Critical care of immunocompromised patients: human immunodeficiency virus

Investigations into the physical and chemical stability of concentrated co-trimoxazole intravenous infusions

Objectives

High dose of intravenous sulfamethoxazole and trimethoprim (co-trimoxazole) is often used in immunocompromised patients for the treatment of Pneumocystis jiroveci pneumonia. Current manufacturer's dilution recommendation for intravenous co-trimoxazole (1:25 v/v) requires the administration of 2 L of additional fluid per day causing serious complications including pulmonary oedema. Intravenous administration of concentrated solution of co-trimoxazole may minimise the risk of fluid overload associated side effects. Therefore, the objective of the study was to investigate the physicochemical stability of concentrated intravenous co-trimoxazole solutions.

Methods

Four ampoules of intravenous co-trimoxazole were injected into an infusion bag containing either 480 (1:25 v/v), 380 (1:20 v/v), 280 (1:15 v/v) or 180 (1:10 v/v) mL of glucose 5% solution. Three bags for each dilution (total 12 bags) were prepared and stored at room temperature. An aliquot was withdrawn immediately (at 0 hour) and after 0.5, 1, 2 and 4 hours of storage for high-performance liquid-chromatography (HPLC) analysis, and additional samples were withdrawn every half an hour for microscopic examination. Each sample was analysed for the concentration of trimethoprim and sulfamethoxazole using a stability indicating HPLC method. Samples were assessed for pH, change in colour (visually) and for particle content (microscopically) immediately after preparation and on each time of analysis.

Results

Intravenous co-trimoxazole at 1:25, 1:20, 1:15 and 1:10 v/v retained more than 98% of the initial concentration of trimethoprim and sulfamethoxazole for 4 hours. There was no major change in pH at time zero and at various time points. Microscopically, no particles were detected for at least 4 hours and 2 hours when intravenous co-trimoxazole was diluted at 1:25 or 1:20 and 1:15 v/v, respectively. More than 1200 particles/mL were detected after 2.5 hours of storage when intravenous co-trimoxazole was diluted at 1:15 v/v.

Conclusions

Intravenous co-trimoxazole is stable over a period of 4 hours when diluted with 380 mL of glucose 5% solution (1:20 v/v) and for 2 hours when diluted with 280 mL glucose 5% solution (1:15 v/v).

Bloodstream Infections

Bacteremia and sepsis are conditions associated with high mortality and are of great impact to health care operations. Among the top causes of mortality in the United States, these conditions cause over 600 fatalities each day. Empiric, broad-spectrum treatment is a common but often a costly approach that may fail to effectively target the correct microbe, may inadvertently harm patients via antimicrobial toxicity or downstream antimicrobial resistance. To meet the diagnostic challenges of bacteremia and sepsis, laboratories must understand the complexity of diagnosing and treating septic patients, in order to focus on creating algorithms that can help direct a more targeted approach to antimicrobial therapy and synergize with existing clinical practices defined in new Surviving Sepsis Guidelines. Significant advances have been made in improving blood culture media; as yet no molecular or antigen-based method has proven superior for the detection of bacteremia in terms of limit of detection. Several methods for rapid molecular identification of pathogens from blood cultures bottles are available and many more are on the diagnostic horizon. Ultimately, early intervention by molecular detection of bacteria and fungi directly from whole blood could provide the most patient benefit and contribute to tailored antibiotic coverage of the patient early on in the course of the disease. Although blood cultures remain as the best means of diagnosing bacteremia and candidemia, complementary testing with antigen tests, microbiologic investigations from other body sites, and histopathology can often aid in the diagnosis of disseminated disease, and application of emerging nucleic acid test methods and other new technology may greatly impact our ability to bacteremic and septic patients, particularly those who are immunocompromised.

Etiologies, clinical features and outcome of cardiac arrest in HIV-infected patients

BACKGROUND

Compared to many other cardiovascular diseases, there is a paucity of data on the characteristics of successfully resuscitated cardiac arrest (CA) patients with human immunodeficiency virus (HIV) infection. We investigated causes, clinical features and outcome of these patients, and assessed the specific burden of HIV on outcome.

