Intensive care of human immunodeficiency virus-infected patients during the era of highly active antiretroviral therapy

Comparing short-term mortality between people with and without HIV admitted to the intensive care unit: A single-centre matched cohort study (2000-2019)

OBJECTIVES

The survival rate of people with HIV admitted to intensive care units (ICUs) is approaching that of people without HIV. We conducted a matched-cohort study of people with and without HIV admitted to ICU at a large hospital to compare short-term mortality, during 2000-2019.

METHODS

People with HIV were matched to people without HIV (1:2) on age, sex, admission year and Acute Physiology and Chronic Health Evaluation (APACHE)-II score. Applying logistic regression models fitted using independence estimating equations, we describe population-averaged associations of HIV with short-term (in-ICU, in-hospital) mortality during a patient's first admission to ICU, and explore whether these varied by year.

RESULTS

A total of 177 people with HIV were matched to 354 people without HIV (71.2% vs. 71.2% male; median age: 47 vs. 48 years, median APACHE-II: 18 vs. 17, median admission year: 2013 vs. 2013). Among people with HIV, 73.4% were on antiretroviral therapy, 51.2% had HIV-RNA ≤50 copies/mL and median CD4 T-cell count was 132 cells/ μ L. People with HIV had higher in-ICU (24.3% vs. 15.3%) and in-hospital (31.6% vs. 20.1%) mortality. People with HIV had 1.69-fold higher odds (95% confidence interval: 1.03-2.76) of in-ICU mortality and 1.86 (1.19-2.91) higher odds of in-hospital mortality than people without HIV, adjusted for age, sex, year and APACHE-II. There was no evidence that these associations varied by year (p-interaction-in-ICU = 0.90; p-interaction-in-hospital = 0.46).

CONCLUSIONS

Our findings suggest that although outcomes have improved over time, people with HIV continue to have higher short-term in-ICU and in-hospital mortality following ICU admission compared with people without HIV with similar characteristics.

Extracorporeal Life Support for Patients With Newly Diagnosed HIV and Acute Respiratory Distress Syndrome: A Systematic Review and Analysis of Individual Patient Data

Extracorporeal membrane oxygenation (ECMO) may improve survival in patients with severe acute respiratory distress syndrome (ARDS). However, presence of immunosuppression is a relative contraindication for ECMO, which is withheld in HIV patients. We performed a systematic review to investigate the outcome of newly diagnosed HIV patients with ARDS receiving ECMO support. Our search yielded 288 publications, with 22 studies finally included. Initial presentation included fever, respiratory distress, and cough. Severe immunodeficiency was confirmed in most patients. Deceased patients had a higher viral load, a lower Horovitz index, and antiretroviral therapy utilized before ECMO. Moreover, ECMO duration was longer ( p = 0.0134), and all deceased suffered from sepsis ( p = 0.0191). Finally, despite the development of therapeutic options for HIV patients, ECMO remains a relative contraindication. We found that ECMO may successfully bridge the time for pulmonary recovery in 93% of patients, with a very good outcome. Using ECMO, the time for antimicrobial therapy, lung-protective ventilation, and immune system restitution may be gained. Further studies clarifying the role of ECMO in HIV are crucial and until these data are available, ECMO might be appropriate in immunocompromised patients. This holds especially true in newly diagnosed HIV patients, who are usually young, without comorbidities, with a good rehabilitation potential.

People living with HIV, HCV and HIV/HCV coinfection in intensive care in a German tertiary referral center 2014-2019

PURPOSE

The epidemiology of HIV-infected individuals on the Medical Intensive Care Units (MICU) has changed after profound progress in treatment of AIDS-defining illnesses and anti-retroviral therapy (ART). Changes of MICU utilization of Hepatitis C (HCV) patients following roll-out of direct-acting antivirals (DAA) are yet to evaluate.

METHODS

We performed a retrospective study on all patients with HIV, HIV/HCV and HCV admitted to the MICU of University Hospital Bonn 2014-2019. We assessed sociodemographic data, available clinical data from HIV patients (CDC stage, CD4 + lymphocyte cell count, HIV-1-RNA, ART) and HCV patients (HCV-RNA, stage of liver cirrhosis, treatment history) and outcome.

RESULTS

237 patients (46 HIV, 22 HIV/HCV, 169 HCV; 168 male, median age 51.3 years) with 325 MICU admissions were included. Admission criteria for HIV patients were infections (39.7% AIDS-associated, 23.8% with controlled HIV-infection) and cardiopulmonary diseases (14.3%). HIV/HCV coinfected patients had infections in controlled/uncontrolled HIV-infection (46.4%), cardiopulmonary diseases and intoxication/drug abuse (17.9% each). Reasons for HCV-mono-infected patients were infections (24.4%), sequelae of liver disease (20.9%), intoxication/drug abuse (18.4%) and cardiopulmonary diseases (15%). 60 patients deceased; most important risk factor was need for mechanical ventilation. The number of HCV-patients admitted to MICU with chronic active disease and sequelae of liver disease decreased while the proportion of patients with completed DAA-treatment increased.

CONCLUSION

Infections remain the most important reason for MICU admission in patients with HIV and/or HCV infection while non-AIDS related conditions increased. DAA roll-out has a beneficial effect on liver-associated morbidity in HCV patients admitted to MICU.

Outcomes in critically Ill HIV-infected patients between 1997 and 2020: analysis of the OUTCOMEREA multicenter cohort

PURPOSE

Despite antiviral therapy (ART), 800,000 deaths still occur yearly and globally due to HIV infection. In parallel with the good virological control and the aging of this population, multiple comorbidities [HIV-associated-non-AIDS (HANA) conditions] may now be observed.

METHODS

HIV adult patients hospitalized in intensive care unit (ICU) from all the French region from university and non-university hospital who participate to the OutcomeRea™ database on a voluntary basis over a 24-year period.

RESULTS

Of the 24,298 stays registered, 630 (2.6%) were a first ICU stay for HIV patients. Over time, the mean age and number of comorbidities (diabetes, renal and respiratory history, solid neoplasia) of patients increased. The proportion of HIV diagnosed on ICU admission decreased significantly, while the median duration of HIV disease as well as the percentage of ART-treated patients increased. The distribution of main reasons for admission remained stable over time (acute respiratory distress > shock > coma). We observed a significant drop in the rate of active opportunistic infection on admission, while the rate of active hemopathy (newly diagnosed or relapsed within the last 6 months prior to admission to ICU) qualifying for AIDS increased-nonsignificantly-with a significant increase in the anticancer chemotherapy administration in ICU. Admissions for HANA or non-HIV reasons were stable over time. In multivariate analysis, predictors of 60-day mortality were advanced age, chronic liver disease, past chemotherapy, sepsis-related organ failure assessment score > 4 at admission, hospitalization duration before ICU admission > 24 h, AIDS status, but not the period of admission.

CONCLUSION

Whereas the profile of ICU-admitted HIV patients has evolved over time (HIV better controlled but more associated comorbidities), mortality risk factors remain stable, including AIDS status.

Mortality in patients with acquired human immunodeficiency virus infection hospitalized in an intensive care unit during the period 2017-2019

Identify risk factors associated with mortality in HIV patients admitted to an ICU in the city of Bogotá. Retrospective cohort study of patients treated in an ICU during the years 2017–2019. The analysis included descriptive statistics, association tests, and a logistic regression model. A predictive model of mortality at the time of admission to the ICU was developed. 110 HIV patients were identified. Association was found between a Charlson index ≥ 6 and mortality (OR = 2.3, 95% CI 1.0–5.1) and an increase in mortality in the first 21 days of ICU stay (OR = 2.2, 95% CI 1.0–4.9). In the logistic regression analysis, the absence of highly active antiretroviral therapy (HAART) upon admission to the ICU (OR = 2.5 95% CI 1.0–6.1) and the first 21 days of ICU stay (OR = 2.3 95% CI 1.0–5.4) were associated with an increase in mortality. The predictive mortality model established that mortality was higher in patients admitted to the ICU without having previously received HAART than in those who did receive therapy at the time of admission to the ICU. In patients with HIV admitted to the ICU, the absence of HAART will negatively impact mortality during their hospital stay.

Early antiretroviral therapy for HIV-infected patients admitted to an intensive care unit (EARTH-ICU): A randomized clinical trial

Background

Highly active antiretroviral therapy (HAART) has reduced HIV-related morbidity and mortality at all stages of infection and reduced transmission of HIV. Currently, the immediate start of HAART is recommended for all HIV patients, regardless of the CD4 count. There are several concerns, however, about starting treatment in critically ill patients. Unpredictable absorption of medication by the gastrointestinal tract, drug toxicity, drug interactions, limited reserve to tolerate the dysfunction of other organs resulting from hypersensitivity to drugs or immune reconstitution syndrome, and the possibility that subtherapeutic levels of drug may lead to viral resistance are the main concerns. The objective of our study was to compare the early onset (up to 5 days) with late onset (after discharge from the ICU) of HAART in HIV-infected patients admitted to the ICU.

Methods

This was a randomized, open-label clinical trial enrolling HIV-infected patients admitted to the ICU of a public hospital in southern Brazil. Patients randomized to the intervention group had to start treatment with HAART within 5 days of ICU admission. For patients in the control group, treatment should begin after discharge from the ICU. The patients were followed up to determine mortality in the ICU, in the hospital and at 6 months. The primary outcome was hospital mortality. The secondary outcome was mortality at 6 months.

Results

The calculated sample size was 344 patients. Unfortunately, we decided to discontinue the study due to a progressively slower recruitment rate. A total of 115 patients were randomized. The majority of admissions were for AIDS-defining illnesses and low CD4. The main cause of admission was respiratory failure. Regarding the early and late study groups, there was no difference in hospital (66.7% and 63.8%, p = 0.75) or 6-month (68.4% and 79.2%, p = 0.20) mortality. After multivariate analysis, the only independent predictors of in-hospital mortality were shock and dialysis during the ICU stay. For the mortality outcome at 6 months, the independent variables were shock and dialysis during the ICU stay and tuberculosis at ICU admission.

Conclusions

Although the early termination of the study precludes definitive conclusions being made, early HAART administration for HIV-infected patients admitted to the ICU compared to late administration did not show benefit in hospital mortality or 6-month mortality.

ClinicalTrials.gov, NCT01455688. Registered 20 October 2011, https://clinicaltrials.gov/show/NCT01455688

Patterns of presentation and survival of HIV-infected patients admitted to a tertiary-level intensive care unit

OBJECTIVES

Compared to other countires internationally, South Africa has the largest number of people living with HIV. There are limited data in developing countries on the outcomes of HIV-infected patients in the intensive care unit (ICU). The objectives of this study were to describe the pattern of presentation of these patients and to determine factors that may influence survival to ICU discharge.

METHODS

The medical charts of 204 consecutive HIV-infected individuals who were admitted to the Charlotte Maxeke Johannesburg Academic Hospital adult general ICU during the calendar year 2017 were retrospectively reviewed. Relevant data were subjected to univariate and multivariate analysis.

RESULTS

Two-hundred and four (22.6%) out of a total of 903 patients who were admitted to the ICU were HIV positive. Sepsis-related illnesses were the most common reason for ICU admission (n = 95; 46.6%), followed by post-operative care (n = 69; 33.8%) and non-sepsis-related illnesses (n = 40; 19.6%). The median length of stay in the ICU was 5 (interquartile range 2-9) days. ICU mortality was 33.3% (n = 68). On univariate analysis, age (P = 0.039), length of stay in the ICU (P = 0.040), primary diagnostic category (P < 0.05), sepsis acquired during the ICU stay (P = 0.012), inotrope/vasopressor administration (P < 0.001), mechanical ventilation (P < 0.001), haemodialysis (P = 0.001), CD4 cell count (P = 0.011), Acute Physiology and Chronic Health Assessment (APACHE) II score (P < 0.001) and Sequential Organ Failure Assessment (SOFA) score (P < 0.001) were significantly associated with mortality.

CONCLUSIONS

Age, diagnostic category, sepsis acquired during the ICU stay, inotrope/vasopressor administration, mechanical ventilation, haemodialysis, CD4 cell count, APACHE II score, SOFA score and length of ICU stay were associated with ICU mortality in HIV-infected patients.

Impact of human immunodeficiency virus infection on mortality of patients who acquired healthcare associated-infection in critical care unit

To evaluate 30-day mortality in human immunodeficiency virus (HIV) and non-HIV patients who acquired a healthcare-associated infection (HAI) while in an intensive care unit (ICU), and to describe the epidemiological and microbiological features of HAI in a population with HIV.This was a retrospective cohort study that evaluated patients who acquired HAI during their stay in an Infectious Diseases ICU from July 2013 to December 2017 at a teaching hospital in Brazil.Data were obtained from hospital infection control committee reports and medical records. Statistical analysis was performed using SPSS and a multivariate model was used to evaluate risk factors associated with 30-day mortality. Epidemiological, clinical, and microbiological characteristics of HAI in HIV and non-HIV patients and 30-day mortality were also evaluated.Among 1045 patients, 77 (25 HIV, 52 non-HIV) patients acquired 106 HAI (31 HIV, 75 non-HIV patients). HIV patients were younger (45 vs 58 years, P = .002) and had more respiratory distress than non-HIV patients (60.0% vs 34.6%, P = .035). A high 30-day mortality was observed and there was no difference between groups (HIV, 52.0% vs non-HIV, 54.9%; P = .812). Ventilator-associated pneumonia (VAP) was more frequent in the HIV group compared with the non-HIV group (45.2% vs 26.7%, P = .063), with a predominance of Gram-negative organisms. Gram-positive agents were the most frequent cause of catheter associated-bloodstream infections in HIV patients. Although there was a high frequency of HAI caused by multidrug-resistant organisms (MDRO), no difference was observed between the groups (HIV, 77.8% vs non-HIV, 64.3%; P = .214). Age was the only independent factor associated with 30-day mortality (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.1, P = .017), while diabetes mellitus (OR: 3.64, 95% CI: 0.84-15.8, P = .085) and the Sequential Organ-Failure Assessment (SOFA) score (OR: 1.16, 95% CI: 0.99-1.37, P = .071) had a tendency to be associated with death.HIV infection was not associated with a higher 30-day mortality in critical care patients with a HAI. Age was the only independent risk factor associated with death. VAP was more frequent in HIV patients, probably because of the higher frequency of respiratory conditions at admission, with a predominance of Gram-negative organisms.

Epidemiology and outcome of HIV-infected patients admitted to the ICU in the current highly active antiretroviral therapy era

PURPOSE

To describe the epidemiology of critical disease in HIV-infected patients during the current highly active antiretroviral therapy (HAART) era and to identify hospital mortality predictors.

