Outcome of Intensive Care in Patients With HIV Infection

doi:10.1378/chest.107.2.506

Chest

Volume 107, Issue 2, February 1995, Pages 506-510

https://doi.org/10.1378/chest.107.2.506 Get rights and content

Objectives

To examine ICU admission rates and diagnoses of patients with HIV infection and to determine the outcomes of different critical illnesses.

Design

Consecutive enrollment of patients admitted to the ICU with confirmed HIV infection or an AIDS-defining diagnosis.

Setting

Medical ICU of an urban teaching hospital.

Patients

65 adult patients with documented HIV infection or AIDS-defining disorder.

Interventions

Standard care.

Results

In 1 year, there were 1,550 hospital admissions for patients with HIV infection, and 65 (4.2%) were admitted to the ICU. The mortality rate of patients admitted to the ICU was 51%; 35 (54%) were admitted with respiratory failure, 22 of whom had Pneumocystis carinii pneumonia (PCP). Sixteen patients with PCP required mechanical ventilation, and 13 (81%) died despite treatment with adjunctive corticosteroids. Other causes of respiratory failure included bacterial pneumonia, pulmonary tuberculosis, adult respiratory distress syndrome, and pulmonary Kaposi’s sarcoma. Overall, 22 of 35 (63%) patients with respiratory failure died in the hospital. Thirty patients (46%) were admitted because of sepsis, neurologic disease, congestive heart failure, hypotension, or drug overdose. These patients had a mortality rate of 37%. Prior antiretroviral and anti-Pneumocystis prophylaxis did not influence outcome, but a body weight of 10% or more below ideal at the time of admission predicted poor survival.

Conclusion

There is a diverse range of indications for critical care in patients with HIV infection. Although respiratory failure due to PCP was the most common reason for admission to the ICU, it accounted for only 34% of the cases. The prognosis of PCP in patients who require mechanical ventilation despite adjunctive corticosteroid treatment is poor.

Section snippets

METHODS

This study includes patients admitted to the Medical ICU of Beth Israel Hospital, New York City between November 1, 1991, and October 31, 1992. Beth Israel is a 960-bed acute care hospital and a designated AIDS treatment center. It has an outpatient AIDS clinic and a 12-bed AIDS inpatient unit. Patients were enrolled in this study during their admission to the ICU if they had proven HIV infection or had an AIDS-defining opportunistic infection.16, 20 Decisions on who is admitted to the ICU are

RESULTS

During the 1-year study period, there were 1,550 hospital admissions for HIV-infected patients, and 199 patients (13%) had PCP. In this period, 65 (4.2%) patients were admitted to the ICU and enrolled in this study.

The characteristics of the patients admitted to the ICU are shown in Table 1. They included 44 men and 21 women, and their mean age was 39.3 years. Black and Hispanic patients accounted for 75% of the study population. Injection drug users represented the largest transmission

DISCUSSION

The literature on intensive care of patients with AIDS emphasizes respiratory failure due to PCP as the major cause of admission.¹ Data collected between 1980 and 1987 describe a dismal outcome for patients with AIDS, PCP, and respiratory failure who require intubation and mechanical ventilation. The National Institutes of Health Workshop on pulmonary complications of AIDS reported on data collected from six centers.³ Eighty-eight of 102 patients (86%) who required mechanical ventilation died

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Cited by (85)

What determines do-not-resuscitate status in critically ill HIV-infected patients admitted to ICU?
2019, Journal of Critical Care
To identify factors associated with do-not-resuscitate (DNR) status in critically ill patients infected with human immunodeficiency virus (HIV) admitted to the Intensive Care Unit (ICU) in the era of combination antiretroviral therapy (cART).
Retrospective cohort study of first-time admissions of HIV-infected patients to ICUs in Edmonton, Alberta, from 2002 to 2014. Multivariable logistic regression analysis was performed to identify factors associated with DNR status.
There were 282 HIV-infected patients with first-time ICU admissions, with an incidence rate of 6.6 per 1000 ICU admissions. Sixty-seven (24%) patients had a DNR designation and support was withdrawn in 37 (13%). In multivariable analysis, APACHE II score (OR 1.13; 95% CI, 1.08–1.19, p < 0.001), coronary artery disease (OR 5.70; 95% CI, 1.18–27.76, p = 0.031), prior opportunistic infection (OR 2.59; 95% CI, 1.20–5.57, p = 0.015) and duration of HIV infection (OR 1.07 per year; 95% CI, 1.01–1.14, p = 0.025) were independently associated with DNR status. Ethnicity, HIV risk factors, CD4 count and viral load were not associated with DNR status.
One in four patients had a DNR designation. Illness acuity, selected comorbidity, previous opportunistic infection and HIV duration were associated with DNR designation.
Characteristics and outcomes of HIV-1-infected patients with acute respiratory distress syndrome
2015, Journal of Critical Care
Citation Excerpt :
HIV-1–infected subjects were also more likely to have prior bouts of sepsis and hospital-acquired infections. As shown in other studies, the most common cause of ARDS in this cohort was severe pneumonia [1,6,18]. HIV-1–infected subjects had significantly higher APACHE II scores due to their lower serum albumin levels, sodium levels, and white blood counts, consistent with previous studies [19].
We determined the prevalence of risk factors for the development of acute respiratory distress syndrome (ARDS), outcomes of critical illness, and the impact of highly active antiretroviral therapy in HIV-1–infected patients. We hypothesized that in an urban county hospital, HIV-1–infected patients with ARDS would have a higher mortality than their HIV-1–uninfected counterparts.
Subjects were enrolled between 2006 and 2012. Baseline patient demographics, comorbidities, illness severity, causes of ARDS, and clinical outcomes were obtained. The primary end point was hospital mortality.
A total of 178 subjects with ARDS were enrolled in the study; 40 (22%) were infected with HIV-1. The median CD4 count was 75 (15.3-198.3), and 25% were on highly active antiretroviral therapy. HIV-1–infected subjects were significantly younger (44 vs 52 years; P < .01) and had higher rates of asthma, chronic obstructive pulmonary disease, pneumonia, history of hospital-acquired infections, and prior sepsis. HIV-1–infected subjects had greater illness severity by Acute Physiology and Chronic Health Evaluation II scores (29 [24-31] vs 24 [22-25]; P < .01). Hospital mortality was not higher among HIV-1–infected subjects compared with HIV-1–uninfected subjects (50.0% vs 38.4%; P = .19).
In patients with ARDS, HIV-1 infection was associated with greater illness severity but was not associated with higher mortality in ARDS. Future studies need to be done to evaluate the factors that contribute to high morbidity and mortality in medically vulnerable populations who develop ARDS.
Survival for patients with HIV admitted to the ICU continues to improve in the current era of combination antiretroviral therapy
2009, Chest
The combination antiretroviral therapy (ART) era (1996 to the present) has been associated with improved survival among HIV-infected outpatients, but ICU data from 2000 to the present are limited.
We conducted a retrospective study of HIV-infected adults who had been admitted to the ICU at San Francisco General Hospital (from 2000 to 2004). The primary outcome was survival to hospital discharge.
During the 5-year study period, there were 311 ICU admissions for 281 patients. Respiratory failure remained the most common indication for ICU admission (42% overall), but the proportion of patients with respiratory failure decreased each year from 52 to 34% (p = 0.02). Hospital survival ratios significantly increased during the 5-year period (p = 0.001). ART use at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts, lower plasma HIV RNA levels, higher serum albumin levels, and lower proportions with AIDS-associated ICU admission diagnoses and with Pneumocystis pneumonia. In a multivariate analysis, a higher serum albumin level (adjusted odds ratio [AOR], 2.08; 95% confidence interval [CI], 1.41 to 3.06; p = 0.002) and the absence of mechanical ventilation (AOR, 6.11; 95% CI, 2.73 to 13.72; p < 0.001) were associated with survival.
In this sixth in a series of consecutive studies started in 1981, we found that the epidemiology of ICU admission diagnoses continues to change. Our study also found that survival for critically ill HIV-infected patients continues to improve in the current era of ART. Although ART use was not associated with survival, it was associated with predictors that were associated with survival in a multivariate analysis.
Predicting mortality from HIV-associated Pneumocystis pneumonia at illness presentation: An observational cohort study
2009, Thorax
Although the use of antiretroviral therapy has led to dramatic declines in AIDS-associated mortality, Pneumocystis pneumonia (PCP) remains a leading cause of death in HIV-infected patients.
To measure mortality, identify predictors of mortality at time of illness presentation and derive a PCP mortality prediction rule that stratifies patients by risk for mortality.
An observational cohort study with case note review of all HIV-infected persons with a laboratory diagnosis of PCP at San Francisco General Hospital from 1997 to 2006.
451 patients were diagnosed with PCP on 524 occasions. In-hospital mortality was 10.3%. Multivariate analysis identified five significant predictors of mortality: age (adjusted odds ratio (AOR) per 10-year increase, 1.69; 95% CI 1.08 to 2.65; p = 0.02); recent injection drug use (AOR 2.86; 95% CI 1.28 to 6.42; p = 0.01); total bilirubin >0.6 mg/dl (AOR 2.59; 95% CI 1.19 to 5.62; p = 0.02); serum albumin <3 g/dl (AOR 3.63; 95% CI 1.72–7.66; p = 0.001); and alveolar–arterial oxygen gradient ≥50 mm Hg (AOR 3.02; 95% CI 1.41 to 6.47; p = 0.004). Using these five predictors, a six-point PCP mortality prediction rule was derived that stratifies patients according to increasing risk of mortality: score 0–1, 4%; score 2–3, 12%; score 4–5, 48%.
The PCP mortality prediction rule stratifies patients by mortality risk at the time of illness presentation and should be validated as a clinical tool.
Benefit of antiretroviral therapy on survival of human immunodeficiency virus-infected patients admitted to an intensive care unit
2009, Critical Care Medicine
To evaluate the impact of antiretroviral therapy (ART) and the prognostic factors for in-intensive care unit (ICU) and 6-month mortality in human immunodeficiency virus (HIV)-infected patients.
A retrospective cohort study was conducted in patients admitted to the ICU from 1996 through 2006. The follow-up period extended for 6 months after ICU admission.
The ICU of a tertiary-care teaching hospital at the Universidade de São Paulo, Brazil.
A total of 278 HIV-infected patients admitted to the ICU were selected. We excluded ICU readmissions (37), ICU admissions who stayed less than 24 hours (44), and patients with unavailable medical charts (36).
In-ICU and 6-month mortality.
Multivariate logistic regression analysis and Cox proportional hazards models demonstrated that the variables associated with in-ICU and 6-month mortality were sepsis as the cause of admission (odds ratio [OR] = 3.16 [95% confidence interval [CI] 1.65–6.06]); hazards ratio [HR] = 1.37 [95% CI 1.01–1.88]), an Acute Physiology and Chronic Health Evaluation II score >19 [OR = 2.81 (95% CI 1.57–5.04); HR = 2.18 (95% CI 1.62–2.94)], mechanical ventilation during the first 24 hours [OR = 3.92 (95% CI 2.20–6.96); HR = 2.25 (95% CI 1.65–3.07)], and year of ICU admission [OR = 0.90 (95% CI 0.81–0.99); HR = 0.92 [95% CI 0.87–0.97)]. CD4 T-cell count <50 cells/mm³ was only associated with ICU mortality [OR = 2.10 (95% CI 1.17–3.76)]. The use of ART in the ICU was negatively predictive of 6-month mortality in the Cox model [HR = 0.50 (95% CI 0.35–0.71)], especially if this therapy was introduced during the first 4 days of admission to the ICU [HR = 0.58 (95% CI 0.41–0.83)]. Regarding HIV-infected patients admitted to ICU without using ART, those who have started this treatment during ICU stay presented a better prognosis when time and potential confounding factors were adjusted for [HR 0.55 (95% CI 0.31–0.98)].
The ICU outcome of HIV-infected patients seems to be dependent not only on acute illness severity, but also on the administration of antiretroviral treatment.
People living with HIV, HCV and HIV/HCV coinfection in intensive care in a German tertiary referral center 2014–2019
2023, Infection

View all citing articles on Scopus

Revision accepted May 26.

Reprint requests: Dr. Rosen, Division of Pulmonary and Critical Care Medicine, Beth Israel Medical Center, 1st Avenue and 16th Street, New York, NY 10003

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Chest

Clinical Investigations in Critical CareOutcome of Intensive Care in Patients With HIV Infection

Objectives

Design

Setting

Patients

Interventions

Results

Conclusion

Section snippets

METHODS

RESULTS

DISCUSSION

Crit Care Clin N Am

Am J Med

Am J Med

Chest

Chest

Crit Care Clin N Am

Critical care of patients with AIDS

JAMA

Pulmonary complications of the acquired immunodeficiency syndrome: report of a National Heart, Lung, and Blood Institute Workshop

N Engl J Med

Outcome of intensive care in patients with the acquired immunodeficiency syndrome

J Intensive Care Med

Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization

Am Rev Respir Dis

ICU survival of patients with the acquired immunodeficiency syndrome

Crit Care Med

Pneumocystis carinii pneumonia (PCP) in AIDS patients in intensive care [abstract]

Chest

Survival and prognostic factors in severe Pneumocystis carinii pneumonia following mechanical ventilation

Am Rev Respir Dis

Admission of AIDS patients to a medical intensive care unit: causes and outcome

Crit Care Med

Clinical Investigations in Critical Care
Outcome of Intensive Care in Patients With HIV Infection