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Richards GA, Zamparini J, Kalla I, Laher A, Murray LW, Shaddock EJ, Stacey S, Venter WF, Feldman C. Critical illness due to infection in people living with HIV. Lancet HIV 2024; 11:e406-e418. [PMID: 38816142 DOI: 10.1016/s2352-3018(24)00096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 06/01/2024]
Abstract
People living with HIV comprise a substantial number of the patients admitted to intensive care. This number varies according to geography, but all areas of the world are affected. In lower-income and middle-income countries, the majority of intensive care unit (ICU) admissions relate to infections, whereas in high-income countries, they often involve HIV-associated non-communicable diseases diagnoses. Management of infections potentially resulting in admission to the ICU in people living with HIV include sepsis, respiratory infections, COVID-19, cytomegalovirus infection, and CNS infections, both opportunistic and non-opportunistic. It is crucial to know which antiretroviral therapy (ART) is appropriate, when is the correct time to administer it, and to be aware of any safety concerns and potential drug interactions with ART. Although ART is necessary for controlling HIV infections, it can also cause difficulties relevant to the ICU such as immune reconstitution inflammatory syndrome, and issues associated with ART administration in patients with gastrointestinal dysfunction on mechanical ventilation. Managing infection in people with HIV in the ICU is complex, requiring collaboration from a multidisciplinary team knowledgeable in both the management of the specific infection and the use of ART. This team should include intensivists, infectious disease specialists, pharmacists, and microbiologists to ensure optimal outcomes for patients.
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Affiliation(s)
- Guy A Richards
- Department of Surgery, Division of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Jarrod Zamparini
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ismail Kalla
- Department of Internal Medicine, Division of Pulmonology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Abdullah Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lyle W Murray
- Department of Internal Medicine, Division of Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Erica J Shaddock
- Department of Internal Medicine, Division of Pulmonology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah Stacey
- Department of Internal Medicine, Division of Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wd Francois Venter
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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2
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Dockrell DH, Breen R, Collini P, Lipman MCI, Miller RF. British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical management of pulmonary opportunistic infections 2024. HIV Med 2024; 25 Suppl 2:3-37. [PMID: 38783560 DOI: 10.1111/hiv.13637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 05/25/2024]
Affiliation(s)
- D H Dockrell
- University of Edinburgh, UK
- Regional Infectious Diseases Unit, NHS Lothian Infection Service, Edinburgh, UK
| | - R Breen
- Forth Valley Royal Hospital, Larbert, Scotland, UK
| | | | - M C I Lipman
- Royal Free London NHS Foundation Trust, UK
- University College London, UK
| | - R F Miller
- Royal Free London NHS Foundation Trust, UK
- Institute for Global Health, University College London, UK
- Central and North West London NHS Foundation Trust, UK
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3
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Venturas JP. HIV and COVID-19 Disease. Semin Respir Crit Care Med 2023; 44:35-49. [PMID: 36646084 DOI: 10.1055/s-0042-1758852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Despite effective antiretroviral therapy (ART), HIV infected individuals throughout the world remain at significant risk of respiratory infections and non-communicable disease. Severe disease from SARS-CoV-2 is associated with a hyperinflammatory phenotype which manifests in the lungs as pneumonia and in some cases can lead to acute respiratory failure. Progression to severe COVID-19 is associated with comorbid disease such as obesity, diabetes mellitus and cardiovascular disease, however data concerning the associated risks of HIV coinfection are still conflicting, with large population studies demonstrating poorer outcomes, whilst smaller, case-controlled studies showing better outcomes. Furthermore, underlying immunopathological processes within the lungs and elsewhere, including interactions with other opportunistic infections (OI), remain largely undefined. Nonetheless, new and repurposed anti-viral therapies and vaccines which have been developed are safe to use in this population, and anti-inflammatory agents are recommended with the caveat that the coexistence of opportunistic infections is considered and excluded. Finally, HIV infected patients remain reliant on good ART adherence practices to maintain HIV viral suppression, and some of these practices were disrupted during the COVID-19 pandemic, putting these patients at further risk for acute and long-term adverse outcomes.
