Bacterial Community Acquired Pneumonia in HIV-Infected Inpatients in the Highly Active Antiretroviral Therapy Era

Chest CT Findings in Patients with HIV Presenting to the Emergency Department: A Single Institute Experience

PURPOSE

The aim of this study was to analyze chest CT imaging findings and relevant clinical factors in patients with HIV presenting to the emergency department (ED).

MATERIALS AND METHODS

A retrospective review was performed to identify patients with HIV who received chest CT imaging evaluation in the acute ED setting. Analyzed patients included adults with a known diagnosis of HIV who presented to the ED at a single tertiary care center between 2004 and 2020 and received chest CT imaging. Chest CT findings were assessed by 2 radiologist readers, and relevant clinical data were gathered. Statistical analysis was performed to determine if imaging and clinical factors demonstrate significant associations with CD4 count, viral load, and antiretroviral therapy status.

RESULTS

A total of 113 patients with HIV were identified who presented to the ED and underwent chest CT imaging evaluation (mean age 47 ± 11 years). Frequently detected chest CT findings included infectious pneumonia (24%), malignancy (11%), pleural effusion (17%), pericardial effusion (13%), and pulmonary embolism (4%). CD4 count, viral load, and active retroviral therapy demonstrated statistically significant associations with a number of key imaging and clinical factors, including presence of pneumonia, malignancy, average length of hospital admission, and survival.

CONCLUSION

Patients with HIV present with a wide range of imaging findings when presenting in the acute ED setting. CD4 count, viral load, and active retroviral therapy status demonstrate statistically significant associations with multiple key imaging findings and clinical factors. Chest CT plays an integral role in the clinical management of this unique patient population.

Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy

Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).

Decreasing incidence and determinants of Bacterial Pneumonia in people with HIV: The Swiss HIV Cohort Study

BACKGROUND

Bacterial pneumonia is one of the leading reasons for hospitalization among people with HIV (PWH), yet there is limited evidence regarding its drivers in the era of potent antiretroviral therapy.

METHODS

We assessed risk-factors for bacterial pneumonia in PWH enrolled in the Swiss HIV Cohort Study using univariable and multivariable marginal models. We further assessed the relationship between risk-factors and changes in bacterial pneumonia incidence using mediation analysis.

RESULTS

We included 12927 PWH with follow-ups between 2008 and 2018. These patients had 985 bacterial pneumonia events during a follow-up of 100779 person-years(py). bacterial pneumonia incidence significantly decreased from 13.2 cases/1000 py in 2008 to 6.8 cases/1000 py in 2018. Older age, lower education-level, intravenous drug use, smoking, lower CD4-cell-count, higher HIV-viral load, and prior pneumonia events were significantly associated with higher bacterial pneumonia incidence. Notably, even CD4-cell-counts 350-499 were significantly associated with an increased risk compared to CD4≥500 (adjusted HR,1.39; 95% CI,1.01-1.89). Finally, we found that the decreasing incidence over the last decade can be explained by decreasing proportion of patients with CD4<500, viral-RNA>200, and smoking>one cigarette/day.

CONCLUSION

Improvements in cascade of care of HIV and decrease in smoking may have mediated a substantial decrease in bacterial pneumonia incidence.

Burden of pneumococcal disease among adults in Southern Europe (Spain, Portugal, Italy, and Greece): a systematic review and meta-analysis

The aim was to summarize pneumococcal disease burden data among adults in Southern Europe and the potential impact of vaccines on epidemiology. Of 4779 identified studies, 272 were selected. Invasive pneumococcal disease (IPD) incidence was 15.08 (95% CI 11.01-20.65) in Spain versus 2.56 (95% CI 1.54-4.24) per 100,000 population in Italy. Pneumococcal pneumonia incidence was 19.59 (95% CI 10.74-35.74) in Spain versus 2.19 (95% CI 1.36-3.54) per 100,000 population in Italy. Analysis of IPD incidence in Spain comparing pre-and post- PCV7 and PCV13 periods unveiled a declining trend in vaccine-type IPD incidence (larger and statistically significant for the elderly), suggesting indirect effects of childhood vaccination programme. Data from Portugal, Greece and, to a lesser extent, Italy were sparse, thus improved surveillance is needed. Pneumococcal vaccination uptake, particularly among the elderly and adults with chronic and immunosuppressing conditions, should be improved, including shift to a higher-valency pneumococcal conjugate vaccine when available.

Prevalence and Etiology of Community-acquired Pneumonia in Immunocompromised Patients

Background

The correct management of immunocompromised patients with pneumonia is debated. We evaluated the prevalence, risk factors, and characteristics of immunocompromised patients coming from the community with pneumonia.

Methods

We conducted a secondary analysis of an international, multicenter study enrolling adult patients coming from the community with pneumonia and hospitalized in 222 hospitals in 54 countries worldwide. Risk factors for immunocompromise included AIDS, aplastic anemia, asplenia, hematological cancer, chemotherapy, neutropenia, biological drug use, lung transplantation, chronic steroid use, and solid tumor.

