Critical care management and outcome of severe Pneumocystis 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.


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.
Monnet
Xavier
X
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
Vidal-Petiot
Emmanuelle
E
Osman
David
D
Hamzaoui
Olfa
O
Durrbach
Antoine
A
Goujard
Cécile
C
Miceli
Corinne
C
Bourée
Patrice
P
Richard
Christian
C
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
D000305:Adrenal Cortex Hormones; D007166:Immunosuppressive Agents