Pneumonia In HIV-infected Children Research Articles

Experience in Immunizing HIV-Infected Children against Pneumococcal Infection and Influenza

Relevance. The lethal outcomes of HIV infection are determined by secondary diseases, among which tuberculosis and pneumonia take the leading place. Vaccination is an important way to reduce and prevent the development of infectious diseases in both adults and children. Particular attention is paid to children with HIV infection, the incidence of which is much higher in comparison with children without HIV positive status. The purpose of the study was to study the effectiveness of the prevention of lower respiratory tract infections with pneumococcal and influenza vaccines in HIV-infected children. Materials & Methods. The material was data from medical records about HIV-infected children. The research method is visual using retrospective analysis. Results. Immunological indicators and the general health status of HIV-infected children were assessed during their registration with the regional AIDS center. Changes in the immunological status of patients under dynamic observation were described. The timing of vaccination was analyzed and a comparison was made with the development of bacterial diseases in HIV-infected children. Conclusions. A low incidence of bacterial infections and the absence of pneumococcal pneumonia in HIV-infected children were revealed. Vaccination against pneumococcal infection and influenza must be given to all HIV-infected children from the moment they are registered with a regional specialized medical institution.

Tuberculosis and pneumonia in HIV-infected children: an overview.

Pneumonia remains the most common cause of hospitalization and the most important cause of death in young children. In high human immunodeficiency virus (HIV)-burden settings, HIV-infected children carry a high burden of lower respiratory tract infection from common respiratory viruses, bacteria and Mycobacterium tuberculosis. In addition, Pneumocystis jirovecii and cytomegalovirus are important opportunistic pathogens. As the vertical transmission risk of HIV decreases and access to antiretroviral therapy increases, the epidemiology of these infections is changing, but HIV-infected infants and children still carry a disproportionate burden of these infections. There is also increasing recognition of the impact of in utero exposure to HIV on the general health of exposed but uninfected infants. The reasons for this increased risk are not limited to socioeconomic status or adverse environmental conditions—there is emerging evidence that these HIV-exposed but uninfected infants may have particular immune deficits that could increase their vulnerability to respiratory pathogens. We discuss the impact of tuberculosis and other lower respiratory tract infections on the health of HIV-infected infants and children.

Serotypes and Antimicrobial Susceptibility Patterns of Nasopharyngeal Pneumococci Isolated from HIV-Infected Children in Selected Pediatric Clinics in Nairobi, Kenya

Background: Streptococcus pneumoniae (pneumococcus) is one of the most frequent causes of bacterial infection in children and is a leading cause of otitis, sinusitis, pneumonia, and meningitis worldwide. Nasopharyngeal colonization is a risk factor for pneumococcal disease, a leading cause of complications and death in infants. HIV-infected persons are at high risk of invasive pneumococcal disease. Method: Nasopharyngeal swabs were collected from 296 HIV infected children below five years recruited from Gertrude’s Children hospital and Nazareth Hospital Nairobi, Kenya. The nasopharyngeal swabs were processed to isolate S. pneumoniae, which were serotyped and tested for drug susceptibility. Results: The carriage prevalence of S. pneumoniae in the study was 30.4% while the isolated serotypes were (in order of decreasing frequency): 35B, 19F, 3, 13, 15A, 11A, 16F, 7C and 23A. Most of the serotypes were resistant to the commonly used antibiotics but all were susceptible to vancomycin and chloramphenicol. Conclusion: Carriage prevalence of nasopharyngeal S. pneumonia in HIV infected children was lower than that of similar prevalence studies in children. Most of the S. pneumoniae isolates were however non pneumococcal vaccine isolates.

Global, regional, and national estimates of pneumonia burden in HIV-infected children in 2010: a meta-analysis and modelling study