Results

At least 1 risk factor for immunocompromise was recorded in 18% of the 3702 patients enrolled. The prevalences of risk factors significantly differed across continents and countries, with chronic steroid use (45%), hematological cancer (25%), and chemotherapy (22%) the most common. Among immunocompromised patients, community-acquired pneumonia (CAP) pathogens were the most frequently identified, and prevalences did not differ from those in immunocompetent patients. Risk factors for immunocompromise were independently associated with neither Pseudomonas aeruginosa nor non–community-acquired bacteria. Specific risk factors were independently associated with fungal infections (odds ratio for AIDS and hematological cancer, 15.10 and 4.65, respectively; both P = .001), mycobacterial infections (AIDS; P = .006), and viral infections other than influenza (hematological cancer, 5.49; P < .001).

Conclusions

Our findings could be considered by clinicians in prescribing empiric antibiotic therapy for CAP in immunocompromised patients. Patients with AIDS and hematological cancer admitted with CAP may have higher prevalences of fungi, mycobacteria, and noninfluenza viruses.

Treating bacterial pneumonia in people living with HIV

Introduction: Bacterial pneumonia remains an important cause of morbidity and mortality in people living with HIV (PLWH) in the antiretroviral therapy (ART) era. In addition to being immunocompromised, as reflected by low CD4 cell counts and elevated HIV viral loads, PLWH often have other behaviors associated with an increased risk of pneumonia including smoking and injected drug use. As PLWH are aging, comorbid conditions such as chronic obstructive pulmonary disease (COPD), cancers, and cardiovascular, renal and liver diseases are emerging as additional risk factors for pneumonia. Pathogens are often similar to those in HIV-uninfected individuals; however, PLWH are at risk for unusual and/or multi-drug resistant organisms causing bacterial pneumonia based, in part, on their CD4 cell counts and other exposures. Areas covered: In this review, we focus on the recognition and management of bacterial community-acquired pneumonia (CAP) in PLWH. Along with antimicrobial treatment, we discuss prevention strategies such as vaccination and smoking cessation. Expert opinion: Early initiation of ART after HIV infection can decrease the risk of pneumonia. Improved efforts at vaccination, smoking cessation, and reduction of other substance use are urgently needed in PLWH to decrease the risk for bacterial pneumonia. As PLWH are aging, comorbidities are additional risk factors for bacterial CAP.

Community-acquired bacterial pneumonia in adult HIV-infected patients

INTRODUCTION

Despite active antiretroviral therapy (ART), community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients and incurs high health costs. Areas covered: This article reviews the most recent publications on bacterial CAP in the HIV-infected population, focusing on epidemiology, prognostic factors, microbial etiology, therapy, and prevention. The data discussed here were mainly obtained from a non-systematic review using Medline, and references from relevant articles. Expert commentary: HIV-infected patients are more susceptible to bacterial CAP. Although ART improves their immune response and has reduced CAP incidence, these patients continue to present increased risk of pneumonia in part because they show altered immunity and because immune activation persists. The risk of CAP in HIV-infected patients and the probability of polymicrobial or atypical infections are inversely associated with the CD4 cell count. Mortality in HIV-infected patients with CAP ranges from 6% to 15% but in well-controlled HIV-infected patients on ART the mortality is low and similar to that seen in HIV-negative individuals. Vaccination and smoking cessation are the two most important preventive strategies for bacterial CAP in well-controlled HIV-infected patients on ART.

Newly diagnosed AIDS with neurosyphilis, Kaposi sarcoma, pancytopenia, oropharyngeal candidiasis, and pseudomonal pneumonia: We shouldn't be seeing this anymore

The incidence of new human immunodeficiency virus (HIV) infections is declining and is half of what it was in the mid 1990s. We present a case of newly diagnosed HIV with acquired immune deficiency syndrome (AIDS), Neurosyphilis, Kaposi Sarcoma, and multiple opportunistic infections. Although this type of patient was not uncommon in the pre-antiretroviral era, we do not often see such a constellation of conditions in a single individual. The significance of this case lies not in the diagnosis, but rather in the number of the diagnoses and the thought process used to attain them.

Determinants of hospitalizations for pneumonia among Finnish drug users

Objective

The study examined the determinants of being hospitalized for pneumonia in a large cohort of drug users.

Methods

Information of 4817 clients seeking treatment for illicit drug use was linked with the Finnish hospital discharge register to identify those who were hospitalized with main/primary diagnoses of pneumonia during 1997-2013. Cox regression models were used to examine the association between age, gender, homelessness, and route of drug administration of the primary drug at initial clinical consultation and pneumonia hospitalization. Findings were presented as adjusted hazard ratios and 95% confidence intervals.