METHODS

Retrospective analysis of HIV-infected patients admitted to 20 French ICUs for successfully resuscitated CA (2000-2012). Characteristics and outcome of HIV-infected patients were compared to those of a large cohort of HIV-uninfected patients admitted after CA in the Cochin Hospital ICU during the same period.

RESULTS

99 patients were included (median CD4 lymphocyte count 233/mm(3), viral load 43 copies/ml). When compared with the control cohort of 1701 patients, HIV-infected patients were younger, with a predominance of male, a majority of in-hospital CA (52%), and non-shockable initial rhythm (80.8%). CA was mostly related to respiratory cause (n=36, including 23 pneumonia), cardiac cause (n=33, including 16 acute myocardial infarction), neurologic cause (n=8) and toxic cause (n=5). CA was deemed directly related to HIV infection in 18 cases. Seventy-one patients died in the ICU, mostly for care withdrawal after post-anoxic encephalopathy. After propensity score matching, ICU mortality was not significantly affected by HIV infection. Similarly, HIV disease characteristics had no impact on ICU outcome.

CONCLUSIONS

Etiologies of CA in HIV-infected patients are miscellaneous and mostly not related to HIV infection. Outcome remains bleak but is similar to outcome of HIV-negative patients.

Treatment of immigrants and residents suffering from neuro-AIDS on a neurological intensive care unit: epidemiology and predictors of outcome

This study aimed at determining the clinical features and predictors for the outcome of patients with Neuro-Aids treated on a neurological intensive care unit (NICU) using retrospective analysis of all patients treated for Neuro-Aids in a tertiary Department of Neurology between 1996 and 2011. Chart review of the patients including the characteristics of intensive care was performed. As negative outcome, "death on the NICU or within 2 months following completion of NICU treatment" was defined. In total, 462 patients were identified of whom 87 were immigrants. 67 of all patients required NICU treatment (mean age 40.2 ± 0.8 years; 64% male). The median of the duration between diagnosis of HIV infection and the onset of treatment on NICU was 8 days for immigrants and 10 years for residents (p < 0.001). 34 of the patients on the NICU died due to severe neuromanifestations. Negative predictors for death were: (1) artificial ventilation; (2) antiretroviral-naïve immigrant; (3) primary cerebral lymphoma; (4) missing antiretroviral therapy upon admission to the NICU. Gender, age, ethnicity, CD4+ cell count, and viral load were no predictors of a negative outcome. The results indicated that the rate of death during treatment on a NICU is much higher as compared with treatment on an internal medicine ICU. A lot of research and effort will be necessary to improve this outcome especially for immigrants with Neuro-Aids.

Etiology and Outcome of Patients with HIV Infection and Respiratory Failure Admitted to the Intensive Care Unit

Background. Although access to HAART has prolonged survival and improved quality of life, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support. Our objective is to evaluate the etiology of respiratory failure in patients with HIV infection admitted to the ICU, its relationship with the T-lymphocytes cell count as well as the use of HAART, and its impact on outcome. Methods. A single-center, prospective, and observational study among all patients with HIV-infection and respiratory failure admitted to the ICU from December 1, 2011, to February 28, 2013, was conducted. Results. A total of 42 patients were admitted during the study period. Their median CD4 cell count was 123 cells/ μ L (mean 205.7, range 2.0-694.0), with a median HIV viral load of 203.5 copies/mL (mean 58,676, range <20-367,649). At the time of admission, 23 patients (54.8%) were receiving HAART. Use of antiretroviral therapy at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts and lower HIV viral loads. Twenty-five patients (59.5%) had respiratory failure secondary to non-HIV-related diseases. Mechanical ventilation was required in 36 patients (85.1%). Thirteen patients (31.0%) died. Conclusions. Noninfectious etiologies of respiratory failure account for majority of HIV-infected patients admitted to ICU. Increased mortality was observed among patients with sepsis as etiology of respiratory failure (HIV related and non-AIDS related), in those receiving mechanical ventilation, and in patients with decreased CD4 cell count. Survival was not associated with the use of HAART. Complementary studies are warranted to address the impact of HAART on outcomes of HIV-infected patients with respiratory failure admitted to ICU.