METHODS

A longitudinal, retrospective observational study was made of HIV-infected adults admitted to the ICU in two Spanish hospitals between 1 January 2000 and 31 December 2014. Demographic and HIV-related variables were analyzed, together with comorbidities, severity scores, reasons for admission and need for organ support. The chi-squared test was used to compare categorical variables, while continuous variables were contrasted with the Student's t-test, Mann-Whitney U-test or Kruskal-Wallis test, assuming an alpha level=0.05. Multivariate logistic regression analysis was used to calculate odds ratios for assessing correlations to mortality during hospital stay. Joinpoint regression analysis was used to study mortality trends over time.

RESULTS

A total of 283 episodes were included for analyses. Hospital mortality was 32.9% (95%CI: 21.2-38.5). Only admission from a site other than the Emergency Care Department (OR 3.64, 95%CI: 1.30-10.20; p=0.01), moderate-severe liver disease (OR 5.65, 95%CI: 1.11-28.87; p=0.04) and the APACHE II score (OR 1.14, 95%CI: 1.04-1.26; p<0.01) and SOFA score at 72h (OR 1.19, 95%CI: 1.02-1.40; p=0.03) maintained a statistically significant relationship with hospital mortality.

CONCLUSIONS

Delayed ICU admission, comorbidities and the severity of critical illness determine the prognosis of HIV-infected patients admitted to the ICU. Based on these data, HIV-infected patients should receive the same level of care as non-HIV-infected patients, regardless of their immunological or nutritional condition.

Outcomes and factors influencing outcomes of critically ill HIV-positive patients in a tertiary care center in South India

The incidence of (Human immune deficiency) HIV in India has fallen by 58% since the onset of the HIV epidemic. As of 2016 there are 2.1 million people living in India with HIV and only 49% of the adults with HIV are on ART (1). The HIV infected individuals may require intensive care due to various reasons. This study attempts to look at the outcomes of these patients admitted in the intensive care unit and the predictors of these outcomes.

The ART of Antiretroviral Therapy in Critically Ill Patients With HIV

The management of patients with human immunodeficiency virus (HIV) can be a complicated specialty within itself, made even more complex when there are so many unanswered questions regarding the care of critically ill patients with HIV. The lack of consensus on the use of antiretroviral medications in the critically ill patient population has contributed to an ongoing clinical debate among intensivists. This review focuses on the pharmacological complications of antiretroviral therapy (ART) in the intensive care setting, specifically the initiation of ART in patients newly diagnosed with HIV, immune reconstitution inflammatory syndrome (IRIS), continuation of ART in those who were on a complete regimen prior to intensive care unit admission, barriers of drug delivery alternatives, and drug-drug interactions.

Extracorporeal membrane oxygenation in an HIV-positive man with severe acute respiratory distress syndrome secondary to pneumocystis and cytomegalovirus pneumonia

The management of critically ill human immunodeficiency virus (HIV)-positive patients is challenging; however, intensive care unit-related mortality has declined significantly in recent years. There are 10 case reports in the literature of extracorporeal membrane oxygenation (ECMO) use in HIV-positive patients, of whom seven survived to hospital discharge. We describe a 33-year-old Brazilian man who presented with Pneumocystis jirovecii pneumonia and severe hypoxic respiratory failure. He developed refractory acute respiratory distress syndrome (ARDS) and was commenced on veno-venous ECMO. He was successfully decannulated following 21 days of ECMO and survived to hospital discharge. Despite poor evidence surrounding the use of ECMO in immunocompromised patients, it is evident that ECMO could represent an important rescue therapy in HIV-positive patients with refractory ARDS.

Epidemiology and Outcomes in Critically Ill Patients with Human Immunodeficiency Virus Infection in the Era of Combination Antiretroviral Therapy

Purpose. The impact of critical illness on survival of HIV-infected patients in the era of antiretroviral therapy remains uncertain. We describe the epidemiology of critical illness in this population and identify predictors of mortality. Materials and Methods. Retrospective cohort of HIV-infected patients was admitted to intensive care from 2002 to 2014. Patient sociodemographics, comorbidities, case-mix, illness severity, and 30-day mortality were captured. Multivariable Cox regression analyses were performed to identify predictors of mortality. Results. Of 282 patients, mean age was 44 years (SD 10) and 169 (59%) were male. Median (IQR) CD4 count and plasma viral load (PVL) were 125 cells/mm³ (30–300) and 28,000 copies/mL (110–270,000). Fifty-five (20%) patients died within 30 days. Factors independently associated with mortality included APACHE II score (adjusted hazard ratio [aHR] 1.12; 95% CI 1.08–1.16; p < 0.001), cirrhosis (aHR 2.30; 95% CI 1.12–4.73; p = 0.024), coronary artery disease (aHR 6.98; 95% CI 2.20–22.13; p = 0.001), and duration of HIV infection (aHR 1.07 per year; 95% CI 1.02–1.13; p = 0.01). CD4 count and PVL were not associated with mortality. Conclusions. Mortality from an episode of critical illness in HIV-infected patients remains high but appears to be driven by acute illness severity and HIV-unrelated comorbid disease rather than degree of immune suppression.

Thrombotic Thrombocytopenic Purpura Associated with Abacavir in a Patient with HIV Infection

A 45-year-old woman with HIV infection presented with thrombotic microangiopathy 1 week after initiating therapy with the nucleoside analogue abacavir. She was successfully treated with plasmapheresis and corticosteroids.

Life-Threatening Complications of HIV Infection

Few modern diseases have experienced as rapid and dramatic change in prognosis and treatment as HIV infection. The introduction of active antiretroviral therapy (ART) and effective prophylaxis of opportunistic infections ushered in a new era in the treatment of HIV infection and changed dramatically the natural history of this disease. The rates of admission to the intensive care unit (ICU) and intensive care mortality in patients with HIV infection have shifted repeatedly during the AIDS epidemic, influenced by attitudes of patients and providers toward utility of care. In the ART era, patients with HIV infection admitted to the ICU fall into 3 general categories: those with AIDS-related opportunistic infections, those who are experiencing complications related to ART, and those with medical problems unrelated to HIV infection. In this article, the authors provide a review of the most common life-threatening complications in patients with HIV infection.

A prospective study on the outcome of human immunodeficiency virus-infected patients requiring mechanical ventilation in a high-burden setting

BACKGROUND

There is a paucity of data on the mortality of patients admitted to the intensive care unit (ICU), despite the fact that human immunodeficiency virus (HIV)-related diseases represent a significant burden to health care resources particularly in sub-Saharan Africa.

AIM

To describe the outcome and prognostic factors of HIV-infected patients requiring mechanical ventilation in an ICU.

DESIGN

Prospective observational study.

METHODS

All 54 patients (34.8 ± 10.4 years, 38 females) admitted with confirmed HIV from October 2012 until May 2013 were enrolled. Disease severity was graded according to APACHEII score. Admission diagnoses, clinical features and laboratory investigations, complications and outcomes were recorded.

RESULTS

The mean length of ICU stay was 11.0 days (range: 1-49 days), and 33 patients survived (ICU mortality: 38.9%). The in-hospital mortality at 30 days was 48.1%. ICU mortality was associated with an AIDS-defining diagnosis (OR = 7.97, P = 0.003). Non-survivors had higher APACHEII scores (25.8 vs. 18.6, P = 0.001) and lower mean admission CD4 counts (102.5 vs. 225.2, P = 0.014). Multiple logistical regression analysis confirmed the independent predictive value of WHO stage 4 disease (P = 0.008), lower mean CD4 count on admission (P = 0.057) and higher APACHEII score (P = 0.010) on ICU mortality, and WHO stage 4 (P = 0.007) and higher APACHE II score (P = 0.003) on 30-day mortality.