Results

There were 354 persons diagnosed with pneumonia, with a total of 522 hospitalizations at the end of 2013. The univariate Cox models revealed that being over 44 years of age, male gender, homelessness, and intravenous drug use at initial clinical consultation increased the risk of being hospitalized for pneumonia. In the fully adjusted multivariate model, being over 44 years was the strongest factor independently associated with pneumonia hospitalization (adjusted hazard ratio: 2.67, 95% confidence interval: 1.56-4.57, p < 0.001), followed by homelessness (adjusted hazard ratio: 1.75, 95% confidence interval: 1.38-2.22, p < 0.001) and intravenous drug use (adjusted hazard ratio: 1.27, 95% confidence interval: 1.01-1.59, p = 0.041). Of the 354 clients hospitalized for pneumonia, 31.9% (n = 113) were rehospitalized within 30 days of being discharged. One-third of the reasons for the 30-day rehospitalization were pneumonia-related.

Conclusion

Vaccination, measures addressing housing instability, safe injecting and good hygienic practices, and treating underlying drug use problems could help to reduce morbidity for pneumonia in this cohort.

Bacterial pneumonia in patients with liver cirrhosis, with or without HIV co-infection: a possible definition of antibiotic prophylaxis associated pneumonia (APAP)

Introducion: Bacterial infections frequently complicate liver cirrhosis. The aim of this study was to identify risk factors and clinical impact of bacterial pneumonia in patients with cirrhosis.

MATERIALS AND METHODS

Bacterial infection prevalence study: consecutive patients with cirrhosis were enroled over a six-month period in 13 Italian centres. Pneumonia and other infections were diagnosed by standard methods. Pneumonia study: cirrhotic patients with pneumonia were enroled for an additional six-month period and HIV-positive patients were included.

RESULTS

Pneumonia was the fourth most frequent infection. In the two parts of the study, 79 cases of pneumonia were recorded and 441 patients with cirrhosis without infections served as controls. Seventy-eight patients had extra-pulmonary infections. There were no clinical differences between HIV-negative and -positive cases with pneumonia. Previous gastro-intestinal bleeding (p = .02) and long-term prophylactic antibiotic use (p < .0001) were associated with pneumonia. Hospital stay was longer and renal failure more frequent than in patients without infections. Pneumonia was hospital acquired (HAP) in 6 cases, healthcare associated (HCAP) in 24 and community acquired (CAP) in 28. A new category of antibiotic prophylaxis associated pneumonia (APAP) was proposed for 21 cases. Cultures were positive in 21/79 patients (26.6%) with Gram-positive isolates in 57%. Unfavourable outcomes were recorded in 11.4% of the cases (3.6% of CAP, 33% of HAP, 12.5% of HCAP and 14.3% of APAP).

CONCLUSIONS

Receiving antibiotic prophylaxis was associated with pneumonia and the study identified a new sub-group of patients, who require broad spectrum initial antibiotic therapy.

Community-Acquired Pneumococcal Pneumonia in Virologically Suppressed HIV-Infected Adult Patients: A Matched Case-Control Study

BACKGROUND

The study aimed to investigate whether the clinical presentations and outcomes (length of stay, ICU admission, and 30-day mortality) of pneumococcal pneumonia in virologically suppressed patients who were HIV-infected on ART with a CD4+ T-cell count > 350 cells/mm³ are comparable to those seen in patients with HIV, using a case-control design.

METHODS

A case-control study was carried out in Hospital Clinic, Barcelona, Spain (2001-2016). Control patients were matched by age (±10 years), sex, comorbidities, and pneumonia diagnosis in the same calendar period. Clinical presentation and outcomes of pneumococcal pneumonia in patients who were and were not infected with HIV were compared.

RESULTS

Pneumococcal pneumonia was studied in 50 cases (HIV infection) and 100 control patients (non-HIV infection). Compared with the control patients, case patients had higher rates of influenza (14% vs 2%, P = .007) and pneumococcal vaccination (10% vs 1%, P = .016). The group of cases also presented a higher rate of coinfection with hepatitis B virus (6% vs 0%, P = .036). Both groups presented similar ICU admission (18% vs 27%, P = .22), need for mechanical ventilation (12% vs 8%; P = .43), length of stay (7 days vs 7 days, P = .76), and 0% of 30-day mortality. No evidence was found of a more severe presentation or a worse clinical outcome in cases than in control patients.

CONCLUSIONS

Pneumococcal pneumonia episodes requiring hospitalization in virologically suppressed patients with HIV with > 350 CD4+ T-cell count/mm³ were neither more severe nor had worse prognosis compared with uninfected patients. These results support the fact that such patients do not need treatment, admission, or care sites different to the general population.

TRIAL REGISTRY

ClinicalTrials.gov; No. 2009/5451; URL: www.clinicaltrials.gov.