Management of persons infected with human immunodeficiency virus requiring admission to the intensive care unit

Rates of admission to the intensive care unit (ICU) for persons infected with human immunodeficiency virus (HIV) remain relatively unchanged in the modern era despite advances in antiretroviral therapy (ART) and improvements in ICU survival. Critical care may be required for patients with HIV because of severe opportunistic infections or malignancy, antiretroviral drug toxicity, or critical illness seemingly unrelated to HIV, and each of these scenarios may present different management challenges. In this article, the epidemiology of HIV-related ICU admission is reviewed and key management issues are discussed.

Admissions to intensive care unit of HIV-infected patients in the era of highly active antiretroviral therapy: etiology and prognostic factors

INTRODUCTION

Although access to highly active antiretroviral therapy (HAART) has prolonged survival and improved life quality, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support in intensive care units (ICU). This study aimed to describe the etiology and analyze the prognostic factors of HIV-infected Taiwanese patients in the HAART era.

METHODS

Medical records of all HIV-infected adults who were admitted to ICU at a university hospital in Taiwan from 2001 to 2010 were reviewed to record information on patient demographics, receipt of HAART, and reason for ICU admission. Factors associated with hospital mortality were analyzed.

RESULTS

During the 10-year study period, there were 145 ICU admissions for 135 patients, with respiratory failure being the most common cause (44.4%), followed by sepsis (33.3%) and neurological disease (11.9%). Receipt of HAART was not associated with survival. However, CD4 count was independently predictive of hospital mortality (adjusted odds ratio [AOR], per-10 cells/mm3 decrease, 1.036; 95% confidence interval [CI], 1.003 to 1.069). Admission diagnosis of sepsis was independently associated with hospital mortality (AOR, 2.91; 95% CI, 1.11 to 7.62). A hospital-to-ICU interval of more than 24 hours and serum albumin level (per 1-g/dl decrease) were associated with increased hospital mortality, but did not reach statistical significance in multivariable analysis.

CONCLUSIONS

Respiratory failure was the leading cause of ICU admissions among HIV-infected patients in Taiwan. Outcome during the ICU stay was associated with CD4 count and the diagnosis of sepsis, but was not associated with HAART in this study.

[Treatment of neuro-AIDS on a neurological intensive care unit: epidemiology and predictors of outcome]

BACKGROUND

Investigations concerning the outcome for patients suffering from neuro-AIDS treated on a neurological intensive care unit and specific predictors indicating "dead" were analyzed.

MATERIAL AND METHODS

A total of 56 patients with a mean age of 39 ± 0.7 years, a mean CD4+ cell count of 130 ± 166 CD4+ cells/µl and viral load of 146,520 ± 198,059 copies/ml were treated on a neurological intensive care unit due to different forms of neuro-AIDS.

RESULTS

Of the patients, 34% were immigrants of whom 74% came from sub-Saharan regions. In 57% of the patients the diagnosis of HIV infection was made during therapy on the neurological intensive care unit. The median for the time between diagnosis of HIV infection and the treatment on the neurological intensive care unit was 8 days for immigrants and 10 years for residents. The most common manifestations of neuro-AIDS were cerebral toxoplasmosis, cryptococcosis and progressive multifocal leukoencephalopathy (PML). Fifty per cent of the patients (n=28) died during treatment on the neurological intensive care unit. Negative predictors for the outcome "dead" were (a) artificial ventilation, (b) antiretroviral naïve immigrant, (c) primary cerebral lymphoma and (d) missing antiretroviral therapy as a result of admission to the intensive care unit.

