Should patients positive for HIV infection receive pneumococcal vaccine?

Invasive pneumococcal disease in patients infected with HIV: still a threat in the era of highly active antiretroviral therapy

We studied all human immunodeficiency virus (HIV)-infected patients with invasive pneumococcal disease who received their diagnosis during 1996-2002 to investigate the incidence of this disease in the highly active antiretroviral therapy era and to study the influence of CD4 lymphocyte count on the clinical presentation and outcome of disease. The overall incidence of invasive pneumococcal disease was 11.3 cases per 100,000 person-years in adult patients without known HIV infection and 677 cases per 100,000 person-years in HIV-infected patients. This incidence remained stable over the study period. Clinical presentation, severity of illness, and number of recurrent episodes were similar in patients with CD4+ cell counts of >200 or < or =200 cells/ microL. Patients receiving trimethoprim-sulfamethoxazole (TMP-SMZ) were more likely to present with TMP-SMZ-resistant pneumococci than were those who were not receiving this agent (76.7% vs. 43.6%; P=.007). The mortality rate was high (21%).

Pneumonia due to antibiotic resistant Streptococcus pneumoniae and Pseudomonas aeruginosa in the HAART era

Antibiotic resistance profiles are useful in directing therapeutic strategies during bacterial infections. Patterns of antimicrobial resistance in Streptococcus pneumoniae and Pseudomonas aeruginosa associated pneumonia were investigated in an HIV-1 infected cohort during the era of highly active antiretroviral therapy. The median CD4 count at presentation was significantly lower for cases of P aeruginosa than for S pneumoniae. However, the number of antibiotic resistant cases of P aeruginosa decreased throughout the study period, while the incidence of S pneumoniae remained unchanged. In contrast to pneumococcal pneumonia, we show that antiretrovirals have protected from pneumonia due to antibiotic resistant P aeruginosa. These findings have implications for the treatment of individuals presenting with serious infections in which antibiotic therapy needs to be instituted before identification and sensitivities are known.

The prevention of pneumococcal disease by vaccines: promises and challenges

This article reviews the epidemiology of pneumococcal disease and the current data on pneumococcal vaccine efficacy, discusses promising new data regarding development of new protein-conjugate pneumococcal vaccines, and addresses controversies surrounding the widespread population use of these vaccines. Armed with these data, physicians, nurses, third party payers, and health care systems should develop systems and eliminate unintentional barriers so as to achieve widespread use of these life-saving vaccines. As history has demonstrated to us, control of pneumococcal disease is highly unlikely to occur from heavy investments in newer and ever more expensive antibiotics, as opposed to better methods of preventing disease through the rational and widespread population use of vaccines.

Enhanced antibody response to pneumococcal polysaccharide vaccine after prior immunization with conjugate pneumococcal vaccine in HIV-infected adults

The antibody production by HIV-infected adults after two vaccinations with conjugated pneumococcal vaccine (CPV) and consecutive vaccination with polysaccharide pneumococcal vaccine (PPV) was studied. Thirty days after the second CPV, the geometric mean antibody concentrations (GMC) against pneumococcal polysaccharide serotypes (PPS) 6B, 14 and 19F were significantly lower in the group HIV-infected individuals with <200x10(6)/l CD4(+) T lymphocytes (group 1) than in the group with >/=200x10(6)/l CD4(+) T lymphocytes (group 2) and healthy controls. Thirty days after PPV vaccination the GMC against PPS 6B, 14, 19F and 23F in group 1, and against 6B and 19F in group 2, were significantly lower compared with healthy controls. Both in HIV-infected and in healthy individuals who received CPV and PPV the postvaccination GMC against PPS 14, 19F and 23F were higher compared with historical controls who were not previously immunized with CPV but only received PPV. We conclude that the antibody response to CPV is impaired in HIV-infected individuals. Higher antibody concentrations were achieved in HIV-infected and healthy individuals after sequential vaccination with CPV and PPV compared with PPV vaccination alone.

Clinical effectiveness of pneumococcal vaccine. Meta-analysis

OBJECTIVE

To determine the clinical effectiveness of pneumococcal vaccine.

DATA SOURCES

Computerized searches of MEDLINE, EMBASE, and SCISEARCH databases were performed, reference lists of retrieved articles were reviewed, and first authors of published studies were contacted.