SummaryBackgroundGlobally, pneumonia is a leading cause of mortality and morbidity in children younger than 5 years. Underlying HIV infection is an important risk factor for pneumonia morbidity and mortality in children. There are, however, no global or country level estimates of pneumonia burden in HIV-infected children. We assessed the role of HIV in pneumonia incidence and mortality and estimated the number of pneumonia cases and deaths in HIV-infected children younger than 5 years in 133 high pneumonia-burden countries in 2010.MethodsWe estimated the risk of hospital admission and case fatality rate caused by pneumonia in HIV-infected children compared with HIV-uninfected children from a systematic review of studies published in Medline, Embase, and Global Health between Jan 1, 1980, and Aug 31, 2013. We estimated nationwide pneumonia incidence and mortality with two different models that incorporated several risk factors for paediatric pneumonia hospital admission and mortality (including HIV infection). We then estimated the number of pneumonia episodes and deaths that occurred in HIV-infected children in 2010.FindingsThe odds ratio (OR) for hospital admission for all-cause pneumonia in HIV-infected children compared with HIV-uninfected children was 6·5 (95% CI 5·9–7·2). The risk of death was higher in children with pneumonia and HIV compared with those with pneumonia only (OR 5·9, 95% CI 2·7–12·7). In 2010, 1·4 million pneumonia episodes (uncertainty range [UR] 0·6 million to 3·3 million) and 88 000 pneumonia deaths (UR 47 400–153 000) occurred in HIV-infected children in low-income countries. Of these, 1·2 million pneumonia episodes (UR 0·5 million–2·7 million) and 85 400 deaths (UR 46 000–147 300) were directly attributable to HIV. 1·3 million (90%) pneumonia episodes and 82 400 (93%) pneumonia deaths in HIV-infected children aged younger than 5 years occurred in the WHO African region.InterpretationGlobally, a small proportion of pneumonia episodes and pneumonia deaths occur in HIV-infected children. However, in the highest HIV-burden countries in sub-Saharan Africa (ie, Swaziland, Lesotho, and Zimbabwe) up to a fifth of all pneumonia cases and 60% of pneumonia deaths occur in HIV-infected children. In these countries, major reductions in child pneumonia mortality can be achieved only if the systemic challenges plaguing the health system (poor coverage of early infant testing for HIV, of antiretroviral drugs in pregnant women and young children, of co-trimoxazole prophylaxis, and of pneumococcal vaccination) can be overcome.FundingWHO.

Pneumonia in HIV-infected children

Pneumonia in HIV-infected children

Duration of hospitalization and appetite of HIV‐infected South African children

Human immunodeficiency virus (HIV)-infected children generally show poor growth. Episodes of diarrhoea and pneumonia in HIV-infected children are thought to be more severe than in HIV-uninfected children. The objective of this study was to compare duration of hospitalization, appetite and nutritional status of HIV-infected children with that of uninfected children. A cross-sectional study was performed on children (2-24 months) admitted with diarrhoea or pneumonia to the university hospital. Children were tested for HIV, and the duration of hospitalization was noted for 189 children. Follow-up for blood analysis (n=154) and appetite measurement (n=48) was performed 4-8 weeks after discharge. Appetite was measured as ad libitum intake of a commercial infant cereal using highly standardized procedures. Hospitalization (in days) was significantly longer in HIV-infected children; among children admitted with diarrhoea (5.9 ± 1.9 vs. 3.8 ± 1.5) (mean ± standard deviation) and with pneumonia (9.0 ± 2.5 vs. 5.9 ± 1.9). Serum zinc, iron and transferrin concentrations, and haemoglobin levels were significantly lower in HIV-infected children compared with uninfected children. Appetites [amounts eaten (g) per kg body weight] of HIV-infected children were significantly poorer than those of HIV-uninfected children (18.6 ± 5.8 vs. 25.2 ± 7.4). The eating rates (g min(-1) ) of HIV-infected children were also slower (17.6 ± 6.2 vs. 10.1 ± 3.7) Mean Z-scores for length-for-age were significantly lower among HIV-infected children compared with HIV-uninfected children. Weight-for-length Z-scores were not significantly different. In summary, HIV-infected children had a 55% longer duration of hospitalization and a 21% lower appetite.

Pneumocystis Pneumonia in HIV-Infected Children: Recent Advances and Future Hurdles

Pneumocystis Pneumonia in HIV-Infected Children: Recent Advances and Future Hurdles

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

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.

Evidence behind the WHO Guidelines: Hospital Care for Children: What is the Aetiology of Pneumonia in HIV-infected Children in Developing Countries?

This clinical review discusses the most common cause of pneumonia in HIV-infected children--bacterial pathogens and includes recommendations for the management of pneumonia in HIV-infected children from World Health Organization (WHO).

Management of community-acquired pneumonia in HIV-infected children

Pneumonia is a major cause of childhood mortality and morbidity worldwide, particularly in low-income countries. Often, these are also the countries most affected by the HIV epidemic. Pneumonia is the leading cause of death in HIV-infected children and a major cause of hospitalization and healthcare utilization. A broader spectrum of organisms, such as Pneumocystis jiroveci and Gram-negative bacteria, cause pneumonia in HIV-infected children compared with uninfected children. Etiologic organisms have higher rates of antimicrobial resistance in HIV-infected children. Polymicrobial disease is more common in HIV-infected children and associated with an exponential increase in mortality rate. HIV-infected children develop more severe pneumonia and have a worse outcome than HIV-uninfected children. HIV-exposed but HIV-negative children are also at higher risk of severe pneumonia and death compared with HIV-unexposed children. Although case-management guidelines for childhood pneumonia have led to an overall decrease in global childhood morbidity and mortality, HIV-infected children continue to have unacceptably high treatment failure and case fatality rates despite adherence to these guidelines. Standard guidelines require adaptation for use in high HIV-prevalence areas. Specific preventive interventions, including chemoprophylaxis for P. jiroveci pneumonia or for TB and early initiation of highly active antiretroviral therapy, may significantly reduce the burden of pneumonia in HIV-infected children.

