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Kanitkar T, Bakewell N, Dissanayake O, Symonds M, Rimmer S, Adlakha A, Lipman MCI, Bhagani S, Agarwal B, Sabin CA, Miller RF. Improving 1-Year Mortality Following Intensive Care Unit Admission in Adults with HIV: A 20-Year Observational Study. J Intensive Care Med 2024; 39:883-894. [PMID: 38563646 DOI: 10.1177/08850666241241480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Despite widespread use of combination antiretroviral therapy, people with HIV (PWH) continue to have an increased risk of admission to and mortality in the intensive care unit (ICU). Mortality risk after hospital discharge is not well described. Using retrospective data on adult PWH (≥18 years) admitted to ICU from 2000-2019 in an HIV-referral centre, we describe trends in 1-year mortality after ICU admission. METHODS One-year mortality was calculated from index ICU admission to date of death; with follow-up right-censored at day 365 for people remaining alive at 1 year, or day 7 after ICU discharge if lost-to-follow-up after hospital discharge. Cox regression was used to describe the association with calendar year before and after adjustment for patient characteristics (age, sex, Acute Physiology and Chronic Health Evaluation II [APACHE II] score, CD4+ T-cell count, and recent HIV diagnosis) at ICU admission. Analyses were additionally restricted to those discharged alive from ICU using a left-truncated design, with further adjustment for respiratory failure at ICU admission in these analyses. RESULTS Two hundred and twenty-one PWH were admitted to ICU (72% male, median [interquartile range] age 45 [38-53] years) of whom 108 died within 1-year (cumulative 1-year survival: 50%). Overall, the hazard of 1-year mortality was decreased by 10% per year (crude hazard ratio (HR): 0.90 (95% confidence interval: 0.87-0.93)); the association was reduced to 7% per year (adjusted HR: 0.93 (0.89-0.98)) after adjustment. Conclusions were similar among the subset of 136 patients discharged alive (unadjusted: 0.91 (0.84-0.98); adjusted 0.92 (0.84, 1.02)). CONCLUSIONS Between 2000 and 2019, 1-year mortality after ICU admission declined at this ICU. Our findings highlight the need for multi-centre studies and the importance of continued engagement in care after hospital discharge among PWH.
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Affiliation(s)
- Tanmay Kanitkar
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Nicholas Bakewell
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK
| | - Oshani Dissanayake
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Maggie Symonds
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Stephanie Rimmer
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Amit Adlakha
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Marc C I Lipman
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
- UCL Respiratory, Division of Medicine, University College London, London, UK
- Respiratory Medicine, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Sanjay Bhagani
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Banwari Agarwal
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Caroline A Sabin
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
| | - Robert F Miller
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK
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Richards GA, Zamparini J, Kalla I, Laher A, Murray LW, Shaddock EJ, Stacey S, Venter WF, Feldman C. Critical illness due to infection in people living with HIV. Lancet HIV 2024; 11:e406-e418. [PMID: 38816142 DOI: 10.1016/s2352-3018(24)00096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 06/01/2024]
Abstract
People living with HIV comprise a substantial number of the patients admitted to intensive care. This number varies according to geography, but all areas of the world are affected. In lower-income and middle-income countries, the majority of intensive care unit (ICU) admissions relate to infections, whereas in high-income countries, they often involve HIV-associated non-communicable diseases diagnoses. Management of infections potentially resulting in admission to the ICU in people living with HIV include sepsis, respiratory infections, COVID-19, cytomegalovirus infection, and CNS infections, both opportunistic and non-opportunistic. It is crucial to know which antiretroviral therapy (ART) is appropriate, when is the correct time to administer it, and to be aware of any safety concerns and potential drug interactions with ART. Although ART is necessary for controlling HIV infections, it can also cause difficulties relevant to the ICU such as immune reconstitution inflammatory syndrome, and issues associated with ART administration in patients with gastrointestinal dysfunction on mechanical ventilation. Managing infection in people with HIV in the ICU is complex, requiring collaboration from a multidisciplinary team knowledgeable in both the management of the specific infection and the use of ART. This team should include intensivists, infectious disease specialists, pharmacists, and microbiologists to ensure optimal outcomes for patients.