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Affiliation(s)
- Jacqui P Venturas
- Department of Internal Medicine and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Universtity of the Witwatersrand, Johannesburg, South Africa
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4
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Zifodya JS, Crothers K. Treating bacterial pneumonia in people living with HIV. Expert Rev Respir Med 2019; 13:771-786. [PMID: 31241378 DOI: 10.1080/17476348.2019.1634546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Jerry S Zifodya
- a Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington , Seattle , Washington , USA
| | - Kristina Crothers
- a Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington , Seattle , Washington , USA
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Buss IM, Birkhamshaw E, Innes MA, Magadoro I, Waitt PI, Rylance J. Validating a novel index (SWAT-Bp) to predict mortality risk of community-acquired pneumonia in Malawi. Malawi Med J 2018; 30:230-235. [PMID: 31798800 PMCID: PMC6863414 DOI: 10.4314/mmj.v30i4.4] [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: 11/17/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia is a major cause of mortality worldwide. Early assessment and initiation of management improves outcomes. In higher-income countries, scores assist in predicting mortality from pneumonia. These have not been validated for use in most lower-income countries. AIM To validate a new score, the SWAT-Bp score, in predicting mortality risk of clinical community-acquired pneumonia amongst hospital admissions at Queen Elizabeth Central Hospital, Blantyre, Malawi. METHODS The five variables constituting the SWAT-Bp score (male [S]ex, muscle [W]asting, non-[A]mbulatory, [T]emperature (>38°C or <35°C) and [B]lood [p]ressure (systolic<100 and/or diastolic<60)) were recorded for all patients with clinical presentation of a lower respiratory tract infection, presumed to be pneumonia, over four months (N=216). The sensitivity and specificity of the score were calculated to determine accuracy of predicting mortality risk. RESULTS Median age was 35 years, HIV prevalence was 84.2% amongst known statuses, and mortality rate was 12.5%. Mortality for scores 0-5 was 0%, 8.5%, 12.7%, 19.0%, 28.6%, 100% respectively. Patients were stratified into three mortality risk groups dependent on their score. SWAT-Bp had moderate discriminatory power overall (AUROC 0.744). A SWAT-Bp score of ≥2 was 82% sensitive and 51% specific for predicting mortality, thereby assisting in identifying individuals with a lower mortality risk. CONCLUSION In this validation cohort, the SWAT-Bp score has not performed as well as in the derivation cohort. However, it could potentially assist clinicians identifying low-risk patients, enabling rapid prioritisation of treatment in a low-resource setting, as it helps contribute towards individual patient risk stratification.
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Affiliation(s)
- Imogen M Buss
- Department of Medicine, North Bristol NHS Trust, Bristol, United Kingdom
| | - Edmund Birkhamshaw
- Department of Infectious Diseases, Heartlands Hospital, Heart of England Foundation Trust, Birmingham, United Kingdom
| | - Michael A Innes
- General Practitioner, Stirchley Medical Practice, Telford, United Kingdom
| | - Itai Magadoro
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Peter I Waitt
- Acute Medical Unit, Wirrall University Hospital Foundation Trust, United Kingdom
| | - Jamie Rylance
- Senior Clinical Lecturer in respiratory medicine, Liverpool School of Tropical Medicine, United Kingdom.,Lung Health Group Lead, Malawi-Liverpool-Wellcome Program, Blantyre, Malawi
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Cillóniz C, García-Vidal C, Moreno A, Miro JM, Torres A. Community-acquired bacterial pneumonia in adult HIV-infected patients. Expert Rev Anti Infect Ther 2018; 16:579-588. [PMID: 29976111 DOI: 10.1080/14787210.2018.1495560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Catia Cillóniz
- a Department of Pulmonary Medicine Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , University of Barcelona (UB) - SGR 911- Ciber de Enfermedades Respiratorias (Ciberes) , Barcelona , Spain
| | - Carolina García-Vidal
- b Infectious Diseases Service, Hospital Clinic-IDIBAPS , University of Barcelona , Barcelona , Spain
| | - Asunción Moreno
- b Infectious Diseases Service, Hospital Clinic-IDIBAPS , University of Barcelona , Barcelona , Spain
| | - José M Miro
- b Infectious Diseases Service, Hospital Clinic-IDIBAPS , University of Barcelona , Barcelona , Spain
| | - Antoni Torres
- a Department of Pulmonary Medicine Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , University of Barcelona (UB) - SGR 911- Ciber de Enfermedades Respiratorias (Ciberes) , Barcelona , Spain
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7
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Feldman C, Anderson R, Rossouw T. HIV-related pneumococcal disease prevention in adults. Expert Rev Respir Med 2017; 11:181-199. [PMID: 28228053 DOI: 10.1080/17476348.2017.1289841] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Charles Feldman
- a Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences , University of the Witwatersrand Medical School , Johannesburg , South Africa
| | - Ronald Anderson
- b Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences , University of Pretoria , Pretoria , South Africa
| | - Theresa Rossouw
- b Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences , University of Pretoria , Pretoria , South Africa
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Cohen C, Naidoo N, Meiring S, de Gouveia L, von Mollendorf C, Walaza S, Naicker P, Madhi SA, Feldman C, Klugman KP, Dawood H, von Gottberg A. Streptococcus pneumoniae Serotypes and Mortality in Adults and Adolescents in South Africa: Analysis of National Surveillance Data, 2003 - 2008. PLoS One 2015; 10:e0140185. [PMID: 26460800 PMCID: PMC4604081 DOI: 10.1371/journal.pone.0140185] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/22/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An association between pneumococcal serotypes and mortality has been suggested. We aimed to investigate this among individuals aged ≥15 years with invasive pneumococcal disease (IPD) in South Africa. METHODS IPD cases were identified through national laboratory-based surveillance at 25 sites, pre-pneumococcal conjugate vaccine (PCV) introduction, from 2003-2008. We assessed the association between the 20 commonest serotypes and in-hospital mortality using logistic regression with serotype 4 (the third commonest serotype with intermediate case-fatality ratio (CFR)) as referent. RESULTS Among 3953 IPD cases, CFR was 55% (641/1166) for meningitis and 23% (576/2484) for bacteremia (p<0.001). Serotype 19F had the highest CFR (48%, 100/207), followed by serotype 23F (39%, 99/252) and serotype 1 (38%, 246/651). On multivariable analysis, factors independently associated with mortality included serotype 1 (OR 1.9, 95%CI 1.1-3.5) and 19F (OR 2.9, 95%CI 1.4-6.1) vs. serotype 4; increasing age (25-44 years, OR 1.8, 95%CI 1.0-3.0; 45-64 years, OR 3.6, 95%CI 2.0-6.4; ≥65 years, OR 5.2, 95%CI 1.9-14.1; vs. 15-24 years); meningitis (OR 4.1, 95%CI 3.0-5.6) vs. bacteremic pneumonia; and HIV infection (OR1.7, 95%CI 1.0-2.8). On stratified multivariate analysis, serotype 19F was associated with increased mortality amongst bacteremic pneumococcal pneumonia cases, while no serotype was associated with increased mortality in meningitis cases. CONCLUSION Mortality was increased in HIV-infected individuals, which may be reduced by increased antiretroviral therapy availability. Serotypes associated with increased mortality are included in the 10-and-13-valent PCV and may become less common in adults due to indirect effects following routine infant immunization.