Pneumococcal conjugate vaccine--a health priority.

Pneumonia is a major cause of childhood mortality and morbidity. Streptococcus pneumoniae is the most important bacterial pathogen causing pneumonia in children. The HIV epidemic has increased the burden and severity of childhood pneumococcal pneumonia and invasive disease fortyfold. Pneumococcal conjugate vaccine (PCV) is a highly effective intervention to reduce invasive pneumococcal disease and pneumonia. Studies evaluating a 9-valent PCV in South Africa and The Gambia reported a 72 - 77% reduction in vaccine-serotype-specific invasive disease in vaccinated children. As many of the pneumococcal serotypes associated with antibiotic resistance are included in PCV, vaccination has also been associated with a reduction in antimicrobial-resistant invasive disease. PCV may also reduce childhood mortality, especially in places with limited access to health care, as shown in Gambian study in which PCV reduced childhood mortality by 16%. In addition to the direct effects of PCV, there is a substantial reduction in disease burden through indirect protection of non-vaccinated populations. PCV is immunogenic in HIV-infected children and provides protection against invasive disease or pneumonia in a substantial number of children. Although the efficacy of PCV for prevention of invasive disease or pneumonia is lower in HIV-infected compared to -uninfected children, the overall burden of disease prevented is much greater in HIV-infected children because of the higher burden of pneumococcal disease in these children. Consequently, vaccine-preventable invasive disease is almost 60 times higher in HIV-infected compared to -uninfected children, while the reduction in pneumonia in HIV-infected children is 15 times greater. However, the long-term efficacy of PCV wanes in HIV-infected children who are not taking antiretroviral therapy, and booster doses are probably indicated. Although there is concern about the potential for replacement disease due to non-vaccine serotypes, a substantial and sustained reduction in invasive disease has occurred overall in populations with widespread childhood immunisation. Routine childhood immunisation is now the standard of care in most developed countries. However, PCV is much less accessible to children in developing countries due to cost and availability. Cost-effectiveness analysis indicates that use of PCV is potentially highly cost-effective, at tiered pricing, even in very low-income countries. Widespread availability and vaccination with PCV is urgently needed for all children under 2 years of age in South Africa. In addition, the use of PCV for all HIV-infected children under 9 years should be prioritised.

HIV-related pulmonary disorders: practice issues

Pulmonary disease is the major cause of morbidity and mortality in infants and children infected with the human immunodeficiency virus (HIV). Diagnosis and management is often difficult in the resource-limited setting, especially as most HIV-related pulmonary disease presents in infancy or early childhood. Knowledge of the causes of pulmonary disease in HIV-infected children in that setting has improved considerably over the last decade, as has the availability of effective treatment for all HIV-infected children, such as cotrimoxazole preventive therapy and antiretroviral therapy. Important causes of acute bacterial pneumonia in HIV-infected children include bacteria such as pneumococci, gram-negatives and staphylococci. Pneumocystis pneumonia is particularly common in HIV-infected infants and a common cause of death. Cytomegalovirus is also found frequently in infants with pneumonia, often as a co-infection with PcP. Tuberculosis (TB) is increasingly recognised as a common cause of acute pneumonia as well as chronic pulmonary disease in regions endemic for TB/HIV. Other important causes of chronic lung disease in HIV-infected children include lymphocytic interstitial pneumonitis and bronchiectasis. This review aims to address practical issues that health workers often face in the management of acute or chronic pulmonary disease presenting in HIV-infected children in the resource-limited setting.

Successful prophylaxis against Pneumocystis carinii pneumonia in HIV-infected children using smaller than recommended dosages of trimethoprim-sulfamethoxazole.

