Pneumocystis carinii pneumonia in patients with and without HIV infection

Advances in the prevention and treatment of Pneumocystis carinii pneumonia in HIV infected patients have led to a decrease in the incidence and improved out-comes. Pneumocystis carinii pneumonia continues to be problematic in non-HIV infected immunocompromised patients. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article.     

Critical care management and outcome of severe <Emphasis Type="Italic">Pneumocystis</Emphasis> pneumonia in patients with and without HIV infection

Background  

Little is known about the most severe forms of Pneumocystis jiroveci pneumonia (PCP) in HIV-negative as compared with HIV-positive patients. Improved knowledge about the differential characteristics and management modalities could guide treatment based on HIV status.     

合并HIV感染对卡氏肺孢菌肺炎临床及预后的影响

目的了解卡氏肺孢菌肺炎(PCP)的发病情况,合并HIV感染对其临床特点的影响,并分析影响预后的因素。方法回顾性分析。结果纳入2001—2005年间的PCP病例40例,其中HIV阴性者22例(55%)。HIV阴性者较合并HIV感染者病情更加严重,就诊时氧合指数314±49对114.2±16.9,APACHEⅡ评分13.2±2.2对7.66±2.1,病死率72.7%对44.4%(P<0.05)。在HIV阴性者中,APACHEⅡ评分、发病至开始用药的时间、合并CMV、曲霉感染是影响预后的危险因素,OR分别为3.1、4.3、3.7、20.7(P<0.05),而CD4细胞计数、激素和免疫抑制剂的累计或每日剂量、氧合指数间无差异。对于合并HIV感染者,死亡组与存活组仅APACHEⅡ评分差异显著,13.2±2.4对7.6±2.1(P=0.04)。结论合并HIV感染,对PCP的临床特点及预后有显著影响。随着免疫抑制剂的使用,HIV阴性人群中PCP的发病率显著增加;较合并HIV感染者该人群的临床进程更加凶险,我们应提高警惕,早期诊断、及时用药,同时注意对混合感染的筛查及治疗,以期提高感染的治愈率。     

HIV血清抗体阴性患者的肺孢子菌肺炎

与艾滋病患者相比,HIV抗体阴性的免疫抑制患者PCP起病更急骤,及时诊断更困难,呼吸衰竭发生率更高,预后更差.支气管肺泡灌洗、口咽冲洗能提高检出率,PCR技术有助于快速诊断.抗菌药物目前仍首选SMZ/TMP,糖皮质激素适用于重度PCP的辅助治疗.对于免疫功能严重低下的患者, 如CD4 T 淋巴细胞低于200/mm3,推荐SMZ/TMP预防治疗.     

Intensive care unit patients with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia: suggested predictors of hospital outcome

OBJECTIVE: To define our ICU experience with AIDS patients, Pneumocystis carinii pneumonia, and respiratory failure, and to delineate factors predictive of hospital survival. DESIGN: A retrospective study in which logistic regression analysis was applied to data obtained during the first 144 hrs of ICU admission. SETTING: A university hospital medical ICU associated with a national AIDS treatment center. PATIENTS: Twenty-seven male patients with AIDS, P. carinii pneumonia, and respiratory failure who desired full supportive and resuscitative care. MEASUREMENTS AND MAIN RESULTS: Of 27 patients who met study criteria, 19 (70%) were nonsurvivors and eight (30%) were survivors. The relative risk of death was 2.2 times greater in patients who exhibited the combination of pH less than 7.35 and a base deficit greater than 4 mEq/L, at any time in their ICU course, than in patients who did not (95% confidence interval = 1.01, 4.81). Furthermore, the relative risk of death was 3.7 times greater in patients who required positive end-expiratory pressure greater than 10 cm H2O after 96 hrs of ICU care than in those patients who did not (95% confidence interval = 1.09, 12.33). Indices of oxygen transfer, severity of chest radiograph abnormalities, concurrent lung infections, and most laboratory studies on hospital admission were not different between the two groups nor predictive of hospital survival. CONCLUSIONS: When dealing with AIDS/P. carinii pneumonia/ICU patients, it is not possible to distinguish who will survive to hospital discharge based on information routinely available before ICU admission. Those patients with the greatest chance of survival demonstrate a significant decrease in the required level of respiratory support within the first 4 days of ICU care. The presence of a metabolic acidemia (pH less than 7.35 and base deficit greater than 4 mEq/L), at any time during the ICU course, is a poor prognostic sign. We suggest that such objective variables should be included in the development of any new outcome predictor model for this group of ICU patients.     