CONCLUSIONS

The ICU mortality of mechanically ventilated HIV-positive patients was high. WHO stage 4 disease and a higher APACHEII score were predictive of both ICU and 30-day mortality, whereas a low CD4 count on admission was associated with ICU mortality.

Characteristics and Outcomes of HIV-Infected Patients With Severe Sepsis: Continued Risk in the Post-Highly Active Antiretroviral Therapy Era

OBJECTIVES

Although highly active antiretroviral therapy has led to improved survival in HIV-infected individuals, outcomes for HIV-infected patients with sepsis in the post-highly active antiretroviral therapy era are conflicting. Access to highly active antiretroviral therapy and healthcare disparities continue to affect outcomes. We hypothesized that HIV-infected patients with severe sepsis would have worse outcomes compared with their HIV-uninfected counterparts in a large safety-net hospital where access to healthcare is low and delivery of critical care is delayed.

DESIGN

Secondary analysis of an ongoing prospective observational study between 2006 and 2010.

SETTING

Three adult ICUs (medical ICU, surgical ICU, and neurologic ICU) at Grady Memorial Hospital, Atlanta, GA.

PATIENTS

Adult patients with severe sepsis in the ICU.

INTERVENTIONS

Baseline patient characteristics and clinical outcomes were collected. HIV-infected and HIV-uninfected patients with sepsis were compared using t tests, chi-square tests, and logistic regression; p values less than 0.05 indicated significance.

MEASUREMENTS AND MAIN RESULTS

Of 1,095 patients with severe sepsis enrolled, 165 (15%) were positive for HIV, with a median CD4 count of 41 (8-167). Twenty-two percent of HIV-infected patients were on highly active antiretroviral therapy prior to admission, and 80% had a CD4 count less than 200. HIV-infected patients had a greater hospital mortality (50% vs 38%; p < 0.01). HIV infection (odds ratio = 1.78; p = 0.005) was an independent predictor of mortality by multivariate regression modeling after adjusting for age, history of pneumonia, history of hospital-acquired infection, and history of sepsis.

CONCLUSIONS

HIV-infected patients with severe sepsis continue to suffer worse outcomes compared with HIV-uninfected patients in a large urban safety-net hospital caring for patients with limited access to medical care. Further studies need to be done to investigate the effect of socioeconomic status and mitigate healthcare disparities among critically ill HIV-infected patients.

Temporal trends in critical events complicating HIV infection: 1999-2010 multicentre cohort study in France

PURPOSE

Multicentre data are limited to appraise the management and prognosis of critically ill human immunodeficiency virus (HIV)-infected patients. We sought to describe temporal trends in demographic and clinical characteristics, indications for intensive care and outcome in this patient population.

METHODS

We conducted a cohort study of unselected HIV-infected patients admitted between 1999 and 2010 to 34 French ICUs contributing to the CUB-Réa prospective database.

RESULTS

We included 6,373 consecutive patients. Over the 12-year period, increases occurred in median age (39 years in 1999-2001; 47 years in 2008-2010, p < 0.0001) and prevalence of comorbidities (notably malignancies, from 6.7 to 16.4%, p < 0.0001). Admissions for respiratory failure (39.8% overall), shock (8.1%) and coma (22.7%) decreased (p < 0.0001), while those for sepsis (19.3%) remained stable. The main final diagnoses were bacterial sepsis (24.6%) and non-bacterial acquired immune deficiency syndrome (AIDS)-defining diseases (steady decline from 26.0 to 17.5%, p < 0.0001). Patients increasingly received mechanical ventilation (from 42.9 to 54.0%) and renal replacement therapy (from 9.6 to 16.8%) (p < 0.0001), whereas vasopressor use remained stable (27.4%). ICU readmissions increased after 2004 (p < 0.0001). ICU and hospital mortality (17.6 and 26.9%, respectively) dropped markedly in the most severely ill patients requiring multiple life-sustaining therapies. Malignancies and chronic liver disease were heavily associated with hospital mortality by multivariate analysis, while the most common AIDS-defining complications (Pneumocystis jirovecii pneumonia, cerebral toxoplasmosis and tuberculosis) had no independent impact.

CONCLUSIONS

Progressive ageing, increasing prevalence of comorbidities (mainly malignancies), a steady decline in AIDS-related illnesses and improved benefits from life-sustaining therapies were the main temporal trends in HIV-infected patients requiring ICU admission.

Mortality of patients infected with HIV in the intensive care unit (2005 through 2010): significant role of chronic hepatitis C and severe sepsis

INTRODUCTION

The combination antiretroviral therapy (cART) has led to decreased opportunistic infections and hospital admissions in human immunodeficiency virus (HIV)-infected patients, but the intensive care unit (ICU) admission rate remains constant (or even increased in some instances) during the cART era. Hepatitis C virus (HCV) infection is associated with an increased risk for hospital admission and/or mortality (particularly those related to severe liver disease) compared with the general population. The aim of this study was to assess the mortality among HIV-infected patients in ICU, and to evaluate the impact of HIV/HCV coinfection and severe sepsis on ICU mortality.

METHODS

We carried out a retrospective study based on patients admitted to ICU who were recorded in the Minimum Basic Data Set (2005 through 2010) in Spain. HIV-infected patients (All-HIV-group (n = 1,891)) were divided into two groups: HIV-monoinfected patients (HIV group (n = 1,191)) and HIV/HCV-coinfected patients (HIV/HCV group (n = 700)). A control group (HIV(-)/HCV(-)) was also included (n = 7,496).

RESULTS

All-HIV group had higher frequencies of severe sepsis (57.7% versus 39.4%; P < 0.001) than did the control group. Overall, ICU mortality in patients with severe sepsis was much more frequent than that in patients without severe sepsis (other causes) at days 30 and 90 in HIV-infected patients and the control group (P < 0.001). Moreover, the all-HIV group in the presence or absence of severe sepsis had a higher percentage of death than did the control group at days 7 (P < 0.001), 30 (P < 0.001) and 90 (P < 0.001). Besides, the HIV/HCV group had a higher percentage of death, both in patients with severe sepsis and in patients without severe sepsis compared with the HIV group at days 7 (P < 0.001) and 30 (P < 0.001), whereas no differences were found at day 90. In a bayesian competing-risk model, the HIV/HCV group had a higher mortality risk (adjusted hazard ratio (aHR) = 1.44 (95% CI = 1.30 to 1.59) and aHR = 1.57 (95% CI = 1.38 to 1.78) for patients with and without severe sepsis, respectively).

CONCLUSIONS

HIV infection was related to a higher frequency of severe sepsis and death among patients admitted to the ICU. Besides, HIV/HCV coinfection contributed to an increased risk of death in both the presence and the absence of severe sepsis.