HIV-related pneumococcal disease prevention in adults

INTRODUCTION

HIV-infected persons are particularly susceptible to the development of severe pneumococcal disease, even in the setting of combination antiretroviral therapy (cART), due to slow, incomplete recovery of anti-pneumococcal host defenses. This risk is increased by avoidable aspects of lifestyle, particularly smoking, which intensify immunosuppression. Clearly, more effective preventive measures are needed to counter this threat. Areas covered: This is a detailed review of the published literature focusing on currently available strategies for prevention of pneumococcal infection in HIV-infected patients, including cotrimoxazole prophylaxis, cART, pneumococcal vaccination, and smoking cessation strategies. This is preceded by a consideration of the epidemiology, clinical presentation, risk factors, and outcome of pneumococcal disease. Expert commentary: Cotrimoxazole prophylaxis has been shown to reduce morbidity and mortality in HIV-infected patients, although there is inconsistent data on the preventive efficacy against pneumococcal infections. Some recent studies have documented unchanged incidences of IPD in adult patients in the cART era. With regard to pneumococcal vaccination, routine acceptance of the efficacy of the PCV13/PPV23 sequential administration prime-boost strategy awaits the outcome of clinical trials in those with HIV infection. Smoking cessation, and discontinuation of excessive alcohol consumption and intravenous drug abuse, are priority strategies to prevent severe pneumococcal infection.

Association between Highly Active Antiretroviral Therapy and Type of Infectious Respiratory Disease and All-Cause In-Hospital Mortality in Patients with HIV/AIDS: A Case Series

BACKGROUND

Respiratory manifestations of HIV disease differ globally due to differences in current availability of effective highly active antiretroviral therapy (HAART) programs and epidemiology of infectious diseases.

OBJECTIVE

To describe the association between HAART and discharge diagnosis and all-cause in-hospital mortality among hospitalized patients with infectious respiratory disease and HIV/AIDS.

MATERIAL AND METHODS

We retrospectively reviewed the records of patients hospitalized at a specialty hospital for respiratory diseases in Mexico City between January 1st, 2010 and December 31st, 2011. We included patients whose discharge diagnosis included HIV or AIDS and at least one infectious respiratory diagnosis. The information source was the clinical chart. We analyzed the association between HAART for 180 days or more and type of respiratory disease using polytomous logistic regression and all-cause hospital mortality by multiple logistic regressions.

RESULTS

We studied 308 patients, of whom 206 (66.9%) had been diagnosed with HIV infection before admission to the hospital. The CD4+ lymphocyte median count was 68 cells/mm3 [interquartile range (IQR): 30-150]. Seventy-five (24.4%) cases had received HAART for more than 180 days. Pneumocystis jirovecii pneumonia (PJP) (n = 142), tuberculosis (n = 63), and bacterial community-acquired pneumonia (n = 60) were the most frequent discharge diagnoses. Receiving HAART for more than 180 days was associated with a lower probability of PJP [Adjusted odd ratio (aOR): 0.245, 95% Confidence Interval (CI): 0.08-0.8, p = 0.02], adjusted for sociodemographic and clinical covariates. HAART was independently associated with reduced odds (aOR 0.214, 95% CI 0.06-0.75) of all-cause in-hospital mortality, adjusting for HIV diagnosis previous to hospitalization, age, access to social security, low socioeconomic level, CD4 cell count, viral load, and discharge diagnoses.

CONCLUSIONS

HAART for 180 days or more was associated with 79% decrease in all-cause in-hospital mortality and lower frequency of PJP as discharge diagnosis. The prevalence of poorly controlled HIV was high, regardless of whether HIV was diagnosed before or during admission. HIV diagnosis and treatment resources should be improved, and strengthening of HAART program needs to be promoted.

Impact of HIV infection and smoking on lung immunity and related disorders

HIV-infected persons not only have higher rates of smoking than the general population, but are also unusually vulnerable to the associated adverse health effects, both infective and noninfective in origin. Indeed, in the setting of well-organised care and availability of highly active antiretroviral therapy, HIV-infected smokers lose more life-years to smoking than to HIV infection per se, presenting a major challenge to healthcare providers. Not surprisingly, the respiratory system is particularly susceptible to the damaging interactive chronic inflammatory and immunosuppressive effects of HIV and smoking, intensifying the risk of the development of opportunistic infections, as well as lung cancer and obstructive lung disorders. The impact of smoking on the immunopathogenesis and frequencies of these respiratory conditions in the setting of HIV infection, as well as on the efficacy of antiretroviral therapy, represent the primary focus of this review.

Comparing clinical outcomes in HIV-infected and uninfected older men hospitalized with community-acquired pneumonia

OBJECTIVES

Outcomes of community-acquired pneumonia (CAP) among HIV-infected older adults are unclear.

METHODS

Associations between HIV infection and three CAP outcomes (30-day mortality, readmission within 30 days post-discharge, and hospital length of stay [LOS]) were examined in the Veterans Aging Cohort Study (VACS) of male Veterans, age ≥ 50 years, hospitalized for CAP from 10/1/2002 through 08/31/2010. Associations between the VACS Index and CAP outcomes were assessed in multivariable models.