Surgery in patients with HIV infection: indications and outcome

We reviewed the records of 12 patients with HIV infection (one stage I, three stage II, two stage III, six stage IV) who received 15 surgical procedures under general or lumbar/epidural anesthesia. We discussed surgical indications, their poor wound healing and precautions for preventing the risk of transmission of HIV to health care workers. Six emergency and nine elective operations were performed. Postoperative complications developed after three emergency and three elective operations. Ten patients showed delay of wound healing which was not directly correlated with the CD4+ cell count. No operative deaths occurred. In any stage of HIV infection, not only palliative but also curative operations can be performed as long as HIV infection, opportunistic infections and HIV-related neoplasms can be controlled. Late stage wound healing is poor, but the wound will heal without keloid formation, although it takes two to three times longer than usual. For operating on patients with HIV infection, precautions for preventing needle sticks, sharp injuries and blood exposure should be learned and used by health care workers. As a result, surgical staff members will be able to perform operations safely on HIV-infected patients to improve both quality of life and the prognosis of their disease.     

Pneumocystis pneumonia during primary HIV infection: a case report and review of the literature

More than 90 % of cases of pneumocystis pneumonia (PCP) in adults occur in patients with chronic HIV infection with CD4 counts lower than 200 cells/ml. Even though primary HIV infection can cause transient profound CD4 lymphocytopenia, PCP is rarely reported during primary HIV infection. We report a case of a 26-year-old man who was diagnosed with PCP in the setting of primary HIV infection. He was successfully treated with a 21-day course of oral co-trimoxazole.     

Azithromycin use and outcomes in severe sepsis patients with and without pneumonia

PurposeStudies investigating the association between macrolides and outcomes in both pulmonary and nonpulmonary critically ill patients are limited. We aimed to examine the association between azithromycin use and clinical outcomes in severe sepsis patients with and without pneumonia receiving mechanical ventilation.Materials and MethodsA retrospective cohort of 105 patients admitted to an adult intensive care unit (ICU) with severe sepsis in an urban university hospital were included in the study. Multivariable linear regression was performed to assess the relationship between azithromycin use and the following outcomes: 28-day ICU-free days and 28-day ventilator-free days.ResultsIn univariate analysis, patients receiving azithromycin had nearly 6 more ICU-free days on average than did patients not receiving azithromycin (P = .005). The increased ICU-free days remained in multivariable analysis adjusting for age, sex, race, ICU type, and presence of shock (P = .005). In stratified analysis examining the association of azithromycin use in severe sepsis patients without pneumonia (n = 74), the results were similar to the full cohort.ConclusionAzithromycin was associated with more ICU-free days in severe sepsis patients with and without pneumonia. Further investigations are warranted to better elicit the association of macrolide use on clinical outcomes in severe sepsis patients, especially those without pneumonia.     

综合气道护理对重症肺炎患儿治疗效果及呼吸道感染的影响

目的探析综合气道护理对重症肺炎患儿治疗效果及呼吸道感染的影响。方法选择91例重症肺炎患儿作为研究对象,按随机数字表法分为观察组(n=46)与对照组(n=45)。对照组予以常规护理,观察组在对照组基础上增加综合气道护理,比较2组咳嗽、喘憋、肺啰音等症状改善时间、住院时间、机械通气时间、呼吸道感染发生率。结果观察组咳嗽、喘憋、肺啰音等临床症状改善时间均显著短于对照组,差异有统计学意义(P0.05)。观察组住院时间、机械通气时间均短于对照组,差异有统计学意义(P0.05)。观察组共5例(10.9%)发生呼吸道感染,对照组共13例(28.9%),2组比较差异有统计学意义(P0.05)。结论综合气道护理应用在重症肺炎患儿中可确保呼吸道通畅,同时强化治疗效果,缩短症状改善时间、住院时间、机械通气时间,降低呼吸道感染发生率,值得推广应用。     