Prophylaxis against Pneumocystis carinii pneumonia (PCP) is an essential part of the management of children with human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS). No dose-ranging studies were ever performed; therefore, the amount of trimethoprim-sulfamethoxazole (TMP-SMX) needed to suppress PCP in children with HIV/AIDS is not known. The dose recommended by the Centers for Disease Control (CDC) has been thought to be just above the threshold needed for prevention, based on anecdotal breakthrough PCP in cancer patients who were improperly dosed. We have been giving prophylaxis based on body weight rather than surface area, and this, combined with growth of our children, has led to a large experience with dosages lower than the currently recommended 150 mg/m2. The medical records of children with HIV who met CDC guidelines for institution of PCP prophylaxis were reviewed. To ascertain the per square meter (m2) dosage each child was receiving, body surface area was calculated from height and weight measurements. Dosages were recalculated every 6 months and at each dosage change. Data regarding PCP infection, bacterial infections, and side effects of TMP-SMX were extracted. Data were compiled from 1,719.5 child-months of TMP-SMX prophylaxis, including 1,532.5 child-months below the currently recommended dose. Sixty-seven percent of our child-months were at or below two-thirds the CDC recommended dose. There were no cases of proven or suspected PCP. Incidence of other serious bacterial infections was low. Bacteremia and sepsis with Streptococcus pneumoniae was the most common proven bacterial infection, at a rate of 5.5 episodes per 100 child-years. The incidence of bacterial infection did not vary by the dose of TMP-SMX. TMP-SMX prophylaxis was well tolerated; most reactions were mild and self-limited and did not recur with re-institution of the drug. Only 6.1% of this cohort had TMP-SMX prophylaxis discontinued due to perceived toxicity. These data show that the currently recommended dose of TMP-SMX (150 mg/m2) may not be required to prevent PCP in children with HIV/AIDS. The drug is well tolerated at all dosage levels. The incidence of serious bacterial infection in this cohort of patients did not depend upon the amount of TMP-SMX prescribed. A prospective, controlled clinical trial of low-dose TMP-SMX for children with HIV infection is warranted.

<b>Current abstracts</b><br><br>Pneumonia in HIV infected children

<b>Current abstracts</b><br><br>Pneumonia in HIV infected children

Pneumocystis carinii severe pneumonia among human immunodeficiency virus-infected children in Thailand: the effect of a primary prophylaxis strategy.

A knowledge of the epidemiology of Pneumocystis carinii pneumonia (PCP) is important for the development of a strategy for primary PCP prophylaxis and empiric treatment for severe pneumonia in HIV-infected children. However, little is known about the epidemiology of PCP in developing countries. Objective. To measure the relative rate of PCP among hospitalized HIV-infected children with severe pneumonia in Bangkok and evaluate the effect of a strategy of primary PCP prophylaxis in HIV-exposed infants. All HIV-infected children hospitalized from January, 1996, to December, 1997, for severe pneumonia were investigated for PCP with the use of specimens obtained from bronchoalveolar lavage, endotracheal aspiration or lung tissue necropsy. Characteristics associated with severe pneumonia were described, and the differences between PCP and non-PCP in these severely ill children were analyzed. In June, 1996, a strategy of primary PCP prophylaxis using trimethoprim-sulfamethoxazole in all HIV-exposed infants from 1 to 6 month of age was initiated in our institution. The effect of this strategy was evaluated. Of 279 hospitalized HIV-infected children 128 (46%) were diagnosed with pneumonia and 26 (20%) of these had severe pneumonia. P. carinii was identified in 9 (35%) children with severe pneumonia. After June, 1996, the rate of severe pneumonia among all hospitalized children decreased from 16% from January through June, 1996, to 7% from July, 1996, through December, 1997 (P = 0.02). Cases of PCP decreased from 9 in 1996 to zero in 1997. The percentage of HIV-infected children receiving PCP prophylaxis at the time of admission increased from 53% before June, 1996, to 72% in late 1997 (P = 0.04). The overall percentage of patients with severe pneumonia receiving PCP prophylaxis at the time of admission was 34%. Breakthrough PCP occurred in 2 children with poor compliance. Patients with PCP were significantly younger than those without PCP (mean age, 10.6+/-10.6 vs. 29.8+/-28.3 months, P = 0.02). PCP occurred in one-third of cases of severe pneumonia in HIV-infected children in Bangkok. The data suggest that PCP prophylaxis can prevent both PCP and non-PCP.

Failure of Pentamidine as Prophylaxis for Pneumocystis carinii Pneumonia in HIV-Infected Children

Use of a combination of oral trimethoprim and sulfamethoxazole (TMP-SMZ) and aerosolized pentamidine are the only medications currently approved by the Centers for Disease Control and Prevention (CDC) for the prevention of Pneumocystis carinii pneumonia (PCP) in human immunodeficiency virus (HIV)–infected children. 1 However, adverse reactions to TMP-SMZ and the difficulty of administering aerosolized pentamidine in the pediatric population often necessitate the use of alternative prophylactic regimens, such as intramuscularly (IM) or intravenously (IV) administered pentamidine or orally administered dapsone. 2,3 At our institution, HIV-positive children who require prophylaxis for PCP and are intolerant of oral TMP-SMZ have received monthly IM or IV pentamidine therapy for prophylaxis for PCP. Pneumocystis carinii pneumonia developed in three of these children who had very low CD4+ cell counts for their age in spite of this regimen. Alternative regimens are necessary to prevent PCP in these severely immunodeficient children. Further clinical studies are needed