Improved survival for HIV infected patients with severe pneumocystis jirovecii pneumonia is independent of highly active antiretroviral therapy

Robert F Miller ^1*, Elizabeth Allen ¹, Andrew Copas ¹, Mervyn Singer ¹ and Simon G Edwards ²

¹ University College London, United Kingdom
² Camden PCT, United Kingdom

^* To whom correspondence should be addressed. E-mail: rmiller{at}gum.ucl.ac.uk.

Accepted 16 March 2006

Abstract

Background: Despite a decline in incidence of Pneumocystis jirovecii pneumonia (PCP), severe PCP continues to be a common cause of admission to the intensive care unit (ICU), where mortality remains high.

Objective: To describe outcome from intensive care for patients with PCP and to identify prognostic factors.

Methods: Retrospective cohort study of HIV-infected adults admitted to a university-affiliated hospital ICU between November 1990 and October 2005. Case-note review collected information on demographic variables, patient's receipt of prophylaxis and highly active antiretroviral therapy (HAART) and hospital course. The main outcome was one month mortality, either on the ICU or in hospital.

Results: Fifty-nine patients were admitted to the ICU on 60 occasions. Thirty four patients (57%) required mechanical ventilation (MV). Overall mortality was 53%. No patient received HAART before, or during ICU admission. In multivariate analysis factors associated with mortality were the year of diagnosis (pre-mid-1996 [mortality = 71%] compared with later [mortality = 34%]) (p=0.008), patient's age (p=0.016) and the need for MV and/or development of pneumothorax (p=0.031). Mortality was not associated with patient's gender, ethnicity, prior receipt of sulpha prophylaxis, haemoglobin, serum albumin, CD4 count, PaO2, A-a O2 gradient, co-pathology in bronchoscopic lavage fluid, medical comorbidity, APACHE II score, or duration of MV.

Conclusions: Observed improved outcomes from severe PCP admitted to the ICU occurred in the absence of intervention with HAART and likely reflect general improvements in ICU management of respiratory failure and ARDS, rather than improvements in the management of PCP.

Keywords: AIDS, pneumocystis jirovecii, intensive care, mechanical ventilation, respiratory failure

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