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Sauvat L, Denis L, Nourrisson C, Poirier P, Ruivard M, Le Guenno G. Pneumocystis jirovecii pneumonia in non-HIV patients: need for a more extended prophylaxis. Front Med (Lausanne) 2024; 11:1414092. [PMID: 38988362 PMCID: PMC11233525 DOI: 10.3389/fmed.2024.1414092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/14/2024] [Indexed: 07/12/2024] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PCP) has a significant mortality rate for non-HIV immunocompromised patients. Prevention is primarily based on combined trimethoprim and sulfamethoxazole (TMP-SMX) but guidelines on pneumocystosis prophylaxis are scattered and not consensual. Objectives This study aims to describe PCP in non-HIV patients and to review case by case the prior indication of prophylaxis according to specific guidelines.We included patients with confirmed diagnosis of PCP admitted to one university hospital from 2007 to 2020. Prior indication for pneumocystis prophylaxis was assessed according to the specific guidelines for the underlying pathology or treatment. Results Of 150 patients with a medical diagnosis of PCP, 78 were included. Four groups of underlying pathologies were identified: hematological pathologies (42%), autoimmune diseases (27%), organ transplantation (17%), and other pathologies at risk of PCP (14%). A small subgroup of 14 patients (18%) had received a prior prescription of pneumocystis prophylaxis but none at the time of the episode. Transfer to intensive care was necessary for 33 (42%) patients, and the mortality rate at 3 months was 20%. According to international disease society guidelines, 52 patients (59%) should have been on prophylaxis at the time of the pneumocystis episode. Lowest compliance with guidelines was observed in the hematological disease group for 24 patients (72%) without prescription of indicated prophylaxis. Conclusion Infectious disease specialists should draw up specific prophylactic guidelines against pneumocystis to promote a better prevention of the disease and include additional criteria in their recommendations according to individual characteristics to prevent fatal cases.
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Affiliation(s)
- Léo Sauvat
- Infection Control Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laure Denis
- Department of Internal Medicine, CH Alpes - Lemans, Contamine sur Arve, France
| | - Céline Nourrisson
- Laboratory of Mycology and Parasitology, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 3IHP, Clermont-Ferrand, France
| | - Philippe Poirier
- Laboratory of Mycology and Parasitology, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 3IHP, Clermont-Ferrand, France
| | - Marc Ruivard
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
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Kamel T, Janssen-Langenstein R, Quelven Q, Chelly J, Valette X, Le MP, Bourenne J, Garot D, Fillatre P, Labruyere M, Heming N, Lambiotte F, Lascarrou JB, Lesieur O, Bachoumas K, Ferre A, Maury E, Chalumeau-Lemoine L, Bougon D, Roux D, Guisset O, Coudroy R, Boulain T. Pneumocystis pneumonia in intensive care: clinical spectrum, prophylaxis patterns, antibiotic treatment delay impact, and role of corticosteroids. A French multicentre prospective cohort study. Intensive Care Med 2024:10.1007/s00134-024-07489-2. [PMID: 38829531 DOI: 10.1007/s00134-024-07489-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE Severe Pneumocystis jirovecii pneumonia (PJP) requiring intensive care has been the subject of few prospective studies. It is unclear whether delayed curative antibiotic therapy may impact survival in these severe forms of PJP. The impact of corticosteroid therapy combined with antibiotics is also unclear. METHODS This multicentre, prospective observational study involving 49 adult intensive care units (ICUs) in France was designed to evaluate the severity, the clinical spectrum, and outcomes of patients with severe PJP, and to assess the association between delayed curative antibiotic treatment and adjunctive corticosteroid therapy with mortality. RESULTS We included 158 patients with PJP from September 2020 to August 2022. Their main reason for admission was acute respiratory failure (n = 150, 94.9%). 12% of them received antibiotic prophylaxis for PJP before ICU admission. The ICU, hospital, and 6-month mortality were 31.6%, 35.4%, and 40.5%, respectively. Using time-to-event analysis with a propensity score-based inverse probability of treatment weighting, the initiation of curative antibiotic treatment after 96 h of ICU admission was associated with faster occurrence of death [time ratio: 6.75; 95% confidence interval (95% CI): 1.48-30.82; P = 0.014]. The use of corticosteroids for PJP was associated with faster occurrence of death (time ratio: 2.48; 95% CI 1.01-6.08; P = 0.048). CONCLUSION This study showed that few patients with PJP admitted to intensive care received prophylactic antibiotic therapy, that delay in curative antibiotic treatment was common and that both delay in curative antibiotic treatment and adjunctive corticosteroids for PJP were associated with accelerated mortality.