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Affiliation(s)
- Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - Nireshni Naidoo
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - Susan Meiring
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Linda de Gouveia
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Claire von Mollendorf
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - Sibongile Walaza
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - Preneshni Naicker
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Shabir A. Madhi
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - Keith P. Klugman
- Hubert School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Halima Dawood
- Department of Internal Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
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9
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Barakat LA, Juthani-Mehta M, Allore H, Trentalange M, Tate J, Rimland D, Pisani M, Akgün KM, Goetz MB, Butt AA, Rodriguez-Barradas M, Duggal M, Crothers K, Justice AC, Quagliarello VJ. Comparing clinical outcomes in HIV-infected and uninfected older men hospitalized with community-acquired pneumonia. HIV Med 2015; 16:421-30. [PMID: 25959543 DOI: 10.1111/hiv.12244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2014] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- L A Barakat
- Infectious Disease, Yale University School of Medicine, New Haven, CT, USA.,Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - M Juthani-Mehta
- Infectious Disease, Yale University School of Medicine, New Haven, CT, USA.,Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - H Allore
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - M Trentalange
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - J Tate
- Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA
| | - D Rimland
- Infectious Disease, VA Medical Center, Decatur, GA, USA
| | - M Pisani
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Pulmonary Disease and Critical Care, Yale University School of Medicine, New Haven, CT, USA
| | - K M Akgün
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA.,Pulmonary Disease and Critical Care, Yale University School of Medicine, New Haven, CT, USA
| | - M B Goetz
- Infectious Disease, VA Greater Los Angles Healthcare System, Los Angelos, CA, USA
| | - A A Butt
- Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Rodriguez-Barradas
- Infectious Diseases (MS 111G), Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - M Duggal
- Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA
| | - K Crothers
- Pulmonary Disease and Critical Care, University of Washington, Seattle, WA, USA
| | - A C Justice
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA
| | - V J Quagliarello
- Infectious Disease, Yale University School of Medicine, New Haven, CT, USA.,Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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10
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Albrich WC, Madhi SA, Adrian PV, van Niekerk N, Telles JN, Ebrahim N, Messaoudi M, Paranhos-Baccalà G, Giersdorf S, Vernet G, Mueller B, Klugman KP. Pneumococcal colonisation density: a new marker for disease severity in HIV-infected adults with pneumonia. BMJ Open 2014; 4:e005953. [PMID: 25113557 PMCID: PMC4127937 DOI: 10.1136/bmjopen-2014-005953] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE A high genomic load of Pneumococcus from blood or cerebrospinal fluid has been associated with increased mortality. We aimed to analyse whether nasopharyngeal colonisation density in HIV-infected patients with community-acquired pneumonia (CAP) is associated with markers of disease severity or poor outcome. METHODS Quantitative lytA real-time PCR was performed on nasopharyngeal swabs in HIV-infected South African adults hospitalised for acute CAP at Chris Hani Baragwanath Hospital, Soweto, South Africa. Pneumonia aetiology was considered pneumococcal if any sputum culture or Gram stain, urinary pneumococcal C-polysaccharide-based antigen, blood culture or whole blood lytA real-time PCR revealed pneumococci. RESULTS There was a moderate correlation between the mean nasopharyngeal colonisation densities and increasing CURB65 scores among all-cause patients with pneumonia (Spearman correlation coefficient r=0.15, p=0.06) or with the Pitt bacteraemia score among patients with pneumococcal bacteraemia (p=0.63). In patients with pneumococcal pneumonia, nasopharyngeal pneumococcal colonisation density was higher among non-survivors than survivors (7.7 vs 6.1 log10 copies/mL, respectively, p=0.02) and among those who had pneumococci identified from blood cultures and/or by whole blood lytA real-time PCR than those with non-bacteraemic pneumococcal pneumonia (6.6 vs 5.6 log10 copies/mL, p=0.03). Nasopharyngeal colonisation density correlated positively with the biomarkers procalcitonin (Spearman correlation coefficient r=0.37, p<0.0001), proadrenomedullin (r=0.39, p=0.008) and copeptin (r=0.30, p=0.01). CONCLUSIONS In addition to its previously reported role as a diagnostic tool for pneumococcal pneumonia, quantitative nasopharyngeal colonisation density also correlates with mortality and prognostic biomarkers. It may also be useful as a severity marker for pneumococcal pneumonia in HIV-infected adults.