Etiology and outcomes for patients infected with HIV in intensive care units in a tertiary care hospital in China

Although the National Free Antiretroviral Treatment Program (NFATP) has resulted in a significant reduction in the incidence of AIDS-defining illnesses in China, severe complications in patients infected with HIV may require aggressive treatment and critical care support. The objective for this study was to investigate the etiology and outcomes of patients infected with HIV admitted to intensive care units in Ditan Hospital, China. The evaluation of the etiology and outcomes of patients infected with HIV admitted to intensive care units was conducted using the clinical data from 122 patients infected with HIV (129 occasions) admitted to the Beijing Ditan hospital from January 1, 2009, to October 1, 2013. Over the five-year study period, 129 occasions occurred for 122 patients infected with HIV admitted to intensive care units. Respiratory failure was the most common condition (53.4%) among the 129 occasions analyzed. This was followed by pneumothorax (12.4%), infectious shock (8.5%), neurological problems (8.5%), renal failure (7.8%), post-operative complications and trauma (5.4%), coronary heart disease (3.1%), adverse effects of HAART (3.1%), lymphoma (2.4%), and liver failure (0.8%). Mortality in intensive care units was 64.5% while in-hospital mortality was 65.9%. The strongest protective predictor for in-hospital mortality was earlier admission to an intensive care unit (OR = 0.050, CI = 0.020-0.126, P < 0.001). Respiratory failure was the most common condition in patients infected with HIV admitted to intensive care units, and the outcome for the patients was poor. Mortality was negatively associated with earlier admission to an intensive care unit, but was not associated with HAART.

The burden of sepsis in critically ill human immunodeficiency virus-infected patients--a brief review

Since the advent of highly active antiretroviral therapy in 1996, we have seen dramatic changes in morbi-mortality rates from human immunodeficiency virus-positive patients. If on the one hand, the immunologic preservation-associated with the use of current antiretroviral therapy markedly diminishes the incidence of opportunistic infections, on the other hand it extended life expectancy of human immunodeficiency virus-infected individuals similarly to the general population. However, the management of critically ill human immunodeficiency virus-infected patients remains challenging and troublesome for practicing clinician. Sepsis - a complex systemic inflammatory syndrome in response to infection - is the second leading cause of intensive care unit admission in both human immunodeficiency virus-infected and uninfected populations. Recent data have emerged describing a substantial burden of sepsis in the infected population, in addition, to a much poorer prognosis in this group. Many factors contribute to this outcome, including specific etiologies, patterns of inflammation, underlying immune dysregulation related to chronic human immunodeficiency virus infection and delays in prompt diagnosis and treatment. This brief review explores the impact of sepsis in the context of human immunodeficiency virus infection, and proposes future directions for better management and prevention of human immunodeficiency virus-associated sepsis.

Alcohol and HIV: Experimental and Clinical Evidence of Combined Impact on the Lung

Despite antiretroviral therapy, lung disease is a leading cause of death in individuals infected with human immunodeficiency virus type 1 (HIV). Individuals infected with HIV are susceptible to serious bacterial and viral infections, such as pneumococcus and influenza, which are particularly problematic for lung health, resulting in lung injury. Additionally, HIV-infected individuals are susceptible to a number of pulmonary diseases for unknown reasons. Alcohol, the most commonly abused drug in the world, continues to exact an enormous toll on morbidity and mortality in individuals living with HIV. Chronic alcohol abuse has been shown to affect lung immunity, resulting in significant lung injury. There is a paucity of literature on the additive effects of HIV and alcohol, two diseases of immune senescence, in the lung. This chapter begins by discussing the latest literature evaluating the epidemiology of HIV, alcohol use, and lung health focusing on two prevalent infections, tuberculosis and pneumococcal pneumonia. In parallel, we discuss the interactions of alcohol and HIV on the risk for acute lung injury and subsequent morbidity and mortality. We then discuss the pathophysiology of how these two diseases of immune dysfunction affect the lung, with a focus on the oxidative stress, alveolar macrophage host immune capacity, and immunomodulatory role of zinc in the airway. Finally, we review the latest literature on how HIV and alcohol affect other pulmonary disorders including chronic obstructive pulmonary disease, pulmonary hypertension, and lung cancer.

Medical ICU admission diagnoses and outcomes in human immunodeficiency virus-infected and virus-uninfected veterans in the combination antiretroviral era

OBJECTIVES

Human immunodeficiency virus (HIV)-infected (HIV+) patients on combination antiretroviral therapy are living longer but have increased risk for aging-associated disease which may lead to increasing critical care requirements. We compare medical ICU admission characteristics and outcomes among HIV infected and demographically similar uninfected patients (uninfected) and considered whether an index which combines routine clinical biomarkers (the Veterans Aging Cohort Study Index) predicts 30-day medical ICU mortality.

DESIGN

Observational data analyses (Veterans Aging Cohort Study).

SETTING

Eight Veterans Affairs medical centers nationwide.

PATIENTS

HIV infected and uninfected with a medical ICU admission between 2002 and 2010.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Medical ICU admission was determined using bedsection (Veterans Affairs) and revenue center codes (Medicare). For Veterans Affairs admissions, we used clinical data to calculate Veterans Aging Cohort Study Index scores and multivariable logistic regression to determine factors associated with 30-day mortality. Overall, 539 of 3,620 (15%) HIV infected and 375 of 3,639 (10%) uninfected had a medical ICU admission; 72% and 78%, respectively, were Veterans Affairs based. HIV+ patients were younger at admission (p < 0.0001). Although most HIV+ patients were on antiretroviral therapy (71%) with undetectable HIV-1 RNA (54%), compared with uninfected they were more commonly admitted with respiratory diagnoses or infections (21% vs. 12%), were more likely to require mechanical ventilation (17% vs. 9%; p = 0.001), and had a higher mortality rate (18.6% vs. 11.2%, p = 0.003). Cardiovascular diagnoses were less common among HIV infected (18% vs. 29%; p < 0.0001). In logistic regression (c-statistic 0.87), a 5-point increment in Veterans Aging Cohort Study Index was associated with an odds ratio of death of 1.22 (95% confidence interval 1.14-1.30) among HIV infected and of 1.50 (95% confidence interval 1.29-1.76) among uninfected; infection/sepsis and respiratory diagnoses were also associated with mortality.

CONCLUSIONS

Medical ICU admission was frequent, 30-day mortality higher, and mechanical ventilation more common in HIV infected compared with uninfected. The Veterans Aging Cohort Study Index calculated at medical ICU admission predicted 30-day mortality for HIV infected and uninfected. As more individuals age with HIV, their requirements for medical ICU care may be greater than demographically similar uninfected individuals.

Clinical review: Respiratory failure in HIV-infected patients--a changing picture

Respiratory failure in HIV-infected patients is a relatively common presentation to ICU. The debate on ICU treatment of HIV-infected patients goes on despite an overall decline in mortality amongst these patients since the AIDS epidemic. Many intensive care physicians feel that ICU treatment of critically ill HIV patients is likely to be futile. This is mainly due to the unfavourable outcome of HIV patients with Pneumocystis jirovecii pneumonia who need mechanical ventilation. However, the changing spectrum of respiratory illness in HIV-infected patients and improved outcome from critical illness remain under-recognised. Also, the awareness of certain factors that can affect their outcome remains low. As there are important ethical and practical implications for intensive care clinicians while making decisions to provide ICU support to HIV-infected patients, a review of literature was undertaken. It is notable that the respiratory illnesses that are not directly related to underlying HIV disease are now commonly encountered in the highly active antiretroviral therapy (HAART) era. The overall incidence of P. jirovecii as a cause of respiratory failure has declined since the AIDS epidemic and sepsis including bacterial pneumonia has emerged as a frequent cause of hospital and ICU admission amongst HIV patients. The improved overall outcome of HIV patients needing ICU admission is related to advancement in general ICU care, including adoption of improved ventilation strategies. An awareness of respiratory illnesses in HIV-infected patients along with an appropriate diagnostic and treatment strategy may obviate the need for invasive ventilation and improve outcome further. HIV-infected patients presenting with respiratory failure will benefit from early admission to critical care for treatment and support. There is evidence to suggest that continuing or starting HAART in critically ill HIV patients is beneficial and hence should be considered after multidisciplinary discussion. As a very high percentage (up to 40%) of HIV patients are not known to be HIV infected at the time of ICU admission, the clinicians should keep a low threshold for requesting HIV testing for patients with recurrent pneumonia.

