Abstract
BackgroundPneumonia is a major cause of mortality among HIV-infected patients. Pneumonia severity scores are promising tools to assist clinicians in predicting patients’ 30-day mortality, but existing scores were developed in populations infected with neither HIV nor tuberculosis (TB) and include laboratory data that may not be available in resource-limited settings. The objective of this study was to develop a score to predict mortality in HIV-infected adults with pneumonia in TB-endemic, resource-limited settings.MethodsWe conducted a secondary analysis of data from a prospective study enrolling HIV-infected adults with cough ≥2 weeks and <6 months and clinically suspected pneumonia admitted to Mulago Hospital in Kampala, Uganda from September 2008 to March 2011. Patients provided two sputum specimens for mycobacteria, and those with Ziehl-Neelsen sputum smears that were negative for mycobacteria underwent bronchoscopy with inspection for Kaposi sarcoma and testing for mycobacteria and fungi, including Pneumocystis jirovecii. A multivariable best subsets regression model was developed, and one point was assigned to each variable in the model to develop a clinical predictor score for 30-day mortality.ResultsOverall, 835 patients were studied (mean age 34 years, 53.4% female, 30-day mortality 18.2%). A four-point clinical predictor score was identified and included heart rate >120 beats/minute, respiratory rate >30 breaths/minute, oxygen saturation <90%, and CD4 cell count <50 cells/mm3. Patients’ 30-day mortality, stratified by score, was: score 0 or 1, 12.6%, score 2 or 3, 23.4%, score 4, 53.9%. For each 1 point change in clinical predictor score, the odds of 30-day mortality increased by 65% (OR 1.65, 95% CI 1.39-1.96, p <0.001).ConclusionsA simple, four-point scoring system can stratify patients by levels of risk for mortality. Rapid identification of higher risk patients combined with provision of timely and appropriate treatment may improve clinical outcomes. This predictor score should be validated in other resource-limited settings.
Highlights
Pulmonary complications are a major cause of morbidity and mortality among HIV-infected patients worldwide
For each 1 point change in clinical predictor score, the odds of 30-day mortality increased by 65%
Rapid identification of higher risk patients combined with provision of timely and appropriate treatment may improve clinical outcomes
Summary
Pulmonary complications are a major cause of morbidity and mortality among HIV-infected patients worldwide. Previous studies have developed pneumonia severity scores, such as the Pneumonia Severity Index (PSI) and the CURB-65, to predict mortality in patients with pneumonia in the general population.[10, 11] these studies were conducted in high-income countries in patients that were infected with neither HIV nor TB. These studies included laboratory data, such as arterial blood gas, that may not be available in resource-limited settings where the majority of HIV-infected persons reside. The objective of this study was to develop a score to predict mortality in HIV-infected adults with pneumonia in TB-endemic, resource-limited settings
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