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Affiliation(s)
- Werner C Albrich
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital St Gallen, St Gallen, Switzerland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases University of the Witwatersrand, Johannesburg, South Africa
| | - Peter V Adrian
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nadia van Niekerk
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - N Ebrahim
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Guy Vernet
- Emerging Pathogens Laboratory, Fondation Mérieux, Lyon, France
- Centre Pasteur du Cameroun, Yaoundé, Cameroun
| | - Beat Mueller
- Department of Internal Medicine, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Keith P Klugman
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Hubert Department of Global Health and Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Pneumonia Program, Bill and Melinda Gates Foundation, Seattle, Washington, USA
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11
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Harboe ZB, Larsen MV, Ladelund S, Kronborg G, Konradsen HB, Gerstoft J, Larsen CS, Pedersen C, Pedersen G, Obel N, Benfield T. Incidence and risk factors for invasive pneumococcal disease in HIV-infected and non-HIV-infected individuals before and after the introduction of combination antiretroviral therapy: persistent high risk among HIV-infected injecting drug users. Clin Infect Dis 2014; 59:1168-76. [PMID: 25038114 DOI: 10.1093/cid/ciu558] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Invasive pneumococcal disease (IPD) is an important cause of morbidity among individuals infected with human immunodeficiency virus (HIV). We described incidence and risk factors for IPD in HIV-infected and uninfected individuals. METHODS Nationwide population-based cohort study of HIV-infected adults treated at all Danish HIV treatment centers during 1995-2012. Nineteen population-matched controls per HIV-infected individual were retrieved. The risk of IPD was assessed using Poisson regression. RESULTS The incidence of IPD was 304.7 cases per 100 000 person-years of follow-up (PYFU) in HIV-infected and 12.8 per 100 000 PYFU in HIV-uninfected individuals. After adjusting for confounders, HIV infection (relative risk [RR], 24.4 [95% confidence interval [CI], 23.7-25.1]), male sex (RR, 1.20 [95% CI, 1.16-1.24]), increasing age (per year) (RR, 1.03 [95% CI, 1.03-1.04]), and calendar period (pre-cART RR, 2.80 [95% CI, 2.70-2.91] compared with late cART) were significantly associated with an increased risk of IPD. Among HIV-infected individuals, male sex (RR, 1.57 [95% CI, 1.49-1.66]), smoking (RR, 1.34 [95% CI, 1.26-1.42]), and injecting drug use (RR, 2.51 [95% CI, 2.26-2.67]) were associated with an increased risk of IPD. Detectable viral loads (RR, 1.88 [95% CI, 1.79-1.98]) and a relative fall in CD4 T-cell counts were also associated with an increased risk (≥500 to 350-500 CD4 T cells/µL: RR, 1.29 [95% CI, 1.21-1.37] and <100 cells/µL: RR, 7.4 [95% CI, 6.87-8.02]). The risk of IPD declined over time, although this was not the case for IDUs where the risk remained unchanged. CONCLUSIONS The incidence of IPD in HIV-infected individuals remained significantly higher than the incidence observed in non-HIV-infected subjects, despite the widespread use of cART. IDUs have a persistently high risk of IPD. Injecting drug use, smoking, and the receipt of cART are suitable targets for preventive measures in the future.
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Affiliation(s)
- Zitta Barrella Harboe
- Department of Infectious Diseases, Rigshospitalet Neisseria and Streptococcus Reference Laboratory, Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen
| | - Mette Vang Larsen
- Department of Infectious Diseases and Clinical Research Center, Copenhagen University Hospital, Hvidovre
| | - Steen Ladelund
- Department of Infectious Diseases and Clinical Research Center, Copenhagen University Hospital, Hvidovre
| | - Gitte Kronborg
- Department of Infectious Diseases and Clinical Research Center, Copenhagen University Hospital, Hvidovre Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen
| | - Helle Bossen Konradsen
- Neisseria and Streptococcus Reference Laboratory, Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen
| | - Jan Gerstoft
- Department of Infectious Diseases, Rigshospitalet
| | | | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital
| | - Gitte Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Rigshospitalet Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen
| | - Thomas Benfield
- Department of Infectious Diseases and Clinical Research Center, Copenhagen University Hospital, Hvidovre Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen
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Cribbs SK, Rimland D. Alcohol and HIV: Experimental and Clinical Evidence of Combined Impact on the Lung. ALCOHOL USE DISORDERS AND THE LUNG 2014. [PMCID: PMC7121129 DOI: 10.1007/978-1-4614-8833-0_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
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.
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Overview of community-acquired pneumonia and the role of inflammatory mechanisms in the immunopathogenesis of severe pneumococcal disease. Mediators Inflamm 2013; 2013:490346. [PMID: 24453422 PMCID: PMC3886318 DOI: 10.1155/2013/490346] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/15/2013] [Accepted: 11/17/2013] [Indexed: 12/23/2022] Open
Abstract
Community-acquired pneumonia (CAP) remains a leading cause of morbidity and mortality among the infectious diseases. Despite the implementation of national pneumococcal polyvalent vaccine-based immunisation strategies targeted at high-risk groups, Streptococcus pneumoniae (the pneumococcus) remains the most common cause of CAP. Notwithstanding the HIV pandemic, major challenges confronting the control of CAP include the range of bacterial and viral pathogens causing this condition, the ever-increasing problem of antibiotic resistance worldwide, and increased vulnerability associated with steadily aging populations in developed countries. These and other risk factors, as well as diagnostic strategies, are covered in the first section of this review. Thereafter, the review is focused on the pneumococcus, specifically the major virulence factors of this microbial pathogen and their role in triggering overexuberant inflammatory responses which contribute to the immunopathogenesis of invasive disease. The final section of the review is devoted to a consideration of pharmacological, anti-inflammatory strategies with adjunctive potential in the antimicrobial chemotherapy of CAP. This is focused on macrolides, corticosteroids, and statins with respect to their modes of anti-inflammatory action, current status, and limitations.