DISCUSSION

The rate of death during treatment of neuro-AIDS on a neurological intensive care unit is much higher than during treatment of internal medicine problems of HIV infection. Antiretroviral naïve immigrants show a much higher rate of death compared to residents in Germany. A lot of research and effort is necessary to improve the availability of the Highly Active Anti-Retroviral Therapy (HAART) worldwide in order to improve the outcome especially for immigrants with neuro-AIDS treated on a neurological intensive care unit.

The changing epidemiology of HIV-infected patients in the intensive care unit

With the introduction of highly active antiretroviral therapy (HAART), HIV has become a chronic disease. As HIV-infected patients are aging, they are at increased risk for comorbid diseases. These non-AIDS related diseases account for a growing proportion of intensive care unit (ICU) admissions in HIV-infected patients in recent studies. HIV-infected patients still present to the ICU with HIV-related conditions such as Pneumocystis jirovecii pneumonia (PCP), but these conditions are becoming less common. Respiratory failure remains the most common indication for ICU admission. Immune reconstitution inflammatory response syndrome and toxicities related to HAART may also result in ICU admission. While ICU survival has improved since the earliest era of the HIV epidemic, hospital mortality for HIV-infected patients admitted to the ICU remains around 30%. Risk factors for ICU mortality include poor functional status, weight loss, more than one year between HIV diagnosis and ICU admission, lower serum albumin, higher severity of illness, need for mechanical ventilation, and respiratory failure-particularly if due to PCP and accompanied by pneumothorax. The impact of HAART on ICU outcomes is unclear. HAART administration in the ICU can be challenging due to limited delivery routes, concern for viral resistance and medication toxicities. There are no data to determine the safety or efficacy of HAART initiation in the ICU. Future studies are needed to address the role of age, associated comorbidities and impact of HAART on outcomes of HIV-infected patients admitted to the ICU.

Neurological complications of HIV infection in critically ill patients: clinical features and outcomes

OBJECTIVE

We aimed to investigate the prognosis of HIV-infected patients with acute neurological complications at the highly active antiretroviral therapy (HAART) era.

METHODS

We performed a retrospective study in HIV-infected patients admitted to a medical ICU with neurological complications between 2001 and 2008.

RESULTS

Among the 210 studied patients (median [interquartile range] CD4-cell count: 80 [18-254]/μL; HIV viral load: 4.8 [2-5.3] log₁₀/mL), 40 (19%) had unknown HIV status at admission. Neurological complications consisted in delirium (45%), coma (39%), seizures (32%) and/or intracranial hypertension (21%). Admission diagnoses were AIDS-defining CNS disease for 88 (42%) patients, non-AIDS-defining CNS disease for 45 (21%), and systemic disease with neurological signs for 77 (37%). Seizures (p=0.003), focal deficit (p<0.001) and intracranial hypertension (p<0.001) were more frequently observed in patients with AIDS-defining CNS disease. Factors independently associated with ICU mortality (29.5%) were intracranial hypertension [odds ratio (OR), 5.09; 95% confidence interval (95% CI), 2.17-11.91], vasopressor use [OR, 3.92; 95% CI, 1.78-8.60] and SAPS II score [per 10-point increment, OR, 1.59; 95% CI, 1.31-1.93].

CONCLUSIONS

Prognosis of HIV-infected patients with neurological complications depends rather on clinical presentation than on HIV-related parameters. Intracranial hypertension symptoms at admission have a major impact on outcome.

Sepsis is a major determinant of outcome in critically ill HIV/AIDS patients

Introduction

New challenges have arisen for the management of critically ill HIV/AIDS patients. Severe sepsis has emerged as a common cause of intensive care unit (ICU) admission for those living with HIV/AIDS. Contrastingly, HIV/AIDS patients have been systematically excluded from sepsis studies, limiting the understanding of the impact of sepsis in this population. We prospectively followed up critically ill HIV/AIDS patients to evaluate the main risk factors for hospital mortality and the impact of severe sepsis on the short- and long-term survival.