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.

Critical care of persons infected with the human immunodeficiency virus

Antiretroviral therapy (ART) has transformed the prognosis for patients infected with the human immunodeficiency virus (HIV). With effective ART, these individuals can expect to live almost as long as their HIV-negative counterparts. Given that more than a million people infected with HIV currently live in the United States, the likelihood that the practicing intensivist will manage a patient infected with HIV is high. This review discusses the challenges associated with management of critically ill patients infected with HIV, including the immune reconstitution inflammatory syndrome (a complication associated with ART initiation), ART-related toxicities, and the management of some common opportunistic infections.

Risk factors for hospitalization and medical intensive care unit (MICU) admission among HIV-infected Veterans

OBJECTIVE

With improved survival of HIV-infected persons on antiretroviral therapy and growing prevalence of non-AIDS diseases, we asked whether the VACS Index, a composite measure of HIV-associated and general organ dysfunction predictive of all-cause mortality, predicts hospitalization and medical intensive care unit (MICU) admission. We also asked whether AIDS and non-AIDS conditions increased risk after accounting for VACS Index score.

METHODS

We analyzed data from the Veterans Aging Cohort Study (VACS), a prospective study of HIV-infected Veterans receiving care between 2002 and 2008. Data were obtained from the electronic medical record, VA administrative databases, and patient questionnaires and were used to identify comorbidities and calculate baseline VACS Index scores. The primary outcome was first hospitalization within 2 years of VACS enrollment. We used multivariable Cox regression to determine risk factors associated with hospitalization and logistic regression to determine risk factors for MICU admission, given hospitalization.

RESULTS

Of 3410 patients, 1141 were hospitalized within 2 years; 203 (17.8%)/1141 patients included an MICU admission. Median VACS Index scores were 25 (no hospitalization), 34 (hospitalization only), and 51 (MICU). In adjusted analyses, a 5-point increment in VACS Index score was associated with 10% higher risk of hospitalization and MICU admission. In addition to VACS Index score, Hispanic ethnicity, current smoking, hazardous alcohol use, chronic obstructive pulmonary disease, hypertension, diabetes, and prior AIDS-defining event predicted hospitalization. Among those hospitalized, VACS Index score, cardiac disease, and prior cancer predicted MICU admission.

CONCLUSIONS

The VACS Index predicted hospitalization and MICU admission as did current smoking, hazardous alcohol use, and AIDS and certain non-AIDS diagnoses.

The potential anesthetic threats, challenges and intensive care considerations in patients with HIV infection

Acquired immunodeficiency syndrome (AIDS) has become a pandemic with ever looming danger of its transmission in health professionals. The number of AIDS patients has increased tremendously over the last two decades, who present for surgical procedures as well as who get admitted in intensive care unit for their critical condition. As such anesthesiologists and intensivists are exposed to potential risk of disease transmission on a daily basis from such patients. The guidelines and protocols formulated in the western world regarding prevention of disease transmission cannot be applied uniformly in the developing nations, such as India due to various factors and limitations. As such there is a continuous need felt in this arena to prevent the catastrophic consequences of AIDS in our medical fraternity while treating such patients in operation theatres and critical care units. This study reviews the various pathophysiological aspects, anesthetic considerations, intensive care implications, and various areas where current knowledge about AIDS can be applied to prevent its potential transmission in high-risk clinical groups.

Predictors of the short- and long-term survival of HIV-infected patients admitted to a Brazilian intensive care unit

The outcomes of HIV-infected patients requiring critical care have improved. However, in developing countries, information about HIV-infected patients admitted to intensive care units (ICUs) is scarce. We describe the prognosis of HIV-infected patients admitted to a Brazilian ICU and the factors predictive of short- and long-term survival. A historical cohort study, including HIV-infected patients admitted to a Brazilian ICU at an HIV/AIDS reference hospital, was conducted. Survivors were followed up for 24 months after ICU discharge. Demographic, clinical and laboratory data, disease severity scores and mortality were evaluated. Data were analysed using survival and regression models. One hundred and twenty-five patients were studied. In-ICU and in-hospital mortality rates were 46.4% and 68.0%, respectively. Multivariate analysis showed that the in-ICU mortality was significantly associated with APACHE (Acute Physiology and Chronic Health Evaluation) II scores (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.03–1.11), mechanical ventilation (OR, 6.39; 95% CI, 1.29–31.76), tuberculosis treatment (OR, 2.62; 95% CI, 1.03–6.71), use of antiretroviral therapy (OR, 0.19; 95% CI, 0.05–0.77) and septic shock (OR, 4.38; 95% CI, 1.78–10.76). Septic shock was also associated with long-term survival (hazard ratio, 3.0; 95% CI, 1.31–6.90). In-hospital and in-ICU mortality were higher than those reported for developed countries. ICU admission mostly due to AIDS-related diseases may explain these differences.

Should highly active antiretroviral therapy be prescribed in critically ill HIV-infected patients during the ICU stay? A retrospective cohort study

Background

The impact of highly active antiretroviral therapy (HAART) in HIV-infected patients admitted to the intensive care unit (ICU) remains controversial. We evaluate impact of HAART prescription in HIV-infected patients admitted to the ICU of Tourcoing Hospital from January 2000 to December 2009.

Results

There were 91 admissions concerning 85 HIV-infected patients. Reasons for ICU admission were an AIDS-related diagnosis in 46 cases (51%). Fifty two patients (57%) were on HAART at the time of ICU admission, leading to 21 immunovirologic successes (23%). During the ICU stay, HAART was continued in 29 patients (32%), and started in 3 patients (3%). Only one patient experienced an adverse event related to HAART. Mortality rate in ICU and 6 months after ICU admission were respectively 19% and 27%. Kaplan-Meier estimates of the cumulative unajusted survival probability over 6 months were higher in patients treated with HAART during the ICU stay (Log rank: p = 0.04). No benefit of HAART in ICU was seen in the adjusted survival proportion at 6 months or during ICU stay. Prescription of HAART during ICU was associated with a trend to lower incidence of new AIDS-related events at 6 months (respectively 17% and 34% with and without HAART, p = 0.07), and with higher incidence of antiretroviral resistance after ICU stay (respectively 25% and 7% with and without HAART, p = 0.02).

Conclusions

Our results suggest a lower death rate over 6 months in critically ill HIV-infected patients taking HAART during ICU stay. The optimal time to prescribe HAART in critically ill patients needs to be better defined.