RESULTS

Among 117 557 Veterans (36 922 HIV-infected and 80 635 uninfected), 1203 met our eligibility criteria. The 30-day mortality rate was 5.3%, the mean LOS was 7.3 days, and 13.2% were readmitted within 30 days of discharge. In unadjusted analyses, there were no significant differences between HIV-infected and uninfected participants regarding the three CAP outcomes (P > 0.2). A higher VACS Index was associated with increased 30-day mortality, readmission, and LOS in both HIV-infected and uninfected groups. Generic organ system components of the VACS Index were associated with adverse CAP outcomes; HIV-specific components were not. Among HIV-infected participants, those not on antiretroviral therapy (ART) had a higher 30-day mortality (HR 2.94 [95% CI 1.51, 5.72]; P = 0.002) and a longer LOS (slope 2.69 days [95% CI 0.65, 4.73]; P = 0.008), after accounting for VACS Index. Readmission was not associated with ART use (OR 1.12 [95% CI 0.62, 2.00] P = 0.714).

CONCLUSION

Among HIV-infected and uninfected older adults hospitalized for CAP, organ system components of the VACS Index were associated with adverse CAP outcomes. Among HIV-infected individuals, ART was associated with decreased 30-day mortality and LOS.

The aetiology and antibiotic management of community-acquired pneumonia in adults in Europe: a literature review

The purpose of this paper was to generate up-to-date information on the aetiology of community-acquired pneumonia (CAP) and its antibiotic management in adults across Europe. Structured searches of PubMed identified information on the aetiology of CAP and its antibiotic management in individuals aged >15 years across Europe. We summarise the data from 33 studies published between January 2005 and July 2012 that reported on the pathogens identified in patients with CAP and antibiotic treatment in patients with CAP. Streptococcus pneumoniae was the most commonly isolated pathogen in patients with CAP and was identified in 12.0–85.0 % of patients. Other frequently identified pathogens found to cause CAP were Haemophilus influenzae, Gram-negative enteric bacilli, respiratory viruses and Mycoplasma pneumoniae. We found several age-related trends: S. pneumoniae, H. influenzae and respiratory viruses were more frequent in elderly patients aged ≥65 years, whereas M. pneumoniae was more frequent in those aged <65 years. Antibiotic monotherapy was more frequent than combination therapy, and beta-lactams were the most commonly prescribed antibiotics. Hospitalised patients were more likely than outpatients to receive combination antibiotic therapy. Limited data on antibiotic resistance were available in the studies. Penicillin resistance of S. pneumoniae was reported in 8.4–20.7 % of isolates and erythromycin resistance was reported in 14.7–17.1 % of isolates. Understanding the aetiology of CAP and the changing pattern of antibiotic resistance in Europe, together with an increased awareness of the risk factors for CAP, will help clinicians to identify those patients most at risk of developing CAP and provide guidance on the most appropriate treatment.

Alcohol and HIV: Experimental and Clinical Evidence of Combined Impact on the Lung

Despite antiretroviral therapy, lung disease is a leading cause of death in individuals infected with human immunodeficiency virus type 1 (HIV). Individuals infected with HIV are susceptible to serious bacterial and viral infections, such as pneumococcus and influenza, which are particularly problematic for lung health, resulting in lung injury. Additionally, HIV-infected individuals are susceptible to a number of pulmonary diseases for unknown reasons. Alcohol, the most commonly abused drug in the world, continues to exact an enormous toll on morbidity and mortality in individuals living with HIV. Chronic alcohol abuse has been shown to affect lung immunity, resulting in significant lung injury. There is a paucity of literature on the additive effects of HIV and alcohol, two diseases of immune senescence, in the lung. This chapter begins by discussing the latest literature evaluating the epidemiology of HIV, alcohol use, and lung health focusing on two prevalent infections, tuberculosis and pneumococcal pneumonia. In parallel, we discuss the interactions of alcohol and HIV on the risk for acute lung injury and subsequent morbidity and mortality. We then discuss the pathophysiology of how these two diseases of immune dysfunction affect the lung, with a focus on the oxidative stress, alveolar macrophage host immune capacity, and immunomodulatory role of zinc in the airway. Finally, we review the latest literature on how HIV and alcohol affect other pulmonary disorders including chronic obstructive pulmonary disease, pulmonary hypertension, and lung cancer.

Risk factors for community-acquired pneumonia in adults in Europe: a literature review

Background

Community-acquired pneumonia (CAP) causes considerable morbidity and mortality in adults, particularly in the elderly.

Methods

Structured searches of PubMed were conducted to identify up-to-date information on the incidence of CAP in adults in Europe, as well as data on lifestyle and medical risk factors for CAP.

Results

The overall annual incidence of CAP in adults ranged between 1.07 to 1.2 per 1000 person-years and 1.54 to 1.7 per 1000 population and increased with age (14 per 1000 person-years in adults aged ≥65 years). Incidence was also higher in men than in women and in patients with chronic respiratory disease or HIV infection. Lifestyle factors associated with an increased risk of CAP included smoking, alcohol abuse, being underweight, having regular contact with children and poor dental hygiene. The presence of comorbid conditions, including chronic respiratory and cardiovascular diseases, cerebrovascular disease, Parkinson's disease, epilepsy, dementia, dysphagia, HIV or chronic renal or liver disease all increased the risk of CAP by twofold to fourfold.

Conclusion

A range of lifestyle factors and underlying medical conditions are associated with an increased risk of CAP in European adults. Understanding of the types of individual at greatest risk of CAP can help to ensure that interventions to reduce the risk of infection and burden of disease are targeted appropriately.

