Empirically treated Pneumocystis carinii pneumonia in Los Angeles, Chicago, and Miami: 1987-1990

Outcome of HIV-associated Pneumocystis pneumonia in hospitalized patients from 2000 through 2003

BACKGROUND

Pneumocystis pneumonia (PCP) remains a leading cause of morbidity and mortality in HIV-infected persons. Epidemiology of PCP in the recent era of highly active antiretroviral therapy (HAART) is not well known and the impact of HAART on outcome of PCP has been debated.

AIM

To determine the epidemiology of PCP in HIV-infected patients and examine the impact of HAART on PCP outcome.

METHODS

We performed a retrospective cohort study of 262 patients diagnosed with PCP between January 2000 and December 2003 at a county hospital at an academic medical center. Death while in the hospital was the main outcome measure. Multivariate modeling was performed to determine predictors of mortality.

RESULTS

Overall hospital mortality was 11.6%. Mortality in patients requiring intensive care was 29.0%. The need for mechanical ventilation, development of a pneumothorax, and low serum albumin were independent predictors of increased mortality. One hundred and seven patients received HAART before hospitalization and 16 patients were started on HAART while in the hospital. HAART use either before or during hospitalization was not associated with mortality.

CONCLUSION

Overall hospital mortality and mortality predictors are similar to those reported earlier in the HAART era. PCP diagnoses in HAART users likely represented failing HAART regimens or non-compliance with HAART.

[Prognostic factors of mortality during the episode of pneumonia due to Pneumocystis carinii in patients with HIV infection]

BACKGROUND

Despite a steady decrease in its incidence, pneumonia caused by Pneumocystis carinii (PCP) are still diagnosed, and they occur frequently in patients unaware of being infected with the human immunodeficiency virus (HIV). Since it is a disease with a high mortality risk, its early diagnosis and therapy would allow these patients to benefit from the advantages afforded Pneumocystis carinii, neumonía, infecciones oportunistas relacionadas con el sida, pronóstico.by anti-retroviral therapy.

PATIENTS AND METHODS

Retrospective study, in which all adult HIV infected patients with microbiologically demonstrated PCP diagnosed at two tertiary-level hospitals in our country between 1985 and 1996 were included. The clinical records of patients were used as information source. The relative risks (RR) of death were estimated by the multivariant logistic regression.

RESULTS

PCP was the first AIDS indicating disease in approximately 70 % of cases. Thirteen percent of patients died during the episode. Patients aged over 45 years had a death RR during the episode of 3.15 (95 % CI from 0.8 to 12.2); patients previously diagnosed of AIDS had a death RR of 3.4 (95 % CI from 1.3 to 9), and those with an alveolar-arterial oxygen gradient (pA-aO2) > 50 mmHg, a death RR of 3 (95% CI from 1.1 to 8).

CONCLUSIONS

Factors independently related to survival to the PCP episode are age below 45 years, not to have had another AIDS indicating disease, and to have a pA-aO2 below 50 mmHg at diagnosis.

Mycobacterial and nonbacterial pulmonary complications in hospitalized patients with human immunodeficiency virus infection: a prospective, cohort study

BACKGROUND

A prospective observational study was done to describe nonbacterial pulmonary complications in hospitalized patients with human immunodeficiency virus (HIV) infection.

METHODS

The study included 1,225 consecutive hospital admissions of 599 HIV-infected patients treated from April 1995 through March 1998. Data included demographics, risk factors for HIV infection, Acute Physiology and Chronic Health Evaluation (APACHE) II score, pulmonary complications, CD4+ lymphocyte count, hospital stay and case-fatality rate.

RESULTS

Patient age (mean +/- SD) was 38.2 +/- 8.9 years, 62% were men, and 84% were African American. The median APACHE II score was 14, and median CD4+ lymphocyte count was 60/microL. Pulmonary complications were Pneumocystis carinii pneumonia (85) in 78 patients, Mycobacterium avium complex (51) in 38, Mycobacterium tuberculosis (40) in 35, Mycobacterium gordonae (11) in 11, Mycobacterium kansasii (10) in 9, Cytomegalovirus (10) in 10, Nocardia asteroides (3) in 3, fungus ball (2) in 2, respiratory syncytial virus (1), herpes simplex virus (1), Histoplasma capsulatum (1), lymphoma (3) in 3, bronchogenic carcinoma (2) in 2, and Kaposi sarcoma (1). The case-fatality rate of patients was 11% with Pneumocystis carinii pneumonia; 5%, Mycobacterium tuberculosis; 6%, Mycobacterium avium complex; and 7%, noninfectious pulmonary complications.