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Affiliation(s)
- Guy A Richards
- Department of Surgery, Division of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Jarrod Zamparini
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ismail Kalla
- Department of Internal Medicine, Division of Pulmonology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Abdullah Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lyle W Murray
- Department of Internal Medicine, Division of Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Erica J Shaddock
- Department of Internal Medicine, Division of Pulmonology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah Stacey
- Department of Internal Medicine, Division of Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wd Francois Venter
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Kanitkar T, Dissanayake O, Bakewell N, Symonds M, Rimmer S, Adlakha A, Lipman MC, Bhagani S, Sabin CA, Agarwal B, Miller RF. Changes in short-term (in-ICU and in-hospital) mortality following intensive care unit admission in adults living with HIV: 2000-2019. AIDS 2023; 37:2169-2177. [PMID: 37605448 PMCID: PMC10621640 DOI: 10.1097/qad.0000000000003683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/18/2023] [Accepted: 08/03/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Limited data suggest intensive care unit (ICU) outcomes have improved in people with HIV (PWH). We describe trends in in-ICU/in-hospital mortality among PWH following admission to ICU in a single UK-based HIV referral centre, from 1 January 2000 to 31 December 2019. METHODS Modelling of associations between ICU admission and calendar year of admission was done using logistic regression with adjustment for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, CD4 + T-cell count and diagnosis of HIV at/within the past 3 months. RESULTS Among 221 PWH (71% male, median [interquartile range (IQR)] age 45 years [38-53]) admitted to ICU, median [IQR] APACHE II score and CD4 + T-cell count were 19 [14-25] and 122 cells/μl [30-297], respectively; HIV-1 viral load was ≤50 copies/ml in 46%. The most common ICU admission diagnosis was lower respiratory tract infection (30%). In-ICU and in-hospital, mortality were 29 and 38.5%, respectively. The odds of in-ICU mortality decreased over the 20-year period by 11% per year [odds ratio (OR): 0.89 (95% confidence interval (CI): 0.84-0.94)] with in-hospital mortality decreasing by 14% per year [0.86 (0.82-0.91)]. After adjusting for patient demographics and clinical factors, both estimates were attenuated, however, the odds of in-hospital mortality continued to decline over time [in-ICU mortality: adjusted OR: 0.97 (0.90-1.05); in-hospital mortality: 0.90 (0.84-0.97)]. CONCLUSION Short-term mortality of critically ill PWH admitted to ICU has continued to decline in the ART era. This may result from changing indications for ICU admission, advances in critical care and improvements in HIV-related immune status.
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Affiliation(s)
- Tanmay Kanitkar
- Intensive Care Unit
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust
| | - Oshani Dissanayake
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust
| | - Nicholas Bakewell
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health
| | - Maggie Symonds
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust
| | | | | | - Marc C.I. Lipman
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust
- UCL Respiratory, Division of Medicine, University College London
- Respiratory Medicine, Royal Free Hospital, Royal Free London NHS Foundation Trust
| | - Sanjay Bhagani
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust
| | - Caroline A. Sabin
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections
| | | | - Robert F. Miller
- HIV Services, Royal Free Hospital, Royal Free London NHS Foundation Trust
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK
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Schulze AB, Mohr M, Sackarnd J, Schmidt LH, Tepasse PR, Rosenow F, Evers G. Risk Factors in HIV-1 Positive Patients on the Intensive Care Unit: A Single Center Experience from a Tertiary Care Hospital. Viruses 2023; 15:v15051164. [PMID: 37243250 DOI: 10.3390/v15051164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
HIV-positive patients with acquired immunodeficiency syndrome (AIDS) often require treatment on intensive care units (ICUs). We aimed to present data from a German, low-incidence region cohort, and subsequently evaluate factors measured during the first 24 h of ICU stay to predict short- and long-term survival, and compare with data from high-incidence regions. We documented 62 patient courses between 2009 and 2019, treated on a non-operative ICU of a tertiary care hospital, mostly due to respiratory deterioration and co-infections. Of these, 54 patients required ventilatory support within the first 24 h with either nasal cannula/mask (n = 12), non-invasive ventilation (n = 16), or invasive ventilation (n = 26). Overall survival at day 30 was 77.4%. While ventilatory parameters (all p < 0.05), pH level (c/o 7.31, p = 0.001), and platelet count (c/o 164,000/µL, p = 0.002) were significant univariate predictors of 30-day and 60-day survival, different ICU scoring systems, such as SOFA score, APACHE II, and SAPS 2 predicted overall survival (all p < 0.001). Next to the presence or history of solid neoplasia (p = 0.026), platelet count (HR 6.7 for <164,000/µL, p = 0.020) and pH level (HR 5.8 for <7.31, p = 0.009) remained independently associated with 30-day and 60-day survival in multivariable Cox regression. However, ventilation parameters did not predict survival multivariably.