The large spectrum of pulmonary complications following illicit drug use: features and mechanisms

Damage to lungs may occur from systemic as well as inhalational exposure to various illegal drugs of abuse. Aspiration pneumonia probably represents the most common pulmonary complication in relation to consciousness impairment. Some pulmonary consequences may be specifically related to one given drug. Prolonged smoking of marijuana may result in respiratory symptoms suggestive of obstructive lung disease. Non-cardiogenic pulmonary edema has been attributed to heroin, despite debated mechanisms including attempted inspiration against a closed glottis, hypoxic damage to alveolar integrity, neurogenic vasoactive response to stress, and opiate-induced anaphylactoid reaction. Naloxone-related precipitated withdrawal resulting in massive sympathetic response with heart stunning has been mistakenly implicated. In crack users, acute respiratory syndromes called "crack-lung" with fever, hemoptysis, dyspnea, and pulmonary infiltration on chest X-rays have been reported up-to 48h after free-base cocaine inhalation, with features of pulmonary edema, interstitial pneumonia, diffuse alveolar hemorrhage, and eosinophil infiltration. The high-temperature of volatilized cocaine and the presence of impurities, as well as cocaine-induced local vasoconstriction have been suggested to explain alveolar damage. Some other drug-related pulmonary insults result from the route of drug self-administration. In intravenous drug users, granulomatous pneumonia with multinodular patterns on thoracic imaging is due to drug contaminants like talcum. Septic embolism from right-sided endocarditis represents an alternative diagnosis in case of sepsis from pulmonary origin. Following inhalation, pneumothorax, and pneumomediastinum have been attributed to increased intrathoracic pressure in relation to vigorous coughing or repeated Valsalva maneuvers, in an attempt to absorb the maximal possible drug amount. In conclusion, pulmonary consequences of illicit drugs are various, resulting in both acute life-threatening conditions and long-term functional respiratory sequelae. A better understanding of their spectrum and the implicated mechanisms of injury should help to improve patient management.

Oxidative stress in immunocompetent patients with severe community-acquired pneumonia. A pilot study

OBJECTIVE

A comparison was made of the oxidative stress (OS) levels of patients with either viral or bacterial severe community-acquired pneumonia (sCAP) and of patients without infection (healthy volunteers (HV) and patients with acute myocardial infarction (AMI)).

DESIGN

A prospective observational study was made.

PATIENTS

Critically ill patients with sCAP.

VARIABLES

The TBARS level was measured as an index of oxidative injury. SOD, CAT and redox glutathione system (GSH, GSSG, GR, GPx) activities were measured as reflecting antioxidant capacity. Severity of illness was assessed by the APACHE II, SOFA and SIRS scores.

RESULTS

Thirty-seven subjects were included: 15 patients with CAP (12 of bacterial origin [BCAP] and 3 due to 2009 A/H1N1 virus [VCAP]), 10 HV and 12 AMI patients. Intensive care CAP mortality was 26.7% (n=4). Plasmatic TBARS levels were higher in CAP patients than in HV, but similar to those recorded in AMI patients. In contrast, VCAP was associated with lower TBARS levels, and some components of the glutathione redox system were higher in BCAP patients and HV. The OS levels did not differ between survivors and non-survivors.

CONCLUSION

Our results suggest the occurrence of higher OS in sCAP patients compared with HV. In contrast, lower TBARS levels were observed in VCAP patients, suggesting an increase of antioxidant activity related to the redox glutathione system. However, further research involving a larger cohort is needed in order to confirm these findings.

Characteristics of Drug-Susceptible and Drug-Resistant Staphylococcus aureus Pneumonia in Patients with HIV

Objectives

To examine predictors and outcomes of Staphylococcus aureus Pneumonia (SAP) in people with HIV compared with Streptococcus pneumoniae Pneumonia (SPP), and to compare Methicillin-Resistant S. aureus (MRSA) with Methicillin-Sensitive S. aureus (MSSA) pneumonias in this population.

Methods

We conducted a retrospective case-control study of HIV-infected patients admitted to a single center with culture-proven S. aureus or S. pneumoniae pneumonia. We identified patients through a computerized database, conducted structured chart reviews, and performed bivariate and multivariate analyses using logistic regression.

Results

We compared 47 SAP episodes in 42 patients with 100 SPP episodes in 93 patients. Use of any antibiotics prior to admission (OR=3.5, p=0.02), a co-morbid illness (OR=4.2, p=0.04), and recent healthcare contact (OR=12.0, p<0.001) were significant independent predictors of SAP. Patients with SAP were more likely to require intensive care (OR=2.7, p=0.02) and mechanical ventilation (OR=3.1, p=0.02), but not to die. MRSA was more common (57% of cases) than MSSA, but outcomes were not significantly worse.

Conclusions

Patients with HIV and SAP have worse outcomes than those with SPP. Clinicians should consider empiric antibiotic coverage for MRSA in patients admitted with HIV and pneumonia, given the high prevalence of MRSA. Further studies are warranted to examine morbidity differences between HIV-associated MSSA and MRSA pneumonia.

