Abstract
BackgroundLittle is known about the most severe forms of Pneumocystis jiroveci pneumonia (PCP) in HIV-negative as compared with HIV-positive patients. Improved knowledge about the differential characteristics and management modalities could guide treatment based on HIV status.MethodsWe retrospectively compared 72 patients (73 cases, 46 HIV-positive) admitted for PCP from 1993 to 2006 in the intensive care unit (ICU) of a university hospital.ResultsThe yearly incidence of ICU admissions for PCP in HIV-negative patients increased from 1993 (0%) to 2006 (6.5%). At admission, all but one non-HIV patient were receiving corticosteroids. Twenty-three (85%) HIV-negative patients were receiving an additional immunosuppressive treatment. At admission, HIV-negative patients were significantly older than HIV-positive patients (64 [18 to 82] versus 37 [28 to 56] years old) and had a significantly higher Simplified Acute Physiology Score (SAPS) II (38 [13 to 90] versus 27 [11 to 112]) but had a similar PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio (160 [61 to 322] versus 183 [38 to 380] mm Hg). Ventilatory support was required in a similar proportion of HIV-negative and HIV-positive cases (78% versus 61%), with a similar proportion of first-line non-invasive ventilation (NIV) (67% versus 54%). NIV failed in 71% of HIV-negative and in 13% of HIV-positive patients (p < 0.01). Mortality was significantly higher in HIV-negative than HIV-positive cases (48% versus 17%). The HIV-negative status (odds ratio 3.73, 95% confidence interval 1.10 to 12.60) and SAPS II (odds ratio 1.07, 95% confidence interval 1.02 to 1.12) were independently associated with mortality at multivariate analysis.ConclusionThe yearly incidence of ICU admissions for PCP in HIV-negative patients in our unit increased from 1993 to 2006. The course of the disease and the outcome were worse in HIV-negative patients. NIV often failed in HIV-negative cases, suggesting that NIV must be watched closely in this population.
Highlights
In developed countries, the introduction of the prophylaxis against Pneumocystis jiroveci pneumonia (PCP) and of highly active antiretroviral therapy has resulted in a decline of this disease in recent years in patients with HIV infection [1]
For testing the time course of mortality, mortality in patients requiring mechanical ventilation, and the proportion of patients requiring ventilation assistance, we evaluated the linear correlation of those variables with time by using the least squares linear regression method
Main characteristics of patients at admission to the intensive care unit From January 1993 to December 2006, we identified 72 PCP patients (73 cases) admitted to our ICU (45 HIV-positive and 27 HIV-negative patients) (Table 1)
Summary
The introduction of the prophylaxis against Pneumocystis jiroveci pneumonia (PCP) and of highly active antiretroviral therapy has resulted in a decline of this disease in recent years in patients with HIV infection [1]. When hospitalized in the ICU, at CI = confidence interval; FiO2 = fraction of inspired oxygen; ICU = intensive care unit; NIMV = non-invasive mechanical ventilation; OR = odds ratio; PCP = Pneumocystis jiroveci pneumonia; SAPS = Simplified Acute Physiology Score. No study has investigated the effect of HIV status on the severe forms of PCP, concerning the effectiveness of mechanical ventilation. This may be important since the lung impairment may be worse in HIV-negative patients. Little is known about the most severe forms of Pneumocystis jiroveci pneumonia (PCP) in HIV-negative as compared with HIV-positive patients. Improved knowledge about the differential characteristics and management modalities could guide treatment based on HIV status
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