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Birkhamshaw E, Waitt CJ, Innes M, Waitt PI. Severity assessment of lower respiratory tract infection in Malawi: derivation of a novel index (SWAT-Bp) which outperforms CRB-65. PLoS One 2013; 8:e82178. [PMID: 24324763 PMCID: PMC3855704 DOI: 10.1371/journal.pone.0082178] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 10/22/2013] [Indexed: 01/20/2023] Open
Abstract
Objective To assess the validity of CRB-65 (Confusion, Respiratory rate >30 breaths/min, BP<90/60 mmHg, age >65 years) as a pneumonia severity index in a Malawian hospital population, and determine whether an alternative score has greater accuracy in this setting. Design Forty three variables were prospectively recorded during the first 48 hours of admission in all patients admitted to Queen Elizabeth Central Hospital, Malawi, for management of lower respiratory tract infection over a two month period (N = 240). Calculation of sensitivity and specificity for CRB-65 in predicting mortality was followed by multivariate modeling to create a score with superior performance in this population. Results Median age 37, HIV prevalence 79.9%, overall mortality 18.3%. CRB-65 predicted mortality poorly, indicated by the area under the ROC curve of 0.649. Independent predictors of death were: Male sex, “S” (AOR 2.6); Wasting, “W” (AOR 6.6); non-ambulatory, “A” (AOR 2.5); Temp >38°C or <35°C, “T” (AOR 3.2); BP<100/60, “Bp” (AOR 3.7). Combining these factors to form a severity index (SWAT-Bp) predicted mortality with high sensitivity and specificity (AUC: 0.867). Mortality for scores 0–5 was 0%, 3.3%, 7.4%, 29.2%, 61.5% and 87.5% respectively. A score ≥3 was 84% sensitive and 77% specific for mortality prediction, with a negative predictive value of 95.8%. Conclusion CRB-65 performs poorly in this population. The SWAT-Bp score can accurately stratify patients; ≤2 indicates non-severe infection (mortality 4.4%) and ≥3 severe illness (mortality 45%).
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Affiliation(s)
- Edmund Birkhamshaw
- Birmingham College of Medicine, Birmingham University, Birmingham, United Kingdom
- * E-mail: (EB); (CW)
| | - Catriona J. Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
- * E-mail: (EB); (CW)
| | - Michael Innes
- Department of Primary Care, Birmingham University, Birmingham, United Kingdom
| | - Peter I. Waitt
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Everett CK, Subramanian A, Jarisberg LG, Fei M, Huang L. Characteristics of Drug-Susceptible and Drug-Resistant Staphylococcus aureus Pneumonia in Patients with HIV. ACTA ACUST UNITED AC 2013; 3. [PMID: 25346868 PMCID: PMC4208302 DOI: 10.4172/2161-1165.1000122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
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.
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Affiliation(s)
- Charles K Everett
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, Box 0841, San Francisco, CA, USA
| | - Anuradha Subramanian
- Division of Infectious Diseases, Department of Medicine, University of Maryland, 655 West Baltimore Street, Baltimore, MD 21201, USA
| | - Leah G Jarisberg
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, Box 0841, San Francisco, CA, USA
| | - Matthew Fei
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Group Health Bellevue Medical Center, 11511 NE 10th St # 3, Bellevue, WA, USA
| | - Laurence Huang
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, Box 0841, San Francisco, CA, USA ; Division of HIV/AIDS, University of California, San Francisco, San Francisco General Hospital, Ward 84, 995 Potrero Avenue, San Francisco, CA 94110, USA
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Influence of HIV infection on the clinical presentation and outcome of adults with acute community-acquired pneumonia in Yaounde, Cameroon: a retrospective hospital-based study. BMC Pulm Med 2012; 12:46. [PMID: 22935579 PMCID: PMC3495717 DOI: 10.1186/1471-2466-12-46] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 08/27/2012] [Indexed: 11/30/2022] Open
Abstract
Background The impact of HIV infection on the evolution of acute community-acquired pneumonia (CAP) is still controversial. The aim of this study was to investigate possible differences in the clinical presentation and in-hospital outcomes of patients with CAP with and without HIV infection in a specialised service in Yaounde. Methods Medical files of 106 patients (51 men) aged 15 years and above, admitted to the Pneumology service of the Yaounde Jamot Hospital between January 2008 and May 2012, were retrospectively studied. Results Sixty-two (58.5%) patients were HIV infected. The median age of all patients was 40 years (interquartile range: 31.75-53) and there was no difference in the clinical and radiological profile of patients with and without HIV infection. The median leukocyte count (interquartile range) was 14,600/mm3 (10,900-20,600) and 10,450/mm3 (6,400-16,850) respectively in HIV negative and HIV positive patients (p = 0.002). Median haemoglobin level (interquartile range) was 10.8 g/dl (8.9-12) in HIV negative and 9.7 g/dl (8–11.6) in HIV positive patients (p = 0.025). In-hospital treatment failure on third day (39.5% vs. 25.5.1%, p = 0.137) and mortality rates (9% vs. 14.5%, p = 0.401) were similar between HIV negative and HIV positive patients. Conclusion Clinical and radiological features as well as response to treatment and in hospital fatal outcomes are similar in adult patients hospitalised with acute community-acquired pneumonia in Yaounde. In contrast, HIV infected patients tend to be more anaemic and have lower white cell counts than HIV negative patients. Larger prospective studies are needed to consolidate these findings.