Methods

All consecutive HIV-infected patients admitted to the ICU of an infectious diseases research center, from June 2006 to May 2008, were included. Severity of illness, time since AIDS diagnosis, CD4 cell count, antiretroviral treatment, incidence of severe sepsis, and organ dysfunctions were registered. The 28-day, hospital, and 6-month outcomes were obtained for all patients. Cox proportional hazards regression analysis measured the effect of potential factors on 28-day and 6-month mortality.

Results

During the 2-year study period, 88 HIV/AIDS critically ill patients were admitted to the ICU. Seventy percent of patients had opportunist infections, median CD4 count was 75 cells/mm³, and 45% were receiving antiretroviral therapy. Location on a ward before ICU admission, cardiovascular and respiratory dysfunctions on the first day after admission, and the presence of severe sepsis/septic shock were associated with reduced 28-day and 6-month survival on a univariate analysis. After a multivariate analysis, severe sepsis determined the highest hazard ratio (HR) for 28-day (adjusted HR, 3.13; 95% CI, 1.21-8.07) and 6-month (adjusted HR, 3.35; 95% CI, 1.42-7.86) mortality. Severe sepsis occurred in 44 (50%) patients, mainly because of lower respiratory tract infections. The survival of septic and nonseptic patients was significantly different at 28-day and 6-month follow-up times (log-rank and Peto test, P < 0.001).

Conclusions

Severe sepsis has emerged as a major cause of admission and mortality for hospitalized HIV/AIDS patients, significantly affecting short- and longer-term survival of critically ill HIV/AIDS patients.

Human immunodeficiency virus infection and hospital mortality in acute lung injury patients

OBJECTIVE

To evaluate the impact of human immunodeficiency virus infection on hospital mortality in patients with acute lung injury and to evaluate predictors of mortality among acute lung injury patients with human immunodeficiency virus.

DESIGN, SETTING, AND PATIENTS

Retrospective study of human immunodeficiency virus-infected patients enrolled in an ongoing prospective cohort study of acute lung injury patients conducted at 13 intensive care units in four teaching hospitals in Baltimore, Maryland.

MEASUREMENTS AND MAIN RESULTS

Of 520 consecutive acute lung injury patients, 66 (13%) were human immunodeficiency virus-positive. In human immunodeficiency virus-positive vs. human immunodeficiency virus-negative patients, pneumonia was the most common acute lung injury risk factor (43 [65%] vs. 184 [41%]; p=.001), and the median (interquartile range) Acute Physiology and Chronic Health Evaluation II score was modestly higher (27 [22-33] vs. 26 [20-33]; p=.06). There was no difference in crude hospital mortality (44% vs. 46%; p=.78) between human immunodeficiency virus-positive and human immunodeficiency virus-negative acute lung injury patients. After adjustment for potential confounders, human immunodeficiency virus infection was not an independent predictor of hospital mortality (odds ratio, 1.39; 95% confidence interval, 0.69-2.78; p=.35). In the human immunodeficiency virus-infected acute lung injury patients, among 23 relevant measures of intensive care unit and human immunodeficiency virus severity of illness, only the presence of an opportunistic infection before hospital admission was independently associated with hospital mortality (odds ratio, 6.4; 95% confidence interval, 1.27-32.3; p=.025).

CONCLUSIONS

In patients with acute lung injury, human immunodeficiency virus-positive patients had similar hospital mortality as human immunodeficiency virus-negative patients; hence, human immunodeficiency virus status should not influence estimates of short-term prognosis for acute lung injury patients in the intensive care unit. Among human immunodeficiency virus-positive patients with acute lung injury, the presence of a previous opportunistic infection, rather than traditional measures of severity of illness, may be most strongly predictive of hospital mortality.

Survival trends in critically ill HIV-infected patients in the highly active antiretroviral therapy era

Introduction

The widespread use of highly active antiretroviral therapy (ART) has reduced HIV-related life-threatening infectious complications. Our objective was to assess whether highly active ART was associated with improved survival in critically ill HIV-infected patients.

Methods

A retrospective study from 1996 to 2005 was performed in a medical intensive care unit (ICU) in a university hospital specialized in the management of immunocompromised patients. A total of 284 critically ill HIV-infected patients were included. Differences were sought across four time periods. Risk factors for death were identified by multivariable logistic regression.

