading cause of ICU admissions among HIV-infected patients in Taiwan. Outcome during the ICU stay was associated with CD4 count and the diagnosis of sepsis, but was not associated with HAART in this study.
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Affiliation(s)
- Hou-Hsien Chiang
- Department of Internal Medicine, Far East Memorial Hospital, Nanya South Road, New Taipei City 220, Taiwan
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Mortality predictors of Pneumocystis jirovecii pneumonia in human immunodeficiency virus-infected patients at presentation: Experience in a tertiary care hospital of northern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 44:274-81. [DOI: 10.1016/j.jmii.2010.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Revised: 06/25/2010] [Accepted: 08/12/2010] [Indexed: 12/21/2022]
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Palliative noninvasive ventilation in patients with acute respiratory failure. Intensive Care Med 2011; 37:1250-7. [DOI: 10.1007/s00134-011-2263-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 04/16/2011] [Indexed: 11/26/2022]
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