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Seale J, Flanagan P. Fulminant fatal Streptococcus pneumoniae serotype 6C infection in two HIV infected individuals. J Infect 2012; 64:529-30. [DOI: 10.1016/j.jinf.2012.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 01/08/2012] [Indexed: 10/14/2022]
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Tajbakhsh M, Garcia Migura L, Rahbar M, Svendsen CA, Mohammadzadeh M, Zali MR, Aarestrup FM, Hendriksen RS. Antimicrobial-resistant Shigella infections from Iran: an overlooked problem? J Antimicrob Chemother 2012; 67:1128-33. [DOI: 10.1093/jac/dks023] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bordon J, Kapoor R, Martinez C, Portela D, Duvvuri P, Klochko A, Ayesu K, Peyrani P, Cillóniz C, Wiemken T, Parra A, Torres A, Rello J, Ramirez J. CD4+ cell counts and HIV-RNA levels do not predict outcomes of community-acquired pneumonia in hospitalized HIV-infected patients. Int J Infect Dis 2011; 15:e822-7. [PMID: 21885316 DOI: 10.1016/j.ijid.2011.05.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 04/26/2011] [Accepted: 05/30/2011] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Outcomes of community-acquired pneumonia (CAP) in relation to CD4+ cell counts have not been established. We examined the correlation of CD4+ cell count and HIV-RNA level with the clinical outcomes of CAP in hospitalized HIV-infected patients. METHODS This was a retrospective study of 127 adult hospitalized patients with HIV infection enrolled with the CAP Organization (CAPO), examining the time to clinical stability (TCS), length of hospital stay (LOS), and all-cause mortality. RESULTS Mortality data were available for 117 HIV-infected patients with CAP. Death within 28 days was reported in 28 patients. The risk of mortality at 28 days was not significant when adjusted for CD4+ cell count (p=0.123), HIV-RNA <400-1000 copies/ml (p=0.093), HIV-RNA ≥ 1000-10,000 copies/ml (p=0.543), and HIV-RNA ≥ 10,000-100,000 copies/ml (p=0.383). The propensity-adjusted Cox proportional hazards regression models did not show any statistically significant differences in LOS or TCS for CD4+ cell counts (p=0.590 and p=0.420, respectively) or HIV-RNA levels (p=0.470 and p=0.080, respectively). Multivariable Cox proportional hazards models did not reveal any statistically significant relationships between CD4+ cell counts or HIV-RNA levels with LOS or TCS. CONCLUSIONS Our study shows that clinical outcomes of HIV-infected patients with CAP are not predicted by CD4+ cell counts or HIV-RNA levels after adjusting for confounders. The management of CAP in patients with HIV infection should not be based on CD4+ cell counts or HIV-RNA levels of the HIV infection.
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Affiliation(s)
- Jose Bordon
- Department of Medicine, Section of Infectious Diseases, Providence Hospital, 1150 Varnum street, NE, Washington, DC 20017, USA.
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Mello CF, Negra MD. Impact of macrolide therapy on mortality of HIV-infected patients with community-acquired pneumonia in a tertiary teaching hospital. Braz J Infect Dis 2011; 15:262-7. [PMID: 21670928 DOI: 10.1016/s1413-8670(11)70186-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 01/15/2011] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Bacterial pneumonia is one of the main causes of morbidity and mortality in patients infected by the human immunodeficiency virus (HIV). The main objective of this study was to evaluate the effect of macrolide therapy in combination with a beta-lactam based empiric regimen for inpatients with community-acquired pneumonia and HIV. METHODS This is a retrospective cohort study of hospitalized patients. Adult patients who had received treatment with ceftriaxone or ceftriaxone plus clarithromycin were included. RESULTS 76 patients met the inclusion criteria. Among baseline characteristics analyzed, only respiratory rate showed significant difference: patients who had received clarithromycin were more likely to have a respiratory rate > 30/min than patients who received only ceftriaxone (64% versus 36%, p = 0.03). ICU admission was the only outcome that showed a significant difference, more frequent in the ceftriaxone plus clarithromycin group (45% versus 20%, p = 0.03). CONCLUSIONS This study does not support the addition of a macrolide to a beta-lactam based regimen in HIV-infected patients. This is probably related to the patients' immunodeficiency status, which impairs the immunomodulatory properties of the macrolides.
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Chew KW, Yen IH, Li JZ, Winston LG. Predictors of pneumonia severity in HIV-infected adults admitted to an Urban public hospital. AIDS Patient Care STDS 2011; 25:273-7. [PMID: 21488749 DOI: 10.1089/apc.2010.0365] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Kara W. Chew
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | - Irene H. Yen
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jonathan Z. Li
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa G. Winston
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California
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Morris A, Crothers K, Beck JM, Huang L. An official ATS workshop report: Emerging issues and current controversies in HIV-associated pulmonary diseases. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2011; 8:17-26. [PMID: 21364216 PMCID: PMC5830656 DOI: 10.1513/pats.2009-047ws] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Pulmonary diseases are major causes of morbidity and death in persons with HIV infection. Millions of people with HIV/AIDS throughout the world are at risk of opportunistic pneumonias such as tuberculosis, bacterial pneumonia, and Pneumocystis pneumonia. However, the availability of combination antiretroviral therapy has turned HIV into a chronic disease, and noninfectious lung diseases such as lung cancer, chronic obstructive pulmonary disease, and pulmonary arterial hypertension are also emerging as important causes of illness. Despite the importance of these diseases and the rapidly evolving understanding of their pathogenesis and epidemiology, few avenues exist for the discussion and dissemination of new clinical and basic insights. In May of 2008, the American Thoracic Society sponsored a 1-day workshop, "Emerging Issues and Current Controversies in HIV-Associated Pulmonary Diseases," which brought together basic and clinical researchers in HIV-associated pulmonary disease. A review of the literature was performed by workshop participants, and the workshop included 18 presentations on diverse topics summarized in this article.
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MESH Headings
- AIDS-Related Opportunistic Infections/diagnosis
- AIDS-Related Opportunistic Infections/drug therapy
- AIDS-Related Opportunistic Infections/epidemiology
- Anti-Bacterial Agents/therapeutic use
- Anti-HIV Agents/therapeutic use
- Antitubercular Agents/therapeutic use
- Comorbidity
- Female
- Humans
- Incidence
- Male
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Bacterial/epidemiology
- Pneumonia, Pneumocystis/diagnosis
- Pneumonia, Pneumocystis/drug therapy
- Pneumonia, Pneumocystis/epidemiology
- Practice Guidelines as Topic
- Prognosis
- Risk Assessment
- Severity of Illness Index
- Societies, Medical
- Survival Rate
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/epidemiology
- United States/epidemiology
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Perelló R, Miró O, Marcos MA, Almela M, Bragulat E, Sánchez M, Agustí C, Miro JM, Moreno A. Predicting bacteremic pneumonia in HIV-1-infected patients consulting the ED. Am J Emerg Med 2010; 28:454-9. [PMID: 20466225 DOI: 10.1016/j.ajem.2009.01.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 11/26/2008] [Accepted: 01/16/2009] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION HIV-1-infected patients have higher incidence of community-acquired pneumonia (CAP) and risk of complications. Bacteremia has been associated with a higher risk of complications in such patients. We investigated factors associated with bacteremia in HIV-1-infected patients with CAP presenting at the emergency department. METHODS We included HIV-1-infected patients with CAP for 3 years (March 2005-February 2008). Only patients in whom blood cultures were performed were finally included. Clinical data (age; sex; CD4(+) count; serum HIV viral load; previous or current intravenous drug use and antiretroviral treatment; systolic blood pressure; and cardiac and respiratory rates), analytical data (leukocyte count, arterial oxygen content, C-reactive protein value, and urgent Streptococcus pneumoniae and Legionella spp antigen urine detection), and APACHE-II (Acute Physiology and Chronic Health Evaluation) score were compiled. The need for intensive care unit admission, mechanical ventilation, mortality, and for patients finally discharged, duration of admission were retrospectively obtained from the clinical history. A multivariate analysis using logistic regression was performed to find independent predictors of bacteremia. RESULTS We diagnosed 129 HIV-1-infected patients with CAP. Blood cultures were performed in 118 cases (91%). Bacteremia was present in 28 (24%). Independent predictors of bacteremia were the detection of S pneumoniae antigen in urine (odds ratio, 9.0; 95% confidence interval, 1.9-42.0) and the absence of current antiretroviral treatment (odds ratio, 7.1; 95% confidence interval, 1.4-33.3). In-hospital mortality was higher in patients with bacteremia (15% vs 0%). CONCLUSION HIV-1-infected patients with CAP who are not on current antiretroviral therapy and have positive S pneumoniae antigenuria are at increased risk of having bacteremia. Bacteremic patients have a poor outcome.
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Affiliation(s)
- Rafael Perelló
- Emergency Department, Hospital Clínic, Barcelona, Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), University of Barcelona 08036, Spain.