Results

Among the 233 (82%) patients with known HIV infection before ICU admission, 64% were on highly active ART. Annual admissions increased over time, with no differences in reasons for admission: proportions of patients with newly diagnosed HIV, previous opportunistic infection, CD4 counts, viral load, or acute disease severity. ICU and 90-day mortality rates decreased steadily: 25% and 37.5% in 1996 to 1997, 17.1% and 17.1% in 1998 to 2000, 13.2% and 13.2% in 2001 to 2003, and 8.6% in 2004 to 2005. Five factors were independently associated with increased ICU mortality: delayed ICU admission (odds ratio (OR), 3.04; 95% confidence interval (CI), 1.29 to 7.17), acute renal failure (OR, 4.21; 95% CI, 1.63 to 10.92), hepatic cirrhosis (OR, 3.78; 95% CI, 1.21 to 11.84), ICU admission for coma (OR, 2.73; 95% CI, 1.16 to 6.46), and severe sepsis (OR, 3.67; 95% CI, 1.53 to 8.80). Admission to the ICU in the most recent period was independently associated with increased survival: admission from 2001 to 2003 (OR, 0.28; 95% CI, 0.08 to 0.99), and between 2004 and 2005 (OR, 0.13; 95% CI, 0.03 to 0.53).

Conclusions

ICU survival increased significantly in the highly active ART era, although disease severity remained unchanged. Co-morbidities and organ dysfunctions, but not HIV-related variables, were associated with death. Earlier ICU admission from the hospital ward might improve survival.

Pulmonary infections in the HIV-infected patient in the era of highly active antiretroviral therapy: an update

The highly active antiretroviral therapy (HAART) era began in 1996 when the combination of multiple antiretroviral agents was found to improve outcomes in HIV-infected patients. HAART has made a tremendous impact on the progression of HIV and on the morbidity and mortality associated with its opportunistic infections. HIV-positive patients who respond to HAART have a decreased incidence of opportunistic infections. Studies have documented close to a 50% decline in the incidence of pneumocystis pneumonia and bacterial pneumonia with the use of antiretroviral therapy. Primary and secondary prophylaxis for pneumocystis pneumonia can be discontinued in patients who show a sustained response to antiretroviral therapy. Unique to the HAART era, immune reconstitution syndrome is characterized by a paradoxical deterioration of a preexisting infection that is temporally related to the recovery of the immune system. Recently, more and more patients are being admitted for non-AIDS related illnesses in the HAART era.

[Massive alveolar hemorrhage due to cytomegalovirus (CMV) and HIV infection]

Alveolar hemorrhage may be a complication of diseases with local and systemic manifestations. Both share the same pathophysiological concept: damage to the alveolar microcirculation. It is a clinical entity that generates a diagnostic challenge for the physician. Early recognition favors aggressive treatment, which can improve the outcome. Despite the technological advances in its diagnosis and treatment, it is still a condition having high morbidity and mortality. We present the case of a 42-year old woman diagnosed of massive alveolar hemorrhage induced by cytomegalovirus (CMV) and HIV infection. Its presentation is atypical because most reported cases have occurred as a pneumonic process, episodes of massive hemorrhage being uncommon. The diagnosis was documented by bronchoscopy with bronchoalveolar lavage and etiological diagnosis with molecular techniques using reverse transcription polymerase chain reaction.

Care of the AIDS patient with Pneumocystis pneumonia

Pneumocystis pneumonia and AIDS have been linked together for many years. In the 1980s and 1990s, these diseases often resulted in admission to the critical care unit for many patients. Since the discovery of antiretroviral therapy and Pneumocystis prophylaxis, this has been a less frequent occurrence. Knowledge about caring for this patient in the critical care unit is often not available. Psychological and physiological needs common to this population are different from other populations and must be addressed. Pharmacological challenges are common and may go unrecognized until complications ensue. This article seeks to alleviate some of the mystery associated with these issues.

