Survival trends in critically ill HIV-infected patients in the highly active antiretroviral therapy era.
BACKGROUND
The widespread use of highly active antiretroviral therapy (ART) has reduced HIV-related life-threatening infectious complications. Our objective was to assess whether highly active ART was associated with improved survival in critically ill HIV-infected patients.


METHODS
A retrospective study from 1996 to 2005 was performed in a medical intensive care unit (ICU) in a university hospital specialized in the management of immunocompromised patients. A total of 284 critically ill HIV-infected patients were included. Differences were sought across four time periods. Risk factors for death were identified by multivariable logistic regression.


RESULTS
Among the 233 (82%) patients with known HIV infection before ICU admission, 64% were on highly active ART. Annual admissions increased over time, with no differences in reasons for admission: proportions of patients with newly diagnosed HIV, previous opportunistic infection, CD4 counts, viral load, or acute disease severity. ICU and 90-day mortality rates decreased steadily: 25% and 37.5% in 1996 to 1997, 17.1% and 17.1% in 1998 to 2000, 13.2% and 13.2% in 2001 to 2003, and 8.6% in 2004 to 2005. Five factors were independently associated with increased ICU mortality: delayed ICU admission (odds ratio (OR), 3.04; 95% confidence interval (CI), 1.29 to 7.17), acute renal failure (OR, 4.21; 95% CI, 1.63 to 10.92), hepatic cirrhosis (OR, 3.78; 95% CI, 1.21 to 11.84), ICU admission for coma (OR, 2.73; 95% CI, 1.16 to 6.46), and severe sepsis (OR, 3.67; 95% CI, 1.53 to 8.80). Admission to the ICU in the most recent period was independently associated with increased survival: admission from 2001 to 2003 (OR, 0.28; 95% CI, 0.08 to 0.99), and between 2004 and 2005 (OR, 0.13; 95% CI, 0.03 to 0.53).


CONCLUSIONS
ICU survival increased significantly in the highly active ART era, although disease severity remained unchanged. Co-morbidities and organ dysfunctions, but not HIV-related variables, were associated with death. Earlier ICU admission from the hospital ward might improve survival.
Coquet
Isaline
I
Service de Réanimation Médicale, AP-HP, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, Université Paris-7 Paris-Diderot, UFR de Médecine, 75010 Paris, France. i.coquet@aol.com
Pavie
Juliette
J
Palmer
Pierre
P
Barbier
François
F
Legriel
Stéphane
S
Mayaux
Julien
J
Molina
Jean Michel
JM
Schlemmer
Benoît
B
Azoulay
Elie
E
D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D015331:Cohort Studies; D015897:Comorbidity; D016638:Critical Illness; D005260:Female; D006679:HIV Seropositivity / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010297:Paris / Q000453:epidemiology; D012044:Regression Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome