Does HIV infection influence outcomes after trauma?

Trauma patients with human immunodeficiency virus (HIV): a propensity matched analysis

Background

Given the growing number of people worldwide living with human immunodeficiency virus (HIV), a larger subset of these patients are now susceptible to sustaining a traumatic injury. However, the impact of HIV on outcomes in trauma with modern antiretroviral treatment remains unclear. We hypothesized mortality and rates of infectious and inflammatory complications would be higher in HIV positive (HIV+) trauma patients.

Methods

The Trauma Quality Improvement Program was queried to identify trauma patients  ≥ 18 years of age with HIV. Due to the imbalance between HIV+ and HIV negative (HIV−) trauma patients, a 1:2 propensity-matched model was utilized. Matched variables included age, injury severity score, mechanism of injury, systolic blood pressure, pulse rate, Glasgow Coma Scale score, and patient comorbidities.

Results

84 HIV+ patients were matched to 168 HIV− patients. Compared to HIV− patients, HIV+ patients had no significant differences in mortality rate (9.5% vs. 4.8%, p = 0.144) or infectious complications, including pneumonia (6.0% vs. 4.2%, p = 0.530), urinary tract infection (1.2% vs. 1.2%, p = 1.000), or severe sepsis (1.2% vs. 0.0%, p = 0.156). However, higher rates of acute respiratory distress syndrome (ARDS) (9.5% vs. 0.6%, p < 0.001) and acute kidney injury (AKI) (4.8% vs. 0.0%, p = 0.004) were observed.

Conclusion

HIV+ trauma patients are not at higher risk of mortality or infectious complications, likely due to the advent and prevalence of combination antiretroviral therapy. However, HIV positivity appears to increase the risk of AKI and ARDS in trauma patients. Further research is needed to confirm this finding to elucidate the etiology underlying this association.

The Effect of Human-Immunodeficiency Virus Status on Outcomes in Penetrating Abdominal Trauma: An Interim Analysis

BACKGROUND

The purpose of this study was to determine whether the outcomes of hemodynamically stable patients undergoing exploratory laparotomy for penetrating abdominal trauma differed as a result of their HIV status.

METHODS

This was an observational, prospective study from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included. The mechanism of injury, the HIV status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days.

RESULTS

A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The two groups were comparable. Ten (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in the HIV negative group. The complication rate was 34% (n = 72). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, older age, and a lower RTS were significant risk factors for ICU admission. After 30 days, 12 patients (5.7%) were still in hospital. Twenty-four patients (11%) underwent a second laparotomy. The PATI score was the single independent predictor for complications, relaparotomy, and hospital stay longer than 30 days.

CONCLUSIONS

Preliminary results reveal that HIV status does not influence outcomes in patients with penetrating abdominal trauma.

Assessing the impact of HIV status on injury outcomes: A multicenter study of trauma patients in Rwanda

BACKGROUND

There is conflicting evidence regarding the impact of human immunodeficiency virus serostatus on trauma outcomes in low-resource settings. This study sought to evaluate the impact of human immunodeficiency virus serostatus on mortality outcomes for Rwandan patients presenting after trauma.

METHODS

This retrospective review of the University of Rwanda trauma registry captured all adult trauma patients with known human immunodeficiency virus status presenting between March 2011 and July 2015. Confirmed human immunodeficiency virus-positive cases were matched 1:2 with known human immunodeficiency virus-negative controls using a modified Kampala Trauma Score, sex, and district of residence or primary hospital. All-cause mortality was compared using multivariable logistic regression.

RESULTS

In total, 11,280 patients were recorded prospectively in the registry (169 human immunodeficiency virus positive; 334 human immunodeficiency virus negative matches). There was no difference in delay of hospital presentation or time until operation (P = .50 and P = .57, respectively). Less than 30% of all patients underwent operation during admission (n = 133), and the rate of operative intervention was independent of human immunodeficiency virus serostatus (P = .946). There was no association between development of any complication and human immunodeficiency virus status (P = .837). The overall mortality rate was 8.9% and 3.3% for human immunodeficiency virus-positive and human immunodeficiency virus-negative patients, respectively (P = .010). Human immunodeficiency virus positivity was associated with increased 30-day mortality when controlling for potential confounders (P = .016; odds ratio 3.60, 95% confidence interval: 1.27-10.2, C statistic 0.88).

CONCLUSION

Both human immunodeficiency virus and trauma pose substantial public health threats in sub-Saharan Africa. Known human immunodeficiency virus seropositivity in Rwandan trauma patients is associated with early mortality. Further investigation regarding testing, treatment, and outcomes in human immunodeficiency virus-positive trauma patients is warranted and provides an opportunity for leveraging human immunodeficiency virus global health efforts in trauma outcomes assessment.

CD4 Count is Still a Valid Indicator of Outcome in HIV-Infected Patients Undergoing Major Abdominal Surgery in the Era of Highly Active Antiretroviral Therapy

BACKGROUND

Patients with HIV/AIDS on antiretroviral therapy (ART) live longer and now require surgery for indications similar to those described for the general population. They have been previously reported to carry higher mortality and complication rates, especially septic complications. The aim of this study was to compare the outcome of major abdominal surgery in three groups of patients with different CD4 counts.

METHODS

This is a prospective study comparing HIV-negative patients and two groups of HIV-infected patients on ART with different CD4 counts. The primary outcomes considered were mortality and complication rates after abdominal surgery. We emphasised on the value of CD4 as a predictor of outcome and the impact of the indication for surgery (septic versus non-septic).

RESULTS

We included 63 patients (21 per group). The majority of patients (71 %) were operated on as an emergency and the indications were similar in all groups. The overall and the septic complication rates were both higher in the group with a low CD4 count. This resulted in a significantly longer admission period but did not result in a higher mortality rate. The duration of ART and the World Health Organisation stage of the disease did not significantly influence surgical outcomes.

CONCLUSIONS

HIV-infected patients on ART can now safely undergo major abdominal surgery with encouraging results though still relatively poorer than those of HIV-negative subjects. CD4 count remains a significant predictor of outcome and patients with a low CD4 count, however, still require closer pre- and post-operative monitoring.

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.

Trauma after transplant: hold the antibiotics please

OBJECTIVE

Despite the increase in transplantation and the prevalence of trauma as a major disease entity, few data exist about transplant patients who suffer trauma. We conducted a study to determine whether transplant patients (TP) have worse outcomes, particularly of infections, than do their non-transplant (NTP) counterparts after trauma.

METHODS

We performed a retrospective review of trauma patients from 2006 to 2010. All patients who had undergone organ transplantation were included and compared through 1:3 propensity matching with their NTP counterparts. Data for the groups were compared to determine differences in outcomes.

RESULTS

The review included 17 TP (13 kidney, 2 liver, 1 kidney/liver, and 1 kidney/pancreas) as compared with 51 NTP. The patients were matched for injury severity score (ISS), age, and gender, with most suffering blunt trauma (82.4% [14/17] TP vs. 90% [46/51] NTP, p = 0.5). The groups had similar initial Glasgow Coma Scale (GCS) scores (13.2 ± 4.5 TP vs. 13.9 ± 2.5 NTP, p=0.6), serum lactate concentrations (2.0 ± 1.8 mmol/L TP vs. 2.3 ± 1.5 mmol/L NTP, p=0.39), and base deficits (-1.5 ± 4.0 TP vs. 0.6 ± 3.0 NTP, p=0.21). Comorbidities were more common in the TP than in the NTP group. The groups had similar lengths of stay (days on ventilator: 0.1 ± 0.3 TP vs. 0.4 ± 1.6 NTP, p=0.9; days in ICU: 0.2 ± 0.6 TP vs. 2.4 ± 5.9 NTP, p=0.16; days in hospital: 5.2 ± 6.8 TP vs. 7.5 ± 10.2 NTP, p=0.86), and two deaths occurred in each of the two groups (p=0.26). Overall complications were similar (52.94% [9/17] TP vs. 62.75% [32/51] NTP, p=0.57), and there were only two infections, both in the NTP group (p=1.0). Antibiotics were given to 59% of the TP vs. 39% of the NTP, with an average duration of 8.4 days for the TP vs. 3.9 days for the NTP.

CONCLUSION

When matched equally for degree of injury, the TP and NTP had similar outcomes. There also appeared to be no differences in infectious complications in the two groups, yet more of the TP had exposure to more days of antibiotics. Similar protocols of antimicrobial therapy should apply to both TP and NTP to avoid the overuse of antimicrobial agents and ensure maintenance of the susceptibility patterns of pathogens.