Approach to the immunocompromised host with infection in the intensive care unit

Despite significant advances in the prevention, diagnosis, and treatment of infection in the immunocompromised host, it remains a major cause of morbidity, increased length of stay, total costs, and of course mortality. Intensive care mortality rates are significantly higher among immunocompromised hosts in part due to the higher incidence of infection severity. The superimposition of the compromised host defenses and critical illness makes the detection and management of infections in such patients more difficult, but crucial toward salvaging patient outcome. Moreover, although there is a rapidly increasing evidence base in intensive care medicine, many interventional trials for the management of severe sepsis (activated protein C, adjunctive corticosteroids, goal-based resuscitation), acute lung injury (low stretch ventilation), and other organ failures have excluded immunocompromised hosts.

Surviving sepsis in low-income and middle-income countries: new directions for care and research

Sepsis is a disorder characterised by systemic inflammation secondary to infection. Despite recent progress in the understanding and treatment of sepsis, no data or recommendations exist that detail effective approaches to sepsis care in resource-limited low-income and middle-income countries (LMICs). Although few data exist on the burden of sepsis in LMICs, the prevalence of HIV and other comorbid conditions in some LMICs suggest that sepsis is a substantial contributor to mortality in these regions. In well-resourced countries, sepsis management relies on protocols and complex invasive technologies not widely available in most LMICs. However, the key concepts and components of sepsis management are potentially translatable to resource-limited environments. Health personnel in LMICs should be educated in the recognition of sepsis and the importance of early and appropriate antibiotic use. Simple and low-cost standardised laboratory testing should be emphasised to allow accurate diagnosis, prognosis, and monitoring of treatment response. Evidence-based interventions and treatment algorithms tailored to LMIC ecology and resources should thus be developed and validated.

Etiologies and outcome of acute respiratory failure in HIV-infected patients

Objective

To assess the etiologies and outcome of acute respiratory failure (ARF) in HIV-infected patients over the first decade of combination antiretroviral therapy (ART) use.

Methods

Retrospective study of all HIV-infected patients (n = 147) admitted to a single intensive care unit (ICU) for ARF between 1996 and 2006.

Results

ARF revealed the diagnosis of HIV infection in 43 (29.2%) patients. Causes of ARF were bacterial pneumonia (n = 74), Pneumocystis jirovecii pneumonia (PCP, n = 52), other opportunistic infections (n = 19), and noninfectious pulmonary disease (n = 33); the distribution of causes did not change over the 10-year study period. Two or more causes were identified in 33 patients. The 43 patients on ART more frequently had bacterial pneumonia and less frequently had opportunistic infections (P = 0.02). Noninvasive ventilation was needed in 49 patients and endotracheal intubation in 42. Hospital mortality was 19.7%. Factors independently associated with mortality were mechanical ventilation [odds ratio (OR) = 8.48, P < 0.0001], vasopressor use (OR, 4.48; P = 0.03), time from hospital admission to ICU admission (OR, 1.05 per day; P = 0.01), and number of causes (OR, 3.19; P = 0.02). HIV-related variables (CD4 count, viral load, and ART) were not associated with mortality.

Conclusion

Bacterial pneumonia and PCP remain the leading causes of ARF in HIV-infected patients in the ART era. Hospital survival has improved, and depends on the extent of organ dysfunction rather than on HIV-related characteristics.

Behandlung von Patienten mit HIV-Infektion auf der Intensivstation

HIV-infizierte Patienten können aus einer Reihe von Indikationen heraus der Intensivbehandlung bedürfen (·Abb. 66.1; [7, 17, 19, 33, 41, 44, 51]). In 50–75% der Fälle stellt akutes respiratorisches Versagen die Indikation für die Behandlung HIV-Infizierter auf der Intensivstation dar [7, 17, 19, 33, 41, 44, 51]. Bei 55–90% dieser Patienten mit intensiv behandlungsbedürftigem respiratorischen Versagen stellt Pneumocystis carinii das für die Erkrankung verantwortliche Pathogen dar [7, 33, 44].