title: Critical care management and outcome of severe Pneumocystis pneumonia in patients with and without HIV infection.
abstract: 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.
  
  
  METHODS
  We retrospectively compared 72 patients (73 cases, 46 HIV-positive) admitted for PCP from 1993 to 2006 in the intensive care unit (ICU) of a university hospital.
  
  
  RESULTS
  The yearly incidence of ICU admissions for PCP in HIV-negative patients increased from 1993 (0%) to 2006 (6.5%). At admission, all but one non-HIV patient were receiving corticosteroids. Twenty-three (85%) HIV-negative patients were receiving an additional immunosuppressive treatment. At admission, HIV-negative patients were significantly older than HIV-positive patients (64 [18 to 82] versus 37 [28 to 56] years old) and had a significantly higher Simplified Acute Physiology Score (SAPS) II (38 [13 to 90] versus 27 [11 to 112]) but had a similar PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio (160 [61 to 322] versus 183 [38 to 380] mm Hg). Ventilatory support was required in a similar proportion of HIV-negative and HIV-positive cases (78% versus 61%), with a similar proportion of first-line non-invasive ventilation (NIV) (67% versus 54%). NIV failed in 71% of HIV-negative and in 13% of HIV-positive patients (p < 0.01). Mortality was significantly higher in HIV-negative than HIV-positive cases (48% versus 17%). The HIV-negative status (odds ratio 3.73, 95% confidence interval 1.10 to 12.60) and SAPS II (odds ratio 1.07, 95% confidence interval 1.02 to 1.12) were independently associated with mortality at multivariate analysis.
  
  
  CONCLUSIONS
  The yearly incidence of ICU admissions for PCP in HIV-negative patients in our unit increased from 1993 to 2006. The course of the disease and the outcome were worse in HIV-negative patients. NIV often failed in HIV-negative cases, suggesting that NIV must be watched closely in this population.
authors.affiliation: AP-HP, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France. xavier.monnet@bct.aphp.fr
authors.forename: Xavier
authors.initials: X
authors.lastname: Monnet
authors.forename: Emmanuelle
authors.initials: E
authors.lastname: Vidal-Petiot
authors.forename: David
authors.initials: D
authors.lastname: Osman
authors.forename: Olfa
authors.initials: O
authors.lastname: Hamzaoui
authors.forename: Antoine
authors.initials: A
authors.lastname: Durrbach
authors.forename: Cécile
authors.initials: C
authors.lastname: Goujard
authors.forename: Corinne
authors.initials: C
authors.lastname: Miceli
authors.forename: Patrice
authors.initials: P
authors.lastname: Bourée
authors.forename: Christian
authors.initials: C
authors.lastname: Richard
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000328:Adult; D003422:Critical Care / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology; D018023:HIV Seronegativity; D017052:Hospital Mortality; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D015994:Incidence; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011020:Pneumonia, Pneumocystis / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D053717:Pneumonia, Ventilator-Associated / Q000382:microbiology*; D012121:Respiration, Artificial; D012189:Retrospective Studies
chemical_list: D000305:Adrenal Cortex Hormones; D007166:Immunosuppressive Agents