Clinical course, treatment and outcome of Pneumocystis pneumonia in immunocompromised adults: a retrospective analysis over 17 years

Abstract

BackgroundDespite modern intensive care with standardized strategies against acute respiratory distress syndrome (ARDS), Pneumocystis pneumonia (PcP) remains a life-threatening disease with a high mortality rate. Here, we analyzed a large mixed cohort of immunocompromised patients with PcP, with regard to clinical course and treatment, and aimed at identifying predictors of outcome.MethodsThis was a single-center retrospective analysis in a tertiary care institution across 17 years. Diagnosis of PcP required typical clinical features and microbiological confirmation of Pneumocystis jirovecii. Epidemiological, clinical, laboratory and outcome data were collected from patient records.ResultsA total of 52,364 specimens from 7504 patients were sent for microbiological assessment (3653 with clinical suspicion of Pneumocystis pneumonia). PcP was confirmed in 240 patients, about half of them HIV positive (52%). The remaining subjects were either solid organ transplant recipients (16.3%) or suffered from malignancy (15.8%) or autoimmune diseases (11.7%). Of note, 95% of patients with PcP were not receiving chemoprophylaxis. Overall in-hospital mortality was 25.4%, increasing to 58% if ICU admission was required. Multivariable regression identified lactate dehydrogenase (LDH) as predictor of in-hospital mortality (adjusted OR 1.17 (95% CI 1.09–1.27), p < 0.0001). Mortality in LDH quartiles increased from 8% to 49%, and a cutoff value of 495 U/L predicted mortality with sensitivity and specificity of 70%. With regard to treatment, 40% of patients received trimethoprim-sulfamethoxazole at doses that were lower than