Early diagnosis and treatment are crucial for the survival of Pneumocystis pneumonia patients without human immunodeficiency virus infection

The mortality of Pneumocystis pneumonia (PCP) patients without human immunodeficiency virus (HIV) infection ranges from 0 to 70 %, whereas that of HIV-infected PCP patients ranges from 10 to 20 %. The reasons for these differences are not known. We retrospectively analyzed factors contributing to the survival of 23 patients with PCP and without HIV infection, in whom PCP developed as community-acquired pneumonia (CAP). The interval from admission to the start of PCP-specific treatment was significantly shorter for survivors (2.71 ± 3.64 days; n = 14) than for non-survivors (8.67 ± 5.5 days; n = 9; p = 0.003). Moreover, although the severity scores/classes assessed by A-DROP, CURB-65, and PSI were no different on admission, scores/classes at the start of PCP-specific treatment were significantly higher for non-survivors. Overall mortality was 39 %, but mortality was approximately 70–100 % for patients classified as severe grade by A-DROP, CURB-65, or PSI scores/classes at the time when PCP-specific treatment was started, which was far higher than expected for these guidelines. In conclusion, early diagnosis and treatment within 3 days are crucial for the survival of PCP patients without HIV infection. We emphasize the limitations of application of guidelines for CAP to patients with PCP.     

Lethal exacerbation of Pneumocystis carinii pneumonia in severe combined immunodeficiency mice after infection by pneumonia virus of mice

Mice homozygous for the mutant allele scid (severe combined immunodeficiency) have been described as excellent models for Pneumocystis carinii (Pc) pneumonia (PCP), a major health problem in patients with acquired immune deficiency syndrome (AIDS) and other immunodeficiency states. Other microorganisms have been shown to infect AIDS patients simultaneously with Pc, but whether one opportunist is able to directly influence the pathogenicity of another has not been determined previously. We have deliberately coinfected scid mice (with extent Pc infection) with a variety of primarily pneumotropic viruses and bacteria and have identified pneumonia virus of mice as causing a dramatic increase in the density of Pc organisms and the morbidity due to PCP in immunodeficient scid mice. This finding has clinical significance in the management of PCP, in that the identification and treatment of coinfecting pneumotropic pathogens may be as important as treatment targeted at Pc. A search for other synergistic (or antagonistic) microorganisms and determination of their mechanism(s) of action in altering the progression of PCP is indicated.     

Critical care management of patients with hemophagocytic lymphohistiocytosis

Objective

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition associated with multiple organ dysfunction. We sought to describe ICU management and outcomes in HLH patients meeting HLH-2004 criteria and to identify determinants of mortality.

Design

Retrospective study between January 1998 and January 2009.

Setting

Medical ICU of a teaching hospital.

Patients

Among the 72 patients fulfilling the HLH-2004 criteria, we report the 56 patients with complete follow-up and no missing data.

Interventions

None.

Measurements and main results

Clinical and laboratory data were abstracted from the medical records. Median SOFA score at admission was 6.5 (IQR, 4–8). At ICU admission, the number of HLH-2004 criteria was 6 (5–7). Sixty-six precipitating factors were found in 52 patients and consisted of 43 tumoral causes (8 Castleman’s diseases, 18 B cell lymphoma and 17 various malignancies), 13 non-viral infections and 10 viral infections. Underlying immune deficiency was present in 38 (67.8%) patients. Etoposide was used in 45 patients, corticosteroids in 31 and intravenous immunoglobulins in 3. Mechanical ventilation was required in 32 patients, vasoactive agents in 30 and renal replacement therapy in 19. Hospital mortality was 29/56 patients. By multivariate analysis, factors associated with increased hospital death were shock at ICU admission [OR, 4.33; 95% confidence interval (95% CI), 1.11–16.90; P = 0.03] and platelet count <30 g/l (OR, 4.75; 95% CI, 1.20–18.81; P = 0.02). B cell lymphoma [odds ratio (OR), 0.17; 95% CI, 0.04–0.80; P = 0.02] and Castleman’s disease (OR, 0.11; 95% CI, 0.02–0.90; P = 0.04) were associated with increased hospital survival.