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Affiliation(s)
- Toufik Kamel
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orleans Cedex 2, France
| | - Ralf Janssen-Langenstein
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Centre Hospitalier Universitaire de Strasbourg, Avenue Molière, 67200, Strasbourg, France
| | - Quentin Quelven
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire Rennes, Pontchaillou, 2, Rue Henri Le Guilloux, 35000, Rennes, France
| | - Jonathan Chelly
- Réanimation Polyvalente, Centre Hospitalier Intercommunal Toulon La Seyne Sur Mer, 54 Rue Henri Sainte Claire Deville, 83100, Toulon, France
| | - Xavier Valette
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Minh-Pierre Le
- Médecine Intensive-Réanimation, Hôpital Cochin, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Jeremy Bourenne
- Réanimation des Urgences et Dechocage Hôpital de La Timone, 264 Rue Saint-Pierre, 13005, Marseille, France
| | - Denis Garot
- Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire Bretonneau, Tours, 37044, Tours, France
| | - Pierre Fillatre
- Réanimation Polyvalente, Centre Hospitalier Yves-Le Foll, 10, Rue Marcel Proust, 22000, Saint Brieuc, France
| | - Marie Labruyere
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Dijon, 14 Rue Gaffarel, BP 77908, 21079, Dijon Cedex, France
| | - Nicholas Heming
- Médecine Intensive-Réanimation, Hôpital Raymond-Poincaré, 104, Boulevard Raymond-Poincaré, 92380, Garches, France
| | - Fabien Lambiotte
- Médecine Intensive-Réanimation, Centre Hospitalier de Valenciennes-CHV, Avenue Désandrouin CS 50479, 59322, Valenciennes Cedex, France
| | - Jean-Baptiste Lascarrou
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu-HME, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Olivier Lesieur
- Médecine Intensive-Réanimation, Hôpital Saint-Louis, Rue Du Dr Schweitzer, 17019, La Rochelle, France
| | - Konstantinos Bachoumas
- Médecine Intensive-Réanimation, Centre Hospitalier Départemental Vendée, Boulevard Stéphane Moreau, 85000, La Roche-Sur-Yon, France
| | - Alexis Ferre
- Intensive Care Unit, Versailles Hospital, 177 Rue De Versailles, 78157, Le Chesnay, France
| | - Eric Maury
- Médecine Intensive-Réanimation, Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Ludivine Chalumeau-Lemoine
- Service de Réanimation Médico-Chirurgicale, Hôpital Privé Claude Galien, 20 Route de Boussy, 91480, Quincy-Sous-Sénart, France
| | - David Bougon
- Médecine Intensive-Réanimation, CH Annecy-Genevois, Site Annecy, 1 Avenue De L'Hôpital, 74370, Annecy, France
| | - Damien Roux
- Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, France
| | - Olivier Guisset
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire-SAINT-ANDRE, Bordeaux, 1 Rue Jean Burguet, 33075, Bordeaux, France
| | - Remi Coudroy
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
- INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Thierry Boulain
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orleans Cedex 2, France.
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Bouhamdi A, Es-Sabbahi B, Amiali R, Serraj M, Biaz M, Benjelloun MC, Amara B. Thirteen Cases of Pulmonary Pneumocystis in HIV-Negative Patients. Cureus 2023; 15:e43409. [PMID: 37706120 PMCID: PMC10496727 DOI: 10.7759/cureus.43409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/15/2023] Open
Abstract
We report 13 cases of pulmonary pneumocystis (PCP) in human immunodeficiency virus (HIV)-uninfected patients. Of eight males and five females, with a mean age of 55 years, one had breast neoplasia, two had common variable immunodeficiency (CVID), one had an autoimmune disease "Goodpasture's syndrome", and one had idiopathic fibrosis (nonspecific interstitial pneumonia/fibrosis (NIP)) undergoing prolonged corticosteroid therapy for two years, with no known immunosuppression in the remaining cases. The clinical picture was characterized by constant dyspnea and severe hypoxia in 11 cases. Lymphopenia was present in nine cases with an average rate of 920.76 elements/mm3. The diagnosis was confirmed by isolation of Pneumocystis jirovecii (PCJ) from induced sputum, except in two cases where analysis of bronchoalveolar lavage (BAL) fluid was required. With trimethoprim/sulfamethoxazole (TMP/SMX) and corticosteroid therapy, the course was favorable in all cases. Prophylactic treatment was indicated in three cases.
