title: CURB-65 and other markers of illness severity in community-acquired pneumonia among HIV-positive patients.
abstract: As the relative burden of community-acquired bacterial pneumonia among HIV-positive patients increases, adequate prediction of case severity on presentation is crucial. We sought to determine what characteristics measurable on presentation are predictive of worse outcomes. We studied all admissions for community-acquired bacterial pneumonia over one year at a tertiary centre. Patient demographics, comorbidities, HIV-specific markers and CURB-65 scores on Emergency Department presentation were reviewed. Outcomes of interest included mortality, bacteraemia, intensive care unit admission and orotracheal intubation. A total of 396 patients were included: 49 HIV-positive and 347 HIV-negative. Mean CURB-65 score was 1.3 for HIV-positive and 2.2 for HIV-negative patients (p < 0.0001), its predictive value for mortality being maintained in both groups (p = 0.03 and p < 0.001, respectively). Adjusting for CURB-65 scores, HIV infection by itself was only associated with bacteraemia (adjusted odds ratio [AOR] 7.1, 95% CI [2.6-19.5]). Patients with < 200 CD4 cells/µL presented similar CURB-65 adjusted mortality (aOR 1.7, 95% CI [0.2-15.2]), but higher risk of intensive care unit admission (aOR 5.7, 95% CI [1.5-22.0]) and orotracheal intubation (aOR 9.1, 95% CI [2.2-37.1]), compared to HIV-negative patients. These two associations were not observed in the > 200 CD4 cells/µL subgroup (aOR 2.2, 95% CI [0.7-7.6] and aOR 0.8, 95% CI [0.1-6.5], respectively). Antiretroviral therapy and viral load suppression were not associated with different outcomes (p > 0.05). High CURB-65 scores and CD4 counts < 200 cells/µL were both associated with worse outcomes. Severity assessment scales and CD4 counts may both be helpful in predicting severity in HIV-positive patients presenting with community-acquired bacterial pneumonia.
authors.affiliation: Central Lisbon Hospital Centre, Department of Internal Medicine 4, Hospital de Santa Marta, Lisbon, Portugal NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal andre.almeida@chlc.min-saude.pt.
authors.forename: André
authors.initials: A
authors.lastname: Almeida
authors.affiliation: Higher Institute of Applied Psychology (ISPA), Psychology and Health Research Unit, Lisbon, Portugal.
authors.forename: Ana Rita
authors.initials: AR
authors.lastname: Almeida
authors.affiliation: Central Lisbon Hospital Centre, Department of Internal Medicine 4, Hospital de Santa Marta, Lisbon, Portugal NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: Sara
authors.initials: S
authors.lastname: Castelo Branco
authors.affiliation: Central Lisbon Hospital Centre, Department of Internal Medicine 4, Hospital de Santa Marta, Lisbon, Portugal NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: Zsófia
authors.initials: Z
authors.lastname: Vesza
authors.affiliation: Central Lisbon Hospital Centre, Intensive Care Unit 7, Hospital Curry Cabral, Lisbon, Portugal.
authors.forename: Rui
authors.initials: R
authors.lastname: Pereira
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000150:complications* / Q000453:epidemiology / Q000401:mortality*; D000368:Aged; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active; D015415:Biomarkers / Q000097:blood; D017714:Community-Acquired Infections / Q000175:diagnosis / Q000453:epidemiology / Q000401:mortality*; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy; D006760:Hospitalization; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000175:diagnosis / Q000453:epidemiology / Q000401:mortality*; D012189:Retrospective Studies; D012720:Severity of Illness Index
chemical_list: D044966:Anti-Retroviral Agents; D015415:Biomarkers
keywords: AIDS; CURB-65 score; HIV; clinical prediction rule; community-acquired pneumonia; opportunistic infection; pneumonia