Community-acquired pneumonia in HIV-infected children: a global perspective

Abstract

Pneumonia is a leading cause of morbidity and death in HIV-infected children. The aim of this study was to review recent advances in the epidemiology, cause, management and prevention of pneumonia in HIV-infected children. Pneumonia remains a major cause of death and hospitalization, particularly in sub-Saharan Africa, where the paediatric HIV epidemic is concentrated. HIV-infected children have a higher risk of developing pneumonia and of more severe disease than immunocompetent children. Bacterial pathogens especially Streptococcus pneumoniae, Staphylococcus aureus and Gram-negative bacteria predominate, with rising rates of antimicrobial resistance. Mycobacterium tuberculosis is increasingly reported to cause acute pneumonia. Pneumocystis jirovecii (PCP) remains an important cause of severe pneumonia especially in infants. Viral infections, especially cytomegalovirus-associated pneumonia are common. Polymicrobial infection is increasingly recognized and associated with a worse prognosis. HIV-exposed, negative children have an increased risk of infection with opportunistic pathogens and a poorer outcome than HIV-unexposed children.Increasing access to highly active antiretroviral therapy (HAART) has reduced the incidence of severe pneumonia, eliminated most opportunistic infections and improved outcome. However, pneumonia remains the major cause of morbidity in HIV-infected children taking HAART. Standard case management guidelines are effective at decreasing mortality but require adaptation for high HIV-prevalence areas. Broad-spectrum antibiotics should be used as empiric therapy. Infants or children who are not taking pneumocystis prophylaxis should be treated for PCP.A number of general or specific preventive strategies are effective including early use of HAART at the time of HIV diagnosis, pathogen-specific immunizations, in particular pneumococcal conjugate vaccine, and antibiotic prophylaxis against PCP. Greater access to preventive and treatment strategies, especially PCP prophylaxis, pneumococcal immunization and HAART, are urgently needed in areas of high childhood HIV prevalence.