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Affiliation(s)
- Abir Bouhamdi
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Btissame Es-Sabbahi
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Rajae Amiali
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Mounia Serraj
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Mohamed Biaz
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Mohamed Chakib Benjelloun
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Bouchra Amara
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
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Hong M, Zhang ZY, Sun XW, Wang WG, Zhang QD, Guo WS. Pneumocystis jiroveci pneumonia after total hip arthroplasty in a dermatomyositis patient: A case report. World J Clin Cases 2022; 10:3313-3320. [PMID: 35603336 PMCID: PMC9082693 DOI: 10.12998/wjcc.v10.i10.3313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/26/2022] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PJP) is a serious opportunistic infection that occurs mostly in patients with immunodeficiency and long-term immunosuppressive therapy. In non-human immunodeficiency virus-infected patients, the most important risk factor for PJP is the use of glucocorticoids in combination with other immunosuppressive treatments. The management of glucocorticoids during the perioperative period in patients with dermatomyositis requires special care.
CASE SUMMARY We report a case of PJP in the perioperative period. A 61-year-old woman with a history of anti-melanoma differentiation-associated gene 5 (MDA5)-positive dermatomyositis and interstitial pneumonia was administered with long-term oral methylprednisolone and cyclosporine. The patient underwent right total hip arthroplasty in the orthopaedic department for bilateral osteonecrosis of the femoral head. She was given intravenous drip hydrocortisone before anesthesia and on the first day after surgery and resumed oral methylprednisolone on the second postoperative day. On the fifth day after surgery, the patient suddenly developed dyspnea. The computed tomography scan showed diffuse grid shadows and ground glass shadows in both lungs. Polymerase chain reaction testing of bronchoalveolar lavage fluid was positive for Pneumocystis jiroveci. The patient was eventually diagnosed with PJP and was administered with oral trimethoprim-sulfamethoxazole. At the 6-mo review, there was no recurrence or progression.
CONCLUSION Continued perioperative glucocorticoid use in patients with anti-MDA5-positive dermatomyositis may increase the risk of PJP.
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Affiliation(s)
- Mao Hong
- Beijing University of Chinese Medicine, Beijing 100029, China
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zi-Yu Zhang
- Beijing University of Chinese Medicine, Beijing 100029, China
| | - Xiao-Wei Sun
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100029, China
| | - Wei-Guo Wang
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Qi-Dong Zhang
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Wan-Shou Guo
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
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A Practical Approach to Antibiotic Use in Critically Ill Obstetric Patients. Obstet Gynecol 2021; 138:459-465. [PMID: 34352843 DOI: 10.1097/aog.0000000000004473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022]
Abstract
In recent years, several new antimicrobials have become available that are safer and more effective compared with older agents commonly used in obstetrics. Basic knowledge of these agents is of paramount importance to obstetricians and maternal fetal medicine specialists, as administration of early adequate broad-spectrum empiric antibiotic coverage plays a pivotal role in the management of septic patients. Of particular importance is the critically ill pregnant patient with life-threatening infectious processes in whom poor initial antibiotic selection may result in higher mortality and significant side effects from antibiotics themselves. In this article we aim to provide a guide for clinicians to select an adequate empirical antibiotic regimen for the most common severe infections that may affect pregnant individuals.