CONCLUSION

Most pulmonary complications in hospitalized patients with HIV are from Pneumocystis and mycobacterial infection.

Variations in intensive care unit utilization for patients with human immunodeficiency virus-related Pneumocystis carinii pneumonia: importance of hospital characteristics and geographic location

OBJECTIVE

To determine whether intensive care unit (ICU) use and outcomes for patients with human immunodeficiency virus (HIV)-related Pneumocystis carinii pneumonia vary by hospital characteristics and geographic location.

DESIGN

Retrospective review of the medical records of 2,174 patients with HIV-related P. carinii pneumonia.

SETTING

Random sample of 73 private, nine public, and 14 Veterans Affairs hospitals in five cities (Chicago, New York, Los Angeles, Miami, and Durham, NC).

PATIENTS

Stratified random sample of patients hospitalized with HIV-related P. carinii pneumonia from 1987 to 1990.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among the 2,174 patients with P. carinii pneumonia, 398 (18%) patients received care in an ICU. ICU utilization varied significantly by patient and hospital characteristics, as well by as geographic location. Non-Hispanic whites, patients with Medicaid, and patients with a prior acquired immunodeficiency syndrome-defining illness were the least likely to receive care in an ICU. Patients in county- or state-owned hospitals and patients in hospitals with more P. carinii pneumonia-experience were also less likely to be cared for in an ICU. These differences in ICU utilization persisted when controlling for severity of illness, as well as other patient characteristics. Significant geographic variation in ICU utilization persisted after controlling for patient and hospital characteristics. Survival to hospital discharge after an ICU stay was significantly higher for patients without a prior acquired immunodeficiency syndrome-defining illness and for patients in hospitals with more P. carinii pneumonia experience.

CONCLUSIONS

We found significant variations in ICU utilization by hospital characteristics and geographic location that remained significant after controlling for severity of illness and patient sociodemographic characteristics. Hospital and geographic variations in ICU utilization may make it difficult to generalize ICU outcomes across different hospitals.

Variations in medical care for HIV-related Pneumocystis carinii pneumonia: a comparison of process and outcome at two hospitals

BACKGROUND

Institutional variation in the quality of medical care may be evaluated by examining process measures, such as use of diagnostic procedures or treatment modalities, or outcome measures, such as mortality. We undertook this study to examine variations in both process and outcome of care for patients with HIV-related Pneumocystis carinii pneumonia (PCP) at two geographically diverse, HIV-experienced, public municipal hospitals.

DESIGN

Retrospective review of hospitalized patients diagnosed as having PCP cared for at two municipal hospitals from 1988 to 1990. At hospital A, charts of all patients diagnosed as having PCP were abstracted (n=209); at hospital B, a random sample of 15% were abstracted (=136).

RESULTS

Among all hospitalized patients diagnosed as having PCP, the frequency of making a definitive diagnosis of PCP (as opposed to treating empirically) differed markedly at the two hospitals (85% in hospital A vs 26% in hospital B; p<0.001), as did the use of intensive care (18% vs 3%; p<0.001) and "do-not-resuscitate" orders (39% vs 14%; p<0.001), although the timing of starting anti-Pneumocystis medications (89% vs 88% within the first 2 hospital days) and the use of corticosteroids (21% vs 23%) were similar. Despite differences in the process of care, survival rates were similar at the two institutions (75% vs 76%; p=0.8) and remained similar when logistic regression was used to control for demographic variables and severity of illness (odds ratio for survival, hospital B vs A, 1.2 [95% confidence interval, 0.7, 2.0]). The 95% confidence intervals (0.7, 2.0), however, were consistent with a considerable (and clinically significant) disparity in survival (from 30% lower to a twofold higher odds of survival). Sample size calculations showed that a sample of 10 cases in each hospital would be required to detect the observed difference in definitive diagnosis rates (85% vs 26%), but 722 cases in each hospital would be required to detect a relevant difference in mortality.