Alcohol Consumption, Progression of Disease and Other Comorbidities, and Responses to Antiretroviral Medication in People Living with HIV

The present paper describes the possible connection between alcohol consumption and adherence to medicine used to treat human deficiency viral (HIV) infection. Highly active antiretroviral therapy (HAART) has a positive influence on longevity in patients with HIV, substantially reducing morbidity and mortality, including resource-poor settings such as South Africa. However, in a systematic comparison of HAART outcomes between low-income and high-income countries in the treatment of HIV-patients, mortality was higher in resource-poor settings. Specifically, in South Africa, patients often suffer from concomitant tuberculosis and other infections that may contribute to these results. Alcohol influences the use of medicine for opportunistic infections (e.g., pneumonia, tuberculosis), or coinfections HIV-hepatitis viruses-B (HBV) and C (HCV), cytomegalovirus, or herpes simplex virus. Furthermore, alcohol use may negatively impact on medication adherence contributing to HIV progression. The materials used provide a data-supported approach. They are based on analysis of published (2006–2011) world literature and the experience of the authors in the specified topic. Intended for use by health care professionals, these recommendations suggest approaches to the therapeutic and preventive aspects of care. Our intention was to fully characterize the quality of evidence supporting recommendations, which are reflecting benefit versus risk, and assessing strength or certainty.

Community-acquired pneumonia due to Panton-Valentine leukocidin-producing Staphylococcus aureus in an HIV-2-infected patient

Pneumonia caused by Panton-Valentine leukocidin-producing Staphylococcus aureus is associated with a high fatality rate. There have been few reported cases in HIV-1-co-infected patients. Here we report a fatal case of severe community-acquired pneumonia caused by Panton-Valentine leukocidin-producing S. aureus in a 45-year-old woman with HIV-2 infection.

Predictors of pneumonia severity in HIV-infected adults admitted to an Urban public hospital

Data on outcomes of community-acquired pneumonia (CAP) in the HIV-infected population are mixed and the perception of worse outcomes in HIV may lead to excess hospitalization. We retrospectively evaluated the utility of the Pneumonia Severity Index, or PORT score, as a prediction rule for mortality in 102 HIV-infected adults hospitalized at an urban public hospital with CAP. Primary outcome was survival at 30 days. Secondary outcomes included survival on discharge, intensive care unit (ICU) admission, length of stay, and readmission within 30 days. The cohort was predominantly male (70%) with a mean age of 45.4 years (standard deviation [SD] ± 7.4). Mean CD4 cell count was 318 cells per microliter; 40 (39%) had CD4 less than 200 cells per microliter. Forty-three percent were on antiretroviral therapy at the time of admission and 31% on prophylactic antibiotics. Twelve patients had bacteremia on admission, predominantly with Streptococcus pneumoniae. Of the 46 patients with admission sputum cultures, 20 yielded an organism, most commonly Haemophilus influenzae and S. pneumoniae. Overall survival in the cohort was high, 96%. Most patients (81%) had a low PORT risk score (class I-III). PORT score predicted 30-day survival (p=0.01) and ICU admission (p=0.03), but antiretroviral use did not. In contrast to a prior study, we did not find that CD4 cell count predicted CAP outcome. Lack of stable housing was not associated with worse outcomes. The PORT score may be a valid tool to predict mortality and need for hospital admission in HIV-infected patients with CAP.

Smoking and the outcome of infection

Smoking has substantial local and systemic adverse effects on the immune system, respiratory tract and skin and soft tissues. Smokers are at increased risk of invasive pneumococcal disease, pneumonia, periodontitis, surgical infections, tuberculosis, influenza and meningococcal disease. The results of several studies indicate that smokers with periodontitis or tuberculosis suffer more severe disease. Data on the impact of smoking on sepsis and pneumonia are controversial and limited, and systematic data regarding the outcome of the majority of infections in smokers are scarce. Abundant data indicate that children exposed to environmental tobacco smoke (ETS) suffer from more severe infections. However, information regarding the effects of ETS on the outcome of infections in adults is limited. Various aspects of the relation between smoking and the outcome of bacterial infection (e.g. potential dose-dependent effects and the interactions between smoking and other environmental factors that may affect the course of infectious diseases) remain to be established.

Alcohol consumption among HIV-infected women: impact on time to antiretroviral therapy and survival

OBJECTIVE

Alcohol use is prevalent among HIV-infected people and is associated with lower antiretroviral adherence and high-risk sexual and injection behaviors. We sought to determine factors associated with alcohol use among HIV-infected women engaged in clinical care and if baseline alcohol use was associated with time to combination antiretroviral therapy (cART) and death in this population.

METHODS

In an observational clinical cohort, alcohol consumption at the initial medical visit was examined and categorized as heavy, occasional, past, or no use. We used multinomial logistic regression to test preselected covariates and their association with baseline alcohol consumption. We then examined the association between alcohol use and time to cART and time to death using Kaplan-Meier statistics and Cox proportional hazards regression.