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6
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Hoefsloot S, Urbanski G, Lacout C, Bouvard B, Lavigne C. [Which adjuvant measures should be associated with long-term oral corticosteroid therapy in inflammatory diseases? A summary of existing French recommendations]. Rev Med Interne 2021; 42:616-624. [PMID: 34148673 DOI: 10.1016/j.revmed.2021.03.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 03/01/2021] [Accepted: 03/21/2021] [Indexed: 11/28/2022]
Abstract
It is common to initiate a long-term corticosteroid therapy for inflammatory diseases. Various specialists are involved in this prescription, and associated measures to prevent side effects are not consensual, with the exception of osteoporosis. The specialty of the prescriber has indeed a significant impact on the attention paid to the adjuvant associated measures. The aim of this review was to draw a summary of the side effects of long-term corticosteroid therapy and of the existing recommendations related to associated measures to prevent them. Unfortunately, it is difficult to give clear recommendations because of the lack of evidence in some fields, especially as they should be adapted to patient's age and comorbidities. We propose a summary table of associated measures to long-term steroid therapy prescription and suggest a monitoring frequency.
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Affiliation(s)
- S Hoefsloot
- Service de rhumatologie, CHU Angers, 4, rue Larrey, Angers, France.
| | - G Urbanski
- Service de médecine interne-immunologie clinique, CHU Angers, 4, rue Larrey, Angers, France
| | - C Lacout
- Service de médecine interne-immunologie clinique, CHU Angers, 4, rue Larrey, Angers, France
| | - B Bouvard
- Service de rhumatologie, CHU Angers, 4, rue Larrey, Angers, France
| | - C Lavigne
- Service de médecine interne-immunologie clinique, CHU Angers, 4, rue Larrey, Angers, France
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7
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Rade Q, Gueit I, Hermet PL, Chassagne P, Roca F. [A rare but increasing aetiology of febrile dyspnea in the elderly]. SOINS. GÉRONTOLOGIE 2020; 26:38-39. [PMID: 33549240 DOI: 10.1016/j.sger.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infectious disease well described in patients living with HIV (PLHIV) but that can occur in other immunosuppressed patients. Currently, its incidence decreases in PLHIV but increases in non-HIV immunosuppressed patients, particularly in case of hematological diseases. Thus, in elderly, the diagnosis of PJP should be evoked in case of subacute pneumonia rapidly evolving to an acute respiratory distress, with or without interstitial pneumonia at chest radiography, and a context of immunosuppression.
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Affiliation(s)
| | | | - Pierre-Louis Hermet
- Pôle imagerie médicale, centre hospitalier universitaire de Rouen, 1 rue de Germont, 76031 Rouen cedex, France
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Seiller H, Schmutz JL, Poreaux C, Bursztejn AC. [Fatal interstitial lung disease and pneumocystis during dermatomyositis associated with anti-MDA5 antibodies]. Ann Dermatol Venereol 2020; 147:862-867. [PMID: 33131899 DOI: 10.1016/j.annder.2020.08.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/24/2020] [Accepted: 08/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dermatomyositis (DM) in an auto-immune inflammatory myopathy with skin lesions, and, occasionally, organ involvement. Herein, we report a case of DM during anti-MDA5 antibody therapy associated with interstitial lung disease (ILD) and pneumocystosis. PATIENTS AND METHODS A 64-year-old woman was hospitalized for impairment of her general health and skin lesions. Dermatological examination revealed classic signs of DM associated with hyperkeratotic papules on the palm creases. This led us to suspect DM with anti-MDA5 antibodies, which was subsequently confirmed by immunologic tests. We also noted dysphonia, exertional dyspnea and proximal muscles weakness. Despite early corticosteroid therapy, combined later with azathioprine, the patient's dyspnoea worsened; one month later, sudden pulmonary decompensation resulted in her admission to intensive care. A chest scan showed evidence of ILD and infectious signs, and the bronchoalveolar lavage was positive for Pneumocystisjiroveci. Despite treatment of this opportunist infection with cotrimoxazole and intensified immunosuppression, the patient died in intensive care. DISCUSSION Anti-MDA5 antibodies are associated with a specific clinical phenotype and a high degree of risk that should alert the dermatologist to the high likelihood of ILD having a poor prognosis. Associated clinical signs are erythematous, hyperkeratotic or ulcerated papules on the palm creases, as well as fingertip or periungual ulcerations or digital necrosis. This situation is associated with a high risk of pneumocystosis. However, no recommendations concerning prophylaxis are currently available.