Human herpes virus co-infection is associated with mortality in HIV-negative patients with Pneumocystis jirovecii pneumonia

The purpose of this investigation was to characterize the management and prognosis of severe Pneumocystis jirovecii pneumonia (PJP) in human immunodeficiency virus (HIV)-negative patients. An observational cohort study of HIV-negative adults with PJP documented by bronchoalveolar lavage (BAL) through Gomori-Grocott staining or immunofluorescence, admitted to one intensive care unit (ICU) for acute respiratory failure, was undertaken. From 1990 to 2010, 70 patients (24 females, 46 males) were included, with a mean age of 58.6 ± 18.3 years. The mean Simplified Acute Physiology Score (SAPS)-II was 36.9 ± 20.4. Underlying conditions included hematologic malignancies (n = 21), vasculitis (n = 13), and solid tumors (n = 13). Most patients were receiving systemic corticosteroids (n = 63) and cytotoxic drugs (n = 51). Not a single patient received trimethoprim-sulfamethoxazole as PJP prophylaxis. Endotracheal intubation (ETI) was required in 42 patients (60.0 %), including 38 with acute respiratory distress syndrome (ARDS). In-ICU mortality was 52.9 % overall, reaching 80.9 % and 86.8 %, respectively, for patients who required ETI and for patients with ARDS. In the univariate analysis, in-ICU mortality was associated with SAPS-II (p = 0.0131), ARDS (p < 0.0001), shock (p < 0.0001), and herpes simplex virus (HSV) or cytomegalovirus (CMV) on BAL (p = 0.0031). In the multivariate analysis, only ARDS was associated with in-ICU mortality (odds ratio [OR] 23.4 [4.5-121.9], p < 0.0001). PJP in non-HIV patients remains a serious disease with high in-hospital mortality. Pulmonary co-infection with HSV or CMV may contribute to fatal outcome.

Short- and long-term outcomes of HIV-infected patients admitted to the intensive care unit: impact of antiretroviral therapy and immunovirological status

Background

The purpose of this study was to assess the short- and long-term outcomes of HIV-infected patients admitted to intensive care units (ICU) according to immunovirological status at admission and highly active antiretroviral therapy (HAART) use in ICU.

Methods

Retrospective study of 98 HIV-infected patients hospitalized between 1997 and 2008 in two medical ICU in Montpellier, France. The primary outcome was mortality in ICU. The secondary end point was probability of survival in the year following ICU admission.

Results

Eighty-two (83.6%) admissions in ICU were related to HIV infection and 45% of patients had received HAART before admission. Sixty-two patients (63.3%) were discharged from ICU, and 34 (34.7%) were alive at 1 year. Plasma HIV RNA viral load (VL) and CD4+ cell count separately were not associated with outcome. Independent predictors of ICU mortality were the use of vasopressive agents (odds ratio (OR), 3.779; 95% confidence interval (CI), 1.11–12.861; p = 0.0334) and SAPS II score (OR, 1.04; 95% CI, 1.003-1.077; p = 0.0319), whereas introducing or continuing HAART in ICU was protective (OR, 0.278; 95% CI, 0.082-0.939; p = 0.0393). Factors independently associated with 1-year mortality were immunovirological status with high VL (>3 log₁₀/ml) and low CD4 (<200/mm³; hazard ratio (HR), 5.19; 95% CI, 1.328-20.279; p = 0.0179) or low VL (<3 log₁₀/ml) and low CD4 (HR, 4.714; 95% CI, 1.178-18.867; p = 0.0284) vs. high CD4 and low VL, coinfection with C hepatitis virus (HR, 3.268; 95% CI, 1.29-8.278; p = 0.0125), the use of vasopressive agents (HR, 3.68; 95% CI, 1.394-9.716; p = 0.0085), and SAPS II score (HR, 1.09; 95% CI, 1.057-1.124; p <0.0001). Introducing HAART in a patient with no HAART at admission was associated with a better long-term outcome (HR, 0.166; 95% CI, 0.043-0.642; p = 0.0093).

Conclusions

In a population of HIV-infected patients admitted to ICU, short- and long-term outcomes are related to acute illness severity and immunovirological status at admission. Complementary studies are necessary to identify HIV-infected patients who benefit from HAART use in ICU according to immunovirological status and the reasons of ICU admission.

The long-term outcome of HIV-infected patients after intensive care admission

Long-term outcomes of HIV-infected patients admitted to the intensive care unit (ICU) since the advent of combination antiretroviral therapy (cART) have not been well described. We reviewed the long-term outcomes and clinical follow-up of HIV-infected patients admitted to the Prince of Wales Hospital ICU between 1999 and 2005 by a retrospective medical record review. Mortality was assessed in the ICU, in hospital and in the long-term. Twenty-four HIV-infected male patients underwent 26 ICU admissions. Their ICU and in-hospital mortalities were 33% and 46%, respectively. Higher APACHE (acute physiology and chronic health evaluation) II scores (median 27 versus 12, P < 0.001), lower CD4 cell counts (median 45 versus 335 cells/μL, P = 0.041) and longer hospitalization times prior to ICU admission (median 4 versus 1 day, P = 0.02) were significantly associated with in-hospital mortality. We found 85% of the subjects who survived hospital admission were still alive at a median of 41 months (4 months to 5 years) of follow-up, all of who were functionally independent. HIV-infected patients who survived ICU admission at our institution had good long-term outcomes in the cART era.

Echocardiographic findings and their impact on outcomes of critically ill patients with AIDS in the era of HAART

Objective. To describe the echocardiographic findings in critically ill patients with AIDS and their impact on clinical outcome. Design. A retrospective chart review of consecutive AIDS patients over 18 years of age, who had a trans-thoracic echocardiogram performed during the course of intensive care unit stay over the course of 2 years at a tertiary care hospital. Main outcome measures. The prevalence of echocardiogram abnormalities in this population and its impact on ICU mortality, ICU length of stay, hospital mortality, hospital length of stay and 60 day survival. Results. Among 107 patients who met the inclusion criteria, an admission echocardiogram was performed in 62 (58%). The prevalence of cardiac abnormalities was 60%. The most common admission diagnosis was respiratory failure n = 27 (43%). The most common finding on echocardiogram was left ventricular (LV) dysfunction n = 31 (50%) followed by pulmonary hypertension n = 25 (40%). None of these findings had a significant impact on clinical outcomes. There was trend toward reduced 60 day survival among patients with depressed LV function. Conclusions. Although echocardiogram abnormalities were prevalent among this population none of these findings had a significant impact on ICU mortality or hospital mortality and ICU length of stay or hospital length of stay.

Comparing outcomes of HIV versus non-HIV patients requiring mechanical ventilation

BACKGROUND

Mechanical ventilation (MV) is a predictor of mortality in patients infected with human immunodeficiency virus (HIV) in the intensive care unit (ICU). Patients with HIV-infections are admitted to the ICU for a variety of reasons that frequently require intubation. While survival rates for HIV-infected patients continue to improve, ICU admission rates have remained consistent.

METHODS

To observe the consequences of MV in HIV-infected patients, we conducted a retrospective chart review on patients with HIV (n=55) vs. matched HIV-negative patients (n=55) who required MV over a one-year period and compared the groups for differences in outcome and complications.

RESULTS

The HIV group had twice the number of deaths (44% vs. 22%, all-cause mortality) (P=0.01). Among the HIV-positive group, 5 of 55 patients required tracheostomy and prolonged MV, compared to 15 of 55 in the control group (9% and 27%, respectively). Successful extubation was virtually identical (47% MV vs. 50% control). Ventilator-associated pneumonia (VAP) was significantly higher among HIV-positive cases (39 of 55 HIV vs. 14 of 55 non-HIV) (P=0.05). Regression analysis revealed that hypotension, hypoalbuminemia, and fever predicted a poorer outcome. Low CD4 cell counts were strongly associated with mortality.