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Affiliation(s)
- Arik Bernard Schulze
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, 48149 Münster, Germany
| | - Michael Mohr
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, 48149 Münster, Germany
| | - Jan Sackarnd
- Department of Cardiovascular Medicine, Internal Intensive Care Medicine, University Hospital Münster, 48149 Münster, Germany
| | - Lars Henning Schmidt
- Medical Department IV, Pneumology, Respiratory Medicine and Thoracic Oncology, Klinikum Ingolstadt, 85049 Ingolstadt, Germany
- Department of Internal Medicine II, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Phil-Robin Tepasse
- Department of Medicine B, Gastroenterology, Hepatology, Endocrinology and Clinical Infectiology, University Hospital Münster, 48149 Münster, Germany
| | - Felix Rosenow
- Department of Cardiovascular Medicine, Internal Intensive Care Medicine, University Hospital Münster, 48149 Münster, Germany
| | - Georg Evers
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, 48149 Münster, Germany
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Burke RM, Twabi HH, Johnston C, Nliwasa M, Gupta-Wright A, Fielding K, Ford N, MacPherson P, Corbett EL. Interventions to reduce deaths in people living with HIV admitted to hospital in low- and middle-income countries: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001557. [PMID: 36963024 PMCID: PMC10022356 DOI: 10.1371/journal.pgph.0001557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
People living with HIV (PLHIV) admitted to hospital have a high risk of death. We systematically appraised evidence for interventions to reduce mortality among hospitalised PLHIV in low- and middle-income countries (LMICs). Using a broad search strategy with terms for HIV, hospitals, and clinical trials, we searched for reports published between 1 Jan 2003 and 23 August 2021. Studies of interventions among adult HIV positive inpatients in LMICs were included if there was a comparator group and death was an outcome. We excluded studies restricted only to inpatients with a specific diagnosis (e.g. cryptococcal meningitis). Of 19,970 unique studies identified in search, ten were eligible for inclusion with 7,531 participants in total: nine randomised trials, and one before-after study. Three trials investigated systematic screening for tuberculosis; two showed survival benefit for urine TB screening vs. no urine screening, and one which compared Xpert MTB/RIF versus smear microscopy showed no difference in survival. One before-after study implemented 2007 WHO guidelines to improve management of smear negative tuberculosis in severely ill PLHIV, and showed survival benefit but with high risk of bias. Two trials evaluated complex interventions aimed at overcoming barriers to ART initiation in newly diagnosed PLHIV, one of which showed survival benefit and the other no difference. Two small trials evaluated early inpatient ART start, with no difference in survival. Two trials investigated protocol-driven fluid resuscitation for emergency-room attendees meeting case-definitions for sepsis, and showed increased mortality with use of a protocol for fluid administration. In conclusion, ten studies published since 2003 investigated interventions that aimed to reduce mortality in hospitalised adults with HIV, and weren't restricted to people with a defined disease diagnosis. Inpatient trials of diagnostics, therapeutics or a package of interventions to reduce mortality should be a research priority. Trial registration: PROSPERO Number: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019150341.
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Affiliation(s)
- Rachael M. Burke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
| | - Hussein H. Twabi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Cheryl Johnston
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Ankur Gupta-Wright
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nathan Ford
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Peter MacPherson
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Elizabeth L. Corbett
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
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Ford N, Patten G, Rangaraj A, Davies MA, Meintjes G, Ellman T. Outcomes of people living with HIV after hospital discharge: a systematic review and meta-analysis. THE LANCET HIV 2022; 9:e150-e159. [PMID: 35245507 PMCID: PMC8905089 DOI: 10.1016/s2352-3018(21)00329-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022]
Abstract
Background The identification and appropriate management of people with advanced HIV disease is a key component in the HIV response. People with HIV who are hospitalised are at a higher risk of death, a risk that might persist after discharge. The aims of this study were to estimate the frequency of negative post-discharge outcomes, and to determine risk factors for such outcomes in people with HIV. Methods Using a broad search strategy combining terms for hospital discharge and HIV infection, we searched MEDLINE via PubMed and Embase from Jan 1, 2003 to Nov 30, 2021 to identify studies reporting outcomes among people with HIV following discharge from hospital. We estimated pooled proportions of readmissions and deaths after hospital discharge using random-effects models. We also did subgroup analyses by setting, region, duration of follow-up, and advanced HIV status at admission, and sensitivity analyses to assess heterogeneity. Findings We obtained data from 29 cohorts, which reported outcomes of people living with HIV after hospital discharge in 92 781 patients. The pooled proportion of patients readmitted to hospital after discharge was 18·8% (95% CI 15·3–22·3) and 14·1% (10·8–17·3) died post-discharge. In sensitivity analyses, no differences were identified in the proportion of patients who were readmitted or died when comparing studies published before 2016 with those published after 2016. Post-discharge mortality was higher in studies from Africa (23·1% [16·5–29·7]) compared with the USA (7·5% [4·4–10·6]). For studies that reported both post-discharge mortality and readmission, the pooled proportion of patients who had this composite adverse outcome was 31·7% (23·9–39·5). Heterogeneity was moderate, and largely explained by patient status and linkage to care. Reported risk factors for readmission included low CD4 cell count at admission, longer length of stay, discharge against medical advice, and not linking to care following discharge; inpatient treatment with antiretroviral therapy (ART) during hospitalisation was protective of post-discharge mortality. Interpretation More than a quarter of patients with HIV had an adverse outcome after hospital discharge with no evidence of improvement in the past 15 years. This systematic review highlights the importance of ensuring post-discharge referral and appropriate management, including ART, to reduce mortality and readmission to hospital among this group of high-risk patients. Funding Bill & Melinda Gates Foundation. Translations For the French and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Nathan Ford
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Gabriela Patten
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ajay Rangaraj
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Tom Ellman
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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