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Affiliation(s)
- H Seiller
- Département de dermato-allergologie, CHRU de Nancy, 6, rue du Morvan, 54500 Vandoeuvre-les-Nancy, France
| | - J-L Schmutz
- Département de dermato-allergologie, CHRU de Nancy, 6, rue du Morvan, 54500 Vandoeuvre-les-Nancy, France
| | - C Poreaux
- Département de dermato-allergologie, CHRU de Nancy, 6, rue du Morvan, 54500 Vandoeuvre-les-Nancy, France
| | - A-C Bursztejn
- Département de dermato-allergologie, CHRU de Nancy, 6, rue du Morvan, 54500 Vandoeuvre-les-Nancy, France.
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Li L, Hsu SH, Gu X, Jiang S, Shang L, Sun G, Sun L, Zhang L, Wang C, Ren Y, Wang J, Pan J, Liu J, Bin C. Aetiology and prognostic risk factors of mortality in patients with pneumonia receiving glucocorticoids alone or glucocorticoids and other immunosuppressants: a retrospective cohort study. BMJ Open 2020; 10:e037419. [PMID: 33109645 PMCID: PMC7592294 DOI: 10.1136/bmjopen-2020-037419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Long-term use of high-dose glucocorticoids can lead to severe immunosuppression and increased risk of treatment-resistant pneumonia and mortality. We investigated the aetiology and prognostic risk factors of mortality in hospitalised patients who developed pneumonia while receiving glucocorticoid therapy alone or glucocorticoid and other immunosuppressant therapies. DESIGN Retrospective cohort study. SETTING Six secondary and tertiary academic hospitals in China. PARTICIPANTS Patients receiving glucocorticoids who were hospitalised with pneumonia between 1 January 2013 and 31 December 2019. MAIN OUTCOMES We analysed the prevalence of comorbidities, microbiology, antibiotic susceptibility patterns, 30-day and 90-day mortality and prognostic risk factors. RESULTS CONCLUSIONS: A total of 716 patients were included, with pneumonia pathogens identified in 69.8% of patients. Significant morbidities occurred, including respiratory failure (50.8%), intensive care unit transfer (40.8%) and mechanical ventilation (36%), with a 90-day mortality of 26.0%. Diagnosis of pneumonia occurred within 6 months of glucocorticoid initiation for 69.7% of patients with Cytomegalovirus (CMV) pneumonia and 79.0% of patients with Pneumocystis jirovecii pneumonia (PCP). Pathogens, including Pneumocystis, CMV and multidrug-resistant bacteria, were identified more frequently in patients with persistent lymphocytopenia and high-dose glucocorticoid treatment (≥30 mg/day of prednisolone or equivalent within 30 days before admission). The 90-day mortality was significantly lower for non-CMV viral pneumonias than for PCP (p<0.05), with a similar mortality as CMV pneumonias (24.2% vs 38.1% vs 27.4%, respectively). Cox regression analysis indicated several independent negative predictors for mortality in this patient population, including septic shock, respiratory failure, persistent lymphocytopenia, interstitial lung disease and high-dose glucocorticoid use.Patients who developed pneumonia while receiving glucocorticoid therapy experienced high rates of opportunistic infections, with significant morbidity and mortality. These findings should be carefully considered when determining treatment strategies for this patient population.