RESULTS

Between 1997 and 2006, 1030 HIV-infected women enrolled in the cohort. Assessment of alcohol use revealed occasional and hazardous consumption in 29% and 17% of the cohort, respectively; 13% were past drinkers. In multivariate regression, heavy drinkers were more likely to be infected with hepatitis C than nondrinkers (relative risk ratios [RRR] 2.06, 95% confidence interval [CI] 1.29-3.44) and endorse current drug (RRR 3.51, 95% CI 2.09-5.91) and tobacco use (RRR 3.85 95% CI 1.81-8.19). Multivariable Cox regression adjusting for all clinical covariates demonstrated an increased mortality risk (hazard ratio [HR] 1.40, 95% CI 1.00-1.97, p < 0.05) among heavy drinkers compared to nondrinkers but no delays in cART initiation (1.04 95% CI 0.81-1.34)

CONCLUSIONS

Among this cohort of HIV-infected women, heavy alcohol consumption was independently associated with earlier death. Baseline factors associated with heavy alcohol use included tobacco use, hepatitis C, and illicit drug use. Alcohol is a modifiable risk factor for adverse HIV-related outcomes. Providers should consistently screen for alcohol consumption and refer HIV-infected women with heavy alcohol use for treatment.

The effectiveness of pneumococcal polysaccharide vaccination in HIV-infected adults: a systematic review

OBJECTIVE

The effectiveness of 23-valent pneumococcal polysaccharide vaccine (PPV-23) in preventing pneumococcal disease in HIV-infected people is a subject of debate. We reviewed the clinical evidence for recommending PPV-23 for use in HIV-infected patients.

METHODS

A systematic search of peer-reviewed publications (EMBASE, the Cochrane Library, and PubMed/BioMed Central), the Internet and grey literature was conducted. Three hundred and eighteen documents were reviewed. Studies reporting risk estimates for all-cause pneumonia, all-pneumococcal disease, and/or invasive pneumococcal disease after PPV-23 immunization in HIV-infected adults were included.

RESULTS

We identified one randomized trial and 15 observational studies. While the randomized trial found a 60% increased risk of all-cause pneumonia among vaccinees, 11 of the 15 observational studies found various degrees of disease protection associated with PPV-23 immunization. However, most studies suffered from limited confounder control in their multivariate analyses, despite study data suggesting substantial differences between the characteristics of exposed and unexposed individuals.

CONCLUSIONS

The current clinical evidence provides only moderate support for PPV-23 immunization of HIV-infected adults. More data are needed on the efficacy of newer conjugated pneumococcal vaccines, which may be more immunogenic and could potentially replace PPV-23 in the future.

Smoking-related health risks among persons with HIV in the Strategies for Management of Antiretroviral Therapy clinical trial

OBJECTIVES

We sought to determine smoking-related hazard ratios (HRs) and population-attributable risk percentage (PAR%) for serious clinical events and death among HIV-positive persons, whose smoking prevalence is higher than in the general population.

METHODS

For 5472 HIV-infected persons enrolled from 33 countries in the Strategies for Management of Antiretroviral Therapy clinical trial, we evaluated the relationship between baseline smoking status and development of AIDS-related or serious non-AIDS events and overall mortality.

RESULTS

Among all participants, 40.5% were current smokers and 24.8% were former smokers. Adjusted HRs were higher for current than for never smokers for overall mortality (2.4; P < .001), major cardiovascular disease (2.0; P = .002), non-AIDS cancer (1.8; P = .008), and bacterial pneumonia (2.3; P < .001). Adjusted HRs also were significantly higher for these outcomes among current than among former smokers. The PAR% for current versus former and never smokers combined was 24.3% for overall mortality, 25.3% for major cardiovascular disease, 30.6% for non-AIDS cancer, and 25.4% for bacterial pneumonia.

CONCLUSIONS

Smoking contributes to substantial morbidity and mortality in this HIV-infected population. Providers should routinely integrate smoking cessation programs into HIV health care.

Global lung health: the colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD

Tuberculosis (TB), smoking, HIV and chronic obstructive pulmonary disease (COPD) are burgeoning epidemics in developing countries. The link between TB and HIV is well established. Less well recognised is the strong relationship between tobacco smoking and the development and natural history of TB. These associations are of considerable relevance to public health and disease outcomes in individuals with TB. Moreover, tobacco smoking, a modifiable risk factor, is associated with poorer outcomes in HIV-associated opportunistic infections, of which TB is the commonest in developing countries. It is now also becoming clear that TB, like tobacco smoke, besides its known consequences of bronchiectasis and other pulmonary morbidity, is also a significant risk factor for the development of COPD. Thus, there is a deleterious and synergistic interaction between TB, HIV, tobacco smoking and COPD in a large proportion of the world's population. Further work, specifically mechanistic and epidemiological studies, is required to clarify the role of tobacco smoke on the progression of TB and HIV infection, and to assess the impact of smoking cessation interventions. These interactions deserve urgent attention and have major implications for coordinated public health planning and policy recommendations in the developing world.