Conclusions

Aggressive supportive care combined with specific treatment of the precipitating factor can produce meaningful survival in patients with HLH responsible for multiple organ failures. Survival is highest in patients with HLH related to Castleman’s disease or B cell lymphoma.     

重症肺炎患者呼吸道管理策略探讨

摘要：目的 通过评估经鼻导管高流量湿化氧疗在肺部感染患者中的临床疗效,为肺部感染尤其是重症肺炎的患者呼吸道管理策略提供一定的参考依据。方法 2015年9月至2017年9月,采用方便抽样方法选取收治于复旦大学附属华山医院感染科的375例肺部感染患者作为研究对象。依据时间将2015年9月1日至2016年8月31日、2016年9月1日至2017年8月31日入院的患者分别纳入对照组和观察组,对照组患者接受常规治疗,观察组患者在对照组的基础上根据病情接受经鼻导管高流量湿化氧疗。比较两组患者的住院时长、气管插管（包括无创/有创气管切开）人数比例以及预后转归。在对照组和观察组的重症肺炎患者中评估接受经鼻导管高流量湿化氧疗的患者预后情况。结果 观察组重症肺炎的患者比例较对照组高,预后较对照组好,均有统计学差异（P < 0.05）。与未使用HFNC治疗的患者比较,发现接受HFNC的重症肺炎患者预后更好,有统计学差异（P < 0.05）。使用HFNC治疗后,重症肺炎患者的多个指标如呼吸频率、心率、氧饱和度、氧分压均有显著改善,均有统计学差异（P < 0.05）。结论 近年来,我院感染科收治患者的肺部感染患者人数越来越多,重症化比例也越来越高。在此情况下,医院的管理、医生的诊疗、护士的护理到位,使整体肺部感染患者的住院天数、预后转归与既往病情较轻的时候并无差异。同时,接受HFNC的重症肺炎患者,预后明显好转,表明HFNC对改善肺部感染患者预后有明显疗效。     

Management of Pneumocystis pneumonia in patients with inflammatory disorders

Pneumocystis jirovecii is an atypical fungus that causes Pneumocystis pneumonia in immunocompromised patients. Underlying diseases associated with Pneumocystis pneumonia mainly consist of hematologic malignancies, solid tumors, organ transplant recipients and inflammatory disorders. Currently, inflammatory disorders represent 20% of underlying diseases. Corticosteroids are considered as a major risk factor. Recently introduced immunosuppressive drugs, such as antitumor necrosis factor monoclonal antibodies, could enhance the risk of Pneumocystis pneumonia. In patients with inflammatory disorders, lymphopenia is probably a determining factor but CD4+ T-cell count associated with the risk of Pneumocystis pneumonia remains unassessed. The diagnosis is based upon clinical, radiologic and biologic data. The identification of P. jirovecii usually requires a lower respiratory tract specimen, even if oral washes samples seem to be promising. According to recent data, immunofluorescent stains should be considered as the new gold standard, and specialized techniques such as PCR should be applied for sputum samples or oral washes. Recommendations on prophylaxis remains controversial except in patients with Wegener's granulomatosis and systemic lupus erythematosus. Cotrimoxazole is the preferred agent for prophylaxis as well as for treatment. An adjunctive corticosteroid therapy is usually prescribed despite the lack of evidence for utility in patients with inflammatory disorders. As person-to-person transmission is the most likely mode of acquiring P. jirovecii, isolation precautions should be advised.