CONCLUSIONS

The process of care for hospitalized patients with PCP in these two institutions differed considerably, but the survival rates were not significantly different, even after adjusting for confounding factors. While sample sizes available at the individual institutions were sufficient for evaluation of the process of care, they did not provide the power necessary to evaluate outcomes. Comparisons of outcomes such as mortality between individual hospitals may not have the statistical power to exclude important differences.

U.S. hospital care for HIV-infected persons and the role of public, private, and Veterans Administration hospitals

Hospitals are a major provider of medical care for human immunodeficiency virus (HIV)-infected persons. Although utilization and patterns of care profiles in public and private hospitals have been evaluated for acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), one of the most costly and common severe complications of AIDS, information from Veterans Administration (VA) hospitals has not been reported previously. This article reports on inpatient care for PCP patients by obtaining data from VA, private, and public hospitals. Cost and resource utilization data were obtained from reviews of medical records, claims, and provider bills from 26 non-VA hospitals and 18 VA hospitals in 10 cities in the United States. Data on severity of illness, patterns of care, and outcomes for PCP were obtained from medical record reviews from 2,174 PCP cases treated in 82 non-VA and 14 VA hospitals in five U.S. cities. Estimates were made of the average costs and the rates of use of diagnostic tests, anti-PCP medications, and intensive care units for samples of public hospital, private hospital, and VA patients with PCP. With mean charges for a single PCP episode of $14,500 to $16,060, PCP remains one of thea most costly complications of AIDS. Although the severity of PCP illness at admission was greatest at public hospitals, the intensity of care was lowest: for frequency of cytologic diagnosis (48% at public, 62% at VA, and 66% at private hospitals), bronchoscopy (45% at public, 60% at VA, and 66% at private hospitals), and intensive care unit use (11% at public, 22% at VA, and 19% at private hospitals). In-hospital mortality rates for PCP also differed in the three types of hospitals (20% at public, 24% at VA, and 18% at private hospitals). Patterns of PCP care differ among VA, public, and private hospitals. Future studies on the HIV epidemic should include data collected from uniform data sources from VA hospitals, in addition to public and private hospitals, to provide insight on the processes of care and outcomes for HIV-infected persons.

HIV-associated respiratory diseases

The lungs of individuals infected with HIV are often affected by opportunistic infections and tumours; over two-thirds of patients have at least one respiratory episode during the course of their disease. Despite the availability of effective prophylaxis, infection with the fungus Pneumocystis carinii remains a common cause of respiratory disease. Bacterial infections, which occur more frequently in HIV-infected persons than in the general population, and tuberculosis are increasing causes of morbidity and mortality. Kaposi's sarcoma, the commonest HIV-associated malignancy, may affect the lungs in addition to the skin. Pulmonary involvement by non-Hodgkin lymphoma is common in those with disseminated disease.

Predictors of resource utilization for hospitalized patients with Pneumocystis carinii pneumonia (PCP): a summary of effects from the multi-city study of quality of PCP care

To determine whether patient and hospital characteristics were significantly associated with variations in Pneumocystis carinii (PCP) care and outcomes, we analyzed the use of diagnostic tests, intensive care units (ICUs), anti-PCP medications for persons hospitalized with human immunodeficiency virus (HIV)-related PCP, and hospital discharge status. We conducted retrospective chart reviews of a cohort of 2,174 patients with PCP hospitalized in 1987-1990. Outcomes included process of care for PCP and in-hospital mortality rates. Persons with PCP who were more severely ill at admission were more likely to have early medical care, to receive care in an intensive care unit, and to die in hospital. After we adjusted for differences in this severity of illness, we noted that Medicaid patients, injection drug users (IDUs), and patients treated at VA or county hospitals were significantly less likely than others to have diagnostic bronchoscopies and that persons covered by Medicaid, with a previous diagnosis of acquired immunodeficiency syndrome (AIDS), who did not receive prior zidovudine (AZT) or who received care in a VA hospital had the highest chances of in-hospital death. Insurance and risk group characteristics, severity of illness, and hospital characteristics appear to be the most important determinants of the intensity and timing of medical care and outcomes among patients hospitalized with PCP.