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Identification and characterization of CTX-M-producing Shigella isolates in the United States. Antimicrob Agents Chemother 2010; 54:2269-70. [PMID: 20211893 DOI: 10.1128/aac.00039-10] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Malinis M, Myers J, Bordon J, Peyrani P, Kapoor R, Nakamatzu R, Lopardo G, Torres A, Feldman C, Allen M, Arnold F, Ramirez J. Clinical outcomes of HIV-infected patients hospitalized with bacterial community-acquired pneumonia. Int J Infect Dis 2010; 14:e22-7. [DOI: 10.1016/j.ijid.2009.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 02/10/2009] [Accepted: 03/01/2009] [Indexed: 11/30/2022] Open
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Adrie C, Francais A, Alvarez-Gonzalez A, Mounier R, Azoulay E, Zahar JR, Clec'h C, Goldgran-Toledano D, Hammer L, Descorps-Declere A, Jamali S, Timsit JF. Model for predicting short-term mortality of severe sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R72. [PMID: 19454002 PMCID: PMC2717433 DOI: 10.1186/cc7881] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Revised: 03/09/2009] [Accepted: 05/19/2009] [Indexed: 12/23/2022]
Abstract
Introduction To establish a prognostic model for predicting 14-day mortality in ICU patients with severe sepsis overall and according to place of infection acquisition and to sepsis episode number. Methods In this prospective multicentre observational study on a multicentre database (OUTCOMEREA) including data from 12 ICUs, 2268 patients with 2737 episodes of severe sepsis were randomly divided into a training cohort (n = 1458) and a validation cohort (n = 810). Up to four consecutive severe sepsis episodes per patient occurring within the first 28 ICU days were included. We developed a prognostic model for predicting death within 14 days after each episode, based on patient data available at sepsis onset. Results Independent predictors of death were logistic organ dysfunction (odds ratio (OR), 1.22 per point, P < 10-4), septic shock (OR, 1.40; P = 0.01), rank of severe sepsis episode (1 reference, 2: OR, 1.26; P = 0.10 ≥ 3: OR, 2.64; P < 10-3), multiple sources of infection (OR; 1.45, P = 0.03), simplified acute physiology score II (OR, 1.02 per point; P < 10-4), McCabe score ([greater than or equal to]2) (OR, 1.96; P < 10-4), and number of chronic co-morbidities (1: OR, 1.75; P < 10-3, ≥ 2: OR, 2.24, P < 10-3). Validity of the model was good in whole cohorts (AUC-ROC, 0.76; 95%CI, 0.74 to 0.79; and HL Chi-square: 15.3 (P = 0.06) for all episodes pooled). Conclusions In ICU patients, a prognostic model based on a few easily obtained variables is effective in predicting death within 14 days after the first to fourth episode of severe sepsis complicating community-, hospital-, or ICU-acquired infection.
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Affiliation(s)
- Christophe Adrie
- Medical-Surgical Intensive Care Unit, Delafontaine Hospital, 93205 Saint Denis, France.
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Grau I, Ardanuy C, Liñares J, Podzamczer D, Schulze MH, Pallares R. Trends in mortality and antibiotic resistance among HIV-infected patients with invasive pneumococcal disease. HIV Med 2009; 10:488-95. [PMID: 19459987 DOI: 10.1111/j.1468-1293.2009.00717.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of the study was to describe trends and risk factors for mortality and changes in antibiotic resistance, serotypes and clones among HIV-infected patients with invasive pneumococcal disease (IPD). METHODS A prospective study of 199 episodes of IPD occurring in a cohort of 4011 HIV-infected patients was carried out. Predictors of mortality included clinical and microbiological data. The 7-valent pneumococcal conjugate vaccine (PCV7) for children was introduced in late 2001. Time periods were classified for mortality studies as pre- (1986-1996), early (1997-2001) and late (2002-2007) highly active antiretroviral therapy (HAART) era, and for serotype studies as pre-PCV7 (1986-2001) and PCV7 (2002-2007) era. RESULTS Of 199 IPD episodes, 71 (36%) occurred in HIV-infected patients with associated comorbidities (mainly liver cirrhosis; 52 of 71), which increased in recent years. The incidence of IPD decreased from the pre-HAART era to the early HAART era and then remained stable in the late HAART era (24.1, 8.4 and 7.4 episodes per 1000 patient-years, respectively). Rates of 30-day mortality have risen over the three periods (8, 19 and 25%, respectively; P = 0.017). In multiple logistic regression analysis, predictors of mortality were shock at presentation [odds ratio (OR) 7.01; 95% confidence interval (CI) 2.05-23.87] and associated comorbidities (OR 4.27; 95% CI 1.53-11.92). In the PCV7 era, IPD caused by non-PCV7 serotypes increased, and resistance to betalactams decreased. The most frequent genotypes were Spain(9V)-ST156, Spain(23F)-ST81, ST88(19F), Sweden(1)-ST304 and Spain(6B)-ST90. CONCLUSIONS In the late HAART era, the incidence of IPD has not significantly decreased. Mortality from IPD has risen in association with an increase in comorbidities such as liver cirrhosis. New vaccination strategies are needed to diminish the burden of IPD in the HIV-infected population.
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Affiliation(s)
- I Grau
- Infectious Disease Service, Idibell, Ciberes, Hospital Bellvitge, University of Barcelona, Barcelona, Spain
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Pneumococcal pneumonia: clinical features, diagnosis and management in HIV-infected and HIV noninfected patients. Curr Opin Pulm Med 2009; 15:236-42. [DOI: 10.1097/mcp.0b013e32832a09e0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pontier S. Le poumon du sujet infecté par le VIH. Rev Mal Respir 2008. [DOI: 10.1016/s0761-8425(08)74078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Snydman D, Anaissie E, Sarosi G. Destruction of Isolates from the Pittsburgh Veterans Affairs Laboratory. Clin Infect Dis 2008; 46:1053-9. [DOI: 10.1086/528853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Bioconversion of Waste gases into Biofuel via Fermentation in a Continuous Stirred Tank Bioreactor. MALAYSIAN JOURNAL OF MICROBIOLOGY 2005. [DOI: 10.1097/cpm.0b013e31818cdc76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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