STUDY SELECTION

Studies of use of pneumococcal vaccines in adults were included if the study design was a randomized or quasi-randomized controlled trial and at least one of the following clinical outcomes was reported: vaccine-type systemic pneumococcal infection, systemic pneumococcal infection, vaccine-type pneumococcal pneumonia, pneumococcal pneumonia, non-vaccine-type pneumococcal pneumonia.

SYNTHESIS

Study quality was assessed and descriptive information concerning the study populations, interventions, and outcome measurements was extracted for 13 trials involving more than 65,000 patients. Estimates of vaccine efficacy, based on a meta-analysis of randomized and quasi-randomized trials, were determined for clinical outcomes.

CONCLUSIONS

Vaccination with pneumococcal polysaccharide vaccine can be expected to reduce the risk of systemic infection due to pneumococcal types included in the vaccine by 83% and systemic infection due to all pneumococci by 73%. We found no evidence that the vaccine was less efficacious for the elderly, institutionalized people, or those with chronic disease.

Uncertainty in illness across the HIV/AIDS trajectory

Uncertainty is a chronic and pervasive source of psychological distress for persons living with HIV. Numerous sources of heightened uncertainty, including complex changing treatments, ambiguous symptom patterns, and fears of ostracizing social response, play a critical role in the experience of HIV-positive persons and are linked with negative perceptions of quality of life and poor psychological adjustment. Currently, research on uncertainty in HIV fails to explicate the uncertainty experience over time. Because the uncertainty of HIV varies over the course of the illness, an explicit consideration of the sources of uncertainty over the HIV illness trajectory is needed to forecast the informational and stress management needs of persons facing uncertainty about HIV illness. A biopsychosocial model developed to characterize the HIV stigma trajectory provides a useful framework modified to depict uncertainty across the HIV illness experience. Uncertainty in four phases of the HIV illness trajectory are differentiated: (a) at risk, (b) diagnosis, (c) latent, and (d) manifest.

Pneumococcal vaccination of HIV-infected individuals: safety and efficacy

The finding of an increased risk of HIV-infected individuals for contracting pneumococcal diseases has led to the recommendation of antipneumococcal vaccination of HIV-infected individuals. However, due to reports of increased viral replication following immune stimulation, the vaccination policy has been called into question. The literature on changes in viral load and CD4 T cells following vaccination and the studies on the clinical efficacy of antipneumococcal vaccination is evaluated. It is concluded that the prevailing data do not lend support to the concern of a lasting effect of vaccination on viral load. Data on the clinical efficacy and serological responses of vaccination are too scanty to support the recommendation of antipneumococcal vaccination to HIV-infected individuals. In addition to the issue of clinical efficacy; many question remain to be addressed; for example, the protective antibody level, optimal timing and vaccination regimen are yet to be determined.

Pneumococcal vaccine

Streptococcus pneumoniae is a frequent cause of pneumonia and meningitis. This article looks at the pneumococcal vaccine, its uses, efficacy, and adverse effects and how vaccination may be improved. We also look at the role of the new conjugate vaccines.

Uptake of medical interventions in women with HIV infection in Britain and Ireland. Study Group for the MRC Collaborative Study of HIV Infection in Women

OBJECTIVE

To determine the uptake of medical interventions amongst women known to be HIV positive and in contact with service providers.

SUBJECTS

400 HIV positive women from 15 STD/HIV clinics in Britain and Ireland recruited to the MRC collaborative study of HIV infection in women between June 1992 and August 1994.

METHODS

Data obtained prospectively through direct questioning of all women by a physician or research nurse and review of medical and laboratory records. Data recorded on standardised forms and analysed centrally.

RESULTS

Nearly one quarter (24%) of women with an AIDS diagnosis had never received Pneumocystis carinii pneumonia prophylaxis, and 24% had never received any antiretroviral therapy. Fewer than two-thirds of black African women had had a chest radiograph. Only one woman had received Pneumovax and only 4% of women had ever taken part in a clinical trial.

CONCLUSIONS

A substantial proportion of women with HIV infection did not receive interventions of proven benefit, and participation in clinical trials was very uncommon. The reasons for such poor uptake should be explored among both health care workers and women with HIV infection.