Higher Risk for Pneumonia in HIV Does Not Mean Worse Outcomes

Vaccination was not associated with the incidence of bacteremia in either group.
Vaccination was not associated with the incidence of bacteremia in either group.

Patients with HIV who develop community-acquired pneumonia (CAP) fare no worse than HIV-negative patients with pneumonia, and do not require special treatment or hospitalization compared with other patients. Despite the significantly higher risk of CAP in HIV-infected patients — reported in a 2005 study2 to be 35 times that of noninfected individuals — a case-controlled comparative study conducted at a Barcelona hospital reported recently in Chest1 showed that the outcomes were no worse.

The investigators identified 50 HIV-positive (defined as CD4 lymphocytes ≥350 cell/mm3) patients age 18 to 50 (70% male) who were diagnosed with pneumococcal pneumonia due to Streptococcus pneumoniae bacterial infection during the study period from 2001 to 2016. The HIV-infected patients had all achieved undetectable HIV-RNA levels on antiretroviral therapy (ART). For each HIV patient, 2 age and sex-matched controls (n=100) were also selected for matching comorbidities and a CAP diagnosis made during the same time period.

The HIV-infected patients were more likely to have been vaccinated against pneumococcal pneumonia than the control group (10% vs 1%, respectively, P =.016), although only 79% of serotypes found in the cohort were covered by the pneumococcal conjugate vaccine (PCV13).

The investigators noted rates of bacteremia in the Barcelona HIV-infected cohort of nearly 50%, consistent with a range of 23% to 75% reported in other studies.3-5 Vaccination was not associated with the incidence of bacteremia in either the HIV group (23 (55%) vs 1 (20%); P =.19) or the non-HIV control group (37 (43%) vs 1 (100%); P =.43).

Higher rates of comorbidities were observed in the HIV-infected group, including influenza (14% vs 2%, P =.007) and hepatitis B virus (HBV) (6% vs 0%, P =.036), and fully one-third (34%) had either HBV, hepatitis C, or both. The median CD4+ cell count at baseline was 517.5 (403; 700)/mm3 218, which was not predictive of outcomes, consistent with previous findings by Bordon, et al.6

Survival was 100% at 30 days, and the average length of hospital stay was 7 days in both groups (P <.76). The rate of admission to the intensive care unit (ICU) was actually higher in the control group (27%, compared with 18% in HIV-infected patients), while the need for ventilation was slightly higher in the HIV-group (12%, compared with 8% in the control group, P =.43).

Overall, patients with HIV did not show signs of more severe CAP at presentation to a hospital compared with patients without HIV, and did not have worse outcomes, the investigators reported.

References

  1. Cillóniz C, Torres A, Manzardo C, et al. Community-acquired pneumococcal pneumonia in virologically suppressed HIV-infected adult patients: a matched case-control study [published online March 14, 2017]. Chest. doi:10.1016/j.chest.2017.03.007
  2. Heffernan RT, Barrett NL, Gallagher KM, et al. Declining incidence of invasive Streptococcus pneumoniae infections among persons with AIDS in an era of highly active antiretroviral therapy, 1995-2000. J Infect Dis. 2005;191:2038-2045. doi:10.1086/430356
  3. Curran A, Falco V, Crespo M, et al. Bacterial pneumonia in HIV-infected patients: use of the pneumonia severity index and impact of current management on incidence, aetiology and outcome. HIV Med. 2008;9:609-615. doi:10.1111/j.1468-1293.2008.00603.x
  4. Meiring S, Cohen C, Quan V, et al. HIV infection and the epidemiology of invasive pneumococcal disease (IPD) in South African adults and older children prior to the introduction of a pneumococcal conjugate vaccine (PCV). PLoS One. 2016;11:e0149104. doi:10.1371/journal.pone.0149104
  5. Albrich WC, Madhi SA, Adrian PV, et al. Pneumococcal colonisation density: a new marker for disease severity in HIV468 infected adults with pneumonia. BMJ Open. 2014;4:e005953. doi:10.1136/bmjopen-2014-005953
  6. Bordon J, Kapoor R, Martinez C, et al. CD4+ cell counts and HIV-RNA levels do not predict outcomes of community-acquired pneumonia in hospitalized HIV-infected patients. Int J Infect Dis. 2011;15:e822-e827. doi:10.1016/j.ijid.2011.05.021
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