CONCLUSION

HIV-infected patients requiring MV have significantly higher mortality and VAP rates than HIV-negative patients. Since VAP is associated with a poor prognosis, discovering ways to prevent it in the HIV-infected patient may improve outcome.

The impact of comorbid [corrected] conditions on critical illness

OBJECTIVE

To review the current knowledge of common comorbidities in the intensive care unit, including diabetes mellitus, chronic obstructive pulmonary disease, cancer, end-stage renal disease, end-stage liver disease, HIV infection, and obesity, with specific attention to epidemiology, contribution to diseases and outcomes, and the impact on treatments in these patients.

DATA SOURCE

Review of the relevant medical literature for specific common comorbidities in the critically ill.

RESULTS

Critically ill patients are admitted to the intensive care unit for various reasons, and often the admission diagnosis is accompanied by a chronic comorbidity. Chronic comorbid conditions commonly seen in critically ill patients may influence the decision to provide intensive care unit care, decisions regarding types and intensity of intensive care unit treatment options, and outcomes. The presence of comorbid conditions may predispose patients to specific complications or forms of organ dysfunction. The impact of specific comorbidities varies among critically ill medical, surgical, and other populations, and outcomes associated with certain comorbidities have changed over time. Specifically, outcomes for patients with cancer and HIV have improved, likely related to advances in therapy. Overall, the negative impact of chronic comorbidity on survival in critical illness may be primarily influenced by the degree of organ dysfunction or the cumulative severity of multiple comorbidities.

CONCLUSION

Chronic comorbid conditions are common in critically ill patients. Both the acute illness and the chronic conditions influence prognosis and optimal care delivery for these patients, particularly for adverse outcomes and complications influenced by comorbidities. Further work is needed to fully determine the individual and combined impact of chronic comorbidities on intensive care unit outcomes.

Lung Disease in Older Patients with HIV

Successful treatment of HIV with combination antiretroviral therapy (ART) has resulted in an aging HIV-infected population. As HIV-infected patients are living longer, noninfectious pulmonary diseases are becoming increasingly prevalent with a proportional decline in the incidence of opportunistic infections (OIs). Pulmonary OIs such as Pneumocystis jirovecii pneumonia (PCP) and tuberculosis are still responsible for a significant proportion of pulmonary diseases in HIV-infected patients. However, bacterial pneumonia (BP) and noninfectious pulmonary diseases such as chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary arterial hypertension (PAH), and interstitial lung disease (ILD) account for a growing number of pulmonary diseases in aging HIV-infected patients. The purpose of this chapter is to discuss the spectrum and management of pulmonary diseases in aging HIV-infected patients, although limited data exists to guide management of many noninfectious pulmonary diseases in HIV-infected patients. In the absence of such data, treatment of lung diseases in HIV-infected patients should generally follow guidelines for management established in HIV-uninfected patients.

Critical illness in HIV-infected patients in the era of combination antiretroviral therapy

As HIV-infected persons on combination antiretroviral therapy (ART) are living longer and rates of opportunistic infections have declined, serious non-AIDS-related diseases account for an increasing proportion of deaths. Consistent with these changes, non-AIDS-related illnesses account for the majority of ICU admissions in more recent studies, in contrast to earlier eras of the AIDS epidemic. Although mortality after ICU admission has improved significantly since the earliest HIV era, it remains substantial. In this article, we discuss the current state of knowledge regarding the impact of ART on incidence, etiology, and outcomes of critical illness among HIV-infected patients. In addition, we consider issues related to administration of ART in the ICU and identify important areas of future research.

Intensive Care Usage by HIV-Positive Patients in the HAART Era

In the 1980s the outlook for patients with the acquired immunodeficiency syndrome (AIDS) and critical illness was poor. Since then several studies of outcome of HIV+ patients on ICU have shown improving prognosis, with anti-retroviral therapy playing a large part. We retrospectively examined intensive care (ICU) admissions in a large HIV unit in London. Between April 2001 and April 2006 43 patients were admitted to the ICU. The mean age of patients was 44 years and 74% were male. Fifty-six percent of admissions were receiving anti-retroviral therapy and 44% had an AIDS defining diagnosis. The median CD4 count was 128 cells/mL and the median APACHE II score was 21. The commonest diagnostic ICU admission category was respiratory disease. This group experienced higher mortality despite slightly lower APACHE II scores, though this did not achieve statistical significance. The follow up period was one year or until April 2007, when data were censored. ICU mortality was 33%, in hospital mortality was 51% and overall mortality at the end of the study period was 67%. Median survival was 1008 days. The CD4 count did not predict long-term survival, although the sample size was too small for this to be conclusive.

Outcomes for critically ill patients with HIV and severe sepsis in the era of highly active antiretroviral therapy

RATIONALE

With the advent of highly active antiretroviral therapy (HAART), sepsis has become a more frequent ICU diagnosis for patients with HIV infections. Yet, little is known about the etiologies of acute infections in critically ill patients with HIV and the factors that affect in-hospital mortality.

METHODS

Cases of patients with HIV requiring intensive care specifically for severe sepsis were identified over 27 months. Demographic information, variables related to acute illness severity, variables related to HIV infection, and all acute infections contributing to ICU stay were recorded.

RESULTS

Of 990 patients admitted to the ICU with severe sepsis, 136 (13.7%) were HIV-infected. There were 194 acute infections among the 125 patients with full data available; 112 of the infections were nosocomial/health care-associated, 55 were AIDS-related, and 27 were community-acquired. Patients with nosocomial/health care-associated and AIDS-related infections had lower CD4 counts and were less likely to be on HAART (P < .05). The inpatient mortality was 42%. In a multivariable logistic regression model, only the APACHE II score (odds ratio, 1.12; 95% confidence interval, 1.02-1.23) was significantly associated with hospital mortality, although any HAART use (odds ratio, 0.53; 95% confidence interval, 0.22-1.33, P = .18) approached statistical significance.

CONCLUSIONS

In this large cohort study, nosocomial/health care-associated infections were common in ICU patients with HIV and severe sepsis. Hospital mortality was associated with acute illness severity, but not clearly associated with variables related to HIV infection. Interventions that aim to prevent or more effectively treat nosocomial infections in critically ill patients with HIV may favorably impact clinical outcomes.

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.

An official ATS workshop report: Emerging issues and current controversies in HIV-associated pulmonary diseases

Pulmonary diseases are major causes of morbidity and death in persons with HIV infection. Millions of people with HIV/AIDS throughout the world are at risk of opportunistic pneumonias such as tuberculosis, bacterial pneumonia, and Pneumocystis pneumonia. However, the availability of combination antiretroviral therapy has turned HIV into a chronic disease, and noninfectious lung diseases such as lung cancer, chronic obstructive pulmonary disease, and pulmonary arterial hypertension are also emerging as important causes of illness. Despite the importance of these diseases and the rapidly evolving understanding of their pathogenesis and epidemiology, few avenues exist for the discussion and dissemination of new clinical and basic insights. In May of 2008, the American Thoracic Society sponsored a 1-day workshop, "Emerging Issues and Current Controversies in HIV-Associated Pulmonary Diseases," which brought together basic and clinical researchers in HIV-associated pulmonary disease. A review of the literature was performed by workshop participants, and the workshop included 18 presentations on diverse topics summarized in this article.