Management of patients with HIV in the intensive care unit

Characteristics of patients admitted to the ICU with Kaposi sarcoma herpesvirus-associated diseases

OBJECTIVE

There are four conditions caused by Kaposi sarcoma herpesvirus (KSHV): Kaposi sarcoma, KSHV-associated multicentric Castleman disease (MCD), primary effusion lymphoma (PEL), and KSHV inflammatory cytokine syndrome (KICS). These KSHV-associated disorders (KADs) often occur in people with HIV and can lead to multiorgan dysfunction requiring admission to the ICU. However, little is known about patient outcomes in this setting.

METHODS

A retrospective study of patients with KADs admitted to the ICU between 2010 and 2021 was conducted, examining KAD admission diagnoses, HIV characteristics, selected cytokine profiles, and ICU interventions. Primary outcomes were 60-day and median overall survival from ICU admission to death from any cause.

RESULTS

Forty-seven patients (all but one with HIV coinfection) were included. At ICU admission, 44 patients (94%) were on antiretroviral therapy with a median CD4 + count of 88 cells/μl and HIV viral load of 23 copies/ml. The most common presentation was respiratory failure alone (19%) or with hypotension (17%). Twenty-two (47%) patients had presumed KICS (with or without Kaposi sarcoma) at admission and an additional KAD was diagnosed in 36% of these patients. IL-6 levels did not vary across KAD subtype. Twenty (43%) patients received KAD-directed therapy in the ICU. Sixty-day survival was 70% and median overall survival was 9 months.

CONCLUSION

The majority of patients with HIV and KADs admitted to the ICU had well controlled HIV. Additional KAD were diagnosed during ICU admission in a proportion of patients who presented with presumed KICS. Critical illness did not preclude a subset of patients from receiving KAD-directed therapy in the ICU.

Cancer Stem Cells: An Ever-Hiding Foe

Cancer stem cells are a population of cells enable to reproduce the original phenotype of the tumor and capable to self-renewal, which is crucial for tumor proliferation, differentiation, recurrence, and metastasis, as well as chemoresistance. Therefore, the cancer stem cells (CSCs) have become one of the main targets for anticancer therapy and many ongoing clinical trials test anti-CSCs efficacy of plenty of drugs. This chapter describes CSCs starting from general description of this cell population, through CSCs markers, signaling pathways, genetic and epigenetic regulation, role of epithelial-mesenchymal transition (EMT) transition and autophagy, cooperation with microenvironment (CSCs niche), and finally role of CSCs in escaping host immunosurveillance against cancer.

Extra Corporeal Membrane Oxygenation in the Treatment of Human Immunodeficiency Virus-Related P. jirovecii Pneumonia

Despite the undeniable complexity one may encounter while managing critically ill patients with human immunodeficiency virus infection (HIV), intensive care unit-related mortality has declined in recent years, not only because of more efficacious antiretroviral therapy (ART) but also due to the advances in critical support. However, the use of extracorporeal membrane oxygenation (ECMO) in these patients remains controversial. We report four cases of HIV-infected patients with Pneumocystis jirovecii pneumonia (PJP) and acute respiratory distress syndrome (ARDS) treated with ECMO support and discuss its indications and possible role in the prevention of barotrauma and ventilator- induced lung injury (VILI). The eventually favorable clinical course of the patients that we present suggests that although immune status is an important aspect in the decision to initiate ECMO support, this technology can provide real benefit in some patients with severe HIV-related refractory ARDS.

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.

The use of extracorporeal membrane oxygenation in HIV-positive patients with severe respiratory failure: a retrospective observational case series

The objective is to describe the outcomes of patients with human immunodeficiency virus (HIV) infection who received extracorporeal membrane oxygenation (ECMO) for severe respiratory failure (SRF). The design and setting was a single centre retrospective observational case series, from January 2012 to June 2017, at a tertiary university hospital and regional referral centre for ECMO in the United Kingdom. The participants were all patients referred with SRF and HIV infection. The main outcome measure was patient 90-day survival. Twenty-four patients were referred, of whom nine received ECMO. Six out of nine (67%) of patients were alive at 90 days. Median duration of ECMO was 18 days. There were no identified differences between survivors and non-survivors. ECMO can be used successfully in selected patients with HIV and SRF, including those with poor HIV control and high illness severity. HIV status alone should not exclude patients from treatment with extracorporeal therapy.

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.

Survival after Pneumocystis jirovecii pneumonia requiring ventilation: A case report

Pneumocystis pneumonia (PCP) in patients with the human immunodeficiency virus (HIV) is associated with a high mortality rate, which increases substantially with the need for mechanical ventilation. Local experience of patients with PCP admitted to the intensive care unit has revealed mortality rates close to 100%. We present a case of a 39-year-old HIV-infected man diagnosed with PCP who was successfully weaned from mechanical ventilation after presenting with respiratory distress and severe hypoxaemia. A short review of the literature will also be presented.

Comparison of two databases to detect potential drug-drug interactions between prescriptions of HIV/AIDS patients in critical care

WHAT IS KNOWN AND OBJECTIVE

Adverse drug events (ADE), common and underestimated in ICU patients, have direct consequences on length of stay, mortality and hospital costs. Critically ill patients with HIV/AIDS are at a high risk of ADE because of their need for multiple drug therapies. ADE can be prevented, especially by the identification of potentially harmful drug-drug interactions (DDIs). Electronic databases are useful tools for the investigation of DDIs to avoid potential ADEs, thereby increasing patient safety. The purpose of this study was to compare the classification and severity rating of potential adverse drug interactions seen in the prescriptions for patients with HIV/AIDS in two databases, one with free access (Drugs.com(™)) and another requiring payment for access (Micromedex(®)).

METHODS

A cross-sectional retrospective study of the prescriptions issued for 40 ICU HIV/AIDS patients on mechanical ventilation, admitted for more than 48 h, in a referral hospital for infectious diseases in Rio de Janeiro, Brazil, was undertaken. One prescription was reviewed each week for each patient from the second day after admission. A list of all drug-drug interactions was generated for each patient using the two drug-drug interactions databases. The weighted kappa index was estimated to assess the agreement between the classifications of DDIs identified by both databases and qualitative assessment made of any discordant classification of recorded drug-drug interactions.

RESULTS AND DISCUSSION

Of the 106 prescriptions analysed, Micromedex(®) and Drugs.com identified 347 and 615 potential DDIs, respectively. A predominance of moderate interactions and pharmacokinetic interactions was observed. The agreement between the databases regarding the severity rating was only 68.3%. The weighted kappa of 0.44 is considered moderate. Better agreement (82.4%) was observed in the classification of mechanism of interaction, with a weighted kappa of 0.61.

WHAT IS NEW AND CONCLUSION

DDIs are common between the prescriptions of patients with HIV/AIDS admitted to the ICU. Although both databases were able to identify the clinically relevant DDIs, we observed a significant discrepancy in the classification of the severity of DDIs in the two bases. The free access database could serve as an alternative to the identification of DDIs in resource-limited settings; however, there is a need for better evidence-based assessments for your use on clinical management of more serious DDIs.

Pharmacological considerations in human immunodeficiency virus-infected adults in the intensive care unit

According to estimates, 1.2 million Americans are infected with human immuno deficiency virus (HIV). Because of antiretroviral therapy, persons who have HIV infection or have progressed to AIDS are living longer. As a result, the likelihood that they will need critical care nursing is increasing. Unlike in years past, when these patients were often admitted because of the consequences of immunosuppression, today they are also being cared for in critical care units for other conditions associated with aging, other chronic health conditions, and trauma. When persons who have HIV disease or AIDS are admitted to the intensive care unit, nurses must be prepared to provide care, especially management of complexities associated with antiretroviral therapy. Therefore, this article examines critical care nurses' role in initiating and administering antiretroviral therapy in the intensive care unit and reducing the risk of drug interactions associated with the therapy.

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

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

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.

[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.

AIDS Patients in the ICU

At the beginning of the AIDS epidemic, there were higher mortality rates in patients requiring admission to an intensive care unit (ICU) most likely due to acute respiratory failure. Whereas the use of prophylaxis and corticosteroids for Pneumocystisjiroveci pneumonia and highly active antiretroviral therapy has changed this outcome and has improved survival rate. However, respiratory failure has remained the most common indication for an ICU admission. When HIV-infected patients are admitted to the ICU, intensivists need to be knowledgeable about the manifestations of common diseases and the new manifestations related to antiretroviral therapy. Much HIV mortality has been linked directly to late diagnosis and late initiation of appropriate antiviral therapy. This l, the most important cause of ICU admission for AIDS patients. We analyzed the characteristics of P.jiroveci pneumonia, bacterial pneumonia, cytomegalovirus pneumonia, mycobacterial infections, pulmonary invasive fungal infections, Kaposi’s sarcoma, and the immune reconstitution inflammatory syndrome.

Care of the AIDS patient with Pneumocystis pneumonia

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

The Challenges of HIV Disease in the Intensive Care Unit

HIV/AIDS continues to be a significant world health issue. Patterns of referral to intensive care units (ICU) have changed in parallel with advances in treatment. Proven Pneumocystis therapy and the introduction of antiretroviral drugs have increased life expectancy. Lower respiratory tract infection predominates as a reason for ICU admission. Pneumocystis jirovecii, TB, fungi and bacterial infections rank highly as respiratory pathogens and should be considered potentially causative. Neurological pathology and severe sepsis commonly necessitate ICU admission in this population. The timing of highly active antiretroviral therapy (HARRT) remains controversial in critically ill patients. Therapy may be difficult due to associated drug interactions, lack of intravenous drug formulation and known toxic side effects. Improvement in survival may have resulted as much from general improvements in ICU care as from advances in highly active antiretroviral therapy, notably lung protective ventilation strategies and approaches to the early recognition and management of sepsis. HIV infection is now considered a chronic illness and should not be seen as a bar to ICU admission. Many HIV-positive patients present with non-HIV related illness and can be expected to make as good a recovery as non-infected patients.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Survival of HIV-infected patients in the intensive care unit in the era of highly active antiretroviral therapy

BACKGROUND

Several studies have described improved outcomes for HIV-infected patients admitted to the intensive care unit (ICU) since the introduction of highly active antiretroviral therapy (HAART). A study was undertaken to examine the outcome from the ICU for HIV-infected patients and to identify prognostic factors.

METHODS

A retrospective study of HIV-infected adults admitted to a university affiliated hospital ICU between January 1999 and December 2005 was performed. Information was collected on patient demographics, receipt of HAART (no patient began HAART on the ICU), reason for ICU admission and hospital course. Outcomes were survival to ICU discharge and to hospital discharge.

RESULTS

102 patients had 113 admissions to the ICU; HIV infection was newly diagnosed in 31 patients. Survival (first episode ICU discharge and hospital discharge) was 77% and 68%, respectively, compared with 74% and 65% for general medical patients. ICU and hospital survival was 78% and 67% in those receiving HAART, and 75% and 66% in those who were not. In univariate analysis, factors associated with survival were: haemoglobin (OR = 1.25, 95% CI 1.03 to 1.51, for an increase of 1 g/dl), CD4 count (OR = 1.59, 95% CI 0.98 to 2.58, for a 10-fold increase in cells/microl), APACHE II score (OR = 0.51, 95% CI 0.29 to 0.90, for a 10 unit increase) and mechanical ventilation (OR = 0.29, 95% CI 0.10 to 0.83).

CONCLUSIONS

The outcome for HIV-infected patients admitted to the ICU was good and was comparable to that in general medical patients. More than a quarter of patients had newly diagnosed HIV infection. Patients receiving HAART did not have a better outcome.