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Affiliation(s)
- Lijuan Li
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Steven H Hsu
- Department of Medical Intensive Care Unit, Houston Methodist Hospital, Houston, Texas, USA
| | - Xiaoying Gu
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Shan Jiang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lianhan Shang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Guolei Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lingxiao Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Li Zhang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Chuan Wang
- Department of Pulmonary and Critical Care Medicine, First Hospital of Shijiazhuang, Shijiazhuang, China
| | - Yali Ren
- Department of Pulmonary and Critical Care Medicine, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jinxiang Wang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jianliang Pan
- Department of Pulmonary and Critical Care Medicine, Second People's Hospital of Weifang, Weifang, China
| | - Jiangbo Liu
- Department of Pulmonary and Critical Care Medicine, Tianjin First Central Hospital, Tianjin, China
| | - Cao Bin
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Science; Tsinghua University-Peking University Joint Center for Life Sciences, China-Japan Friendship Hospital, Beijing, China
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10
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Cillóniz C, Dominedò C, Álvarez-Martínez MJ, Moreno A, García F, Torres A, Miro JM. Pneumocystis pneumonia in the twenty-first century: HIV-infected versus HIV-uninfected patients. Expert Rev Anti Infect Ther 2019; 17:787-801. [PMID: 31550942 DOI: 10.1080/14787210.2019.1671823] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: Pneumocystis pneumonia (PcP) has classically been described as a serious complication in patients infected with the human immunodeficiency virus (HIV). However, the emerging number of conditions associated with immunosuppression has led to its appearance in other patient populations. Areas covered: This article reviews the most recent publications on PcP in the HIV-infected and HIV-uninfected population, focusing on epidemiology, diagnostic, therapy and prevention. The data discussed here were mainly obtained from a non-systematic review using Medline and references from relevant articles including randomized clinical trials, meta-analyses, observational studies and clinical reviews. Expert opinion: The growing incidence of Pneumocystis infection in the HIV-uninfected population suggests the need for new global epidemiological studies in order to identify the true scale of the disease in this population. These data would allow us to improve diagnosis, therapeutic strategies, and clinical management. It is very important that both patients and physicians realize that HIV-uninfected patients are at risk of PcP and that rapid diagnosis and early initiation of treatment are associated with better prognosis. Currently, in-hospital mortality rates are very high: 15% for HIV-infected patients and 50% in some HIV-uninfected patients. Therefore, adequate preventive measures should be implemented to avoid the high mortality rates seen in recent decades.
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Affiliation(s)
- Catia Cillóniz
- Department of Pneumology, Hospital Clinic, Barcelona; August Pi i Sunyer Biomedical Research Institute (IDIBAPS); University of Barcelona; SGR 911; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES) , Barcelona , Spain
| | - Cristina Dominedò
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore , Rome , Italy
| | | | - Asunción Moreno
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
| | - Felipe García
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic, Barcelona; August Pi i Sunyer Biomedical Research Institute (IDIBAPS); University of Barcelona; SGR 911; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES) , Barcelona , Spain
| | - José M Miro
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
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Abstract
Fungi in the genus Pneumocystis live in the lungs of mammals, where they can cause a fatal pneumonia (PCP [Pneumocystis pneumonia]) in hosts with compromised immune systems. The absence of a continuous in vitro culture system for any species of Pneumocystis has led to limited understanding of these fungi, especially for the discovery of new therapies. We recently reported that Pneumocystis carinii, Pneumocystis murina, and most significantly, Pneumocystis jirovecii lack both enzymes necessary for myo-inositol biosynthesis but contain genes with homologies to fungal myo-inositol transporters. Since myo-inositol is essential for eukaryotic viability, the primary transporter, ITR1, was functionally and structurally characterized in P. carinii The predicted structure of P. carinii ITR1 (PcITR1) contained 12 transmembrane alpha-helices with intracellular C and N termini, consistent with other inositol transporters. The apparent Km was 0.94 ± 0.08 (mean ± standard deviation), suggesting that myo-inositol transport in P. carinii is likely through a low-affinity, highly selective transport system, as no other sugars or inositol stereoisomers were significant competitive inhibitors. Glucose transport was shown to use a different transport system. The myo-inositol transport was distinct from mammalian transporters, as it was not sodium dependent and was cytochalasin B resistant. Inositol transport in these fungi offers an attractive new drug target because of the reliance of the fungi on its transport, clear differences between the mammalian and fungal transporters, and the ability of the host to both synthesize and transport this critical nutrient, predicting low toxicity of potential inhibitors to the fungal transporter. IMPORTANCE myo-Inositol is a sugarlike nutrient that is essential for life in most organisms. Humans and microbes alike can obtain it by making it, which involves only 2 enzymes, by taking it from the environment by a transport process, or by recycling it from other cellular constituents. Inspection of the genomes of the pathogenic fungi of the genus Pneumocystis showed that these pneumonia-causing parasites could not make myo-inositol, as they lacked the 2 enzymes. Instead, we found evidence of inositol transporters, which would import the sugar from the lungs where the fungi reside. In the present report, we characterized the transport of myo-inositol in the fungus and found that the transporter was highly selective for myo-inositol and did not transport any other molecules. The transport was distinct from that in mammalian cells, and since mammals can both make and transport myo-inositol, while Pneumocystis fungi must transport it, this process offers a potential new drug target.
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