Higher Risk for Pneumonia in HIV Does Not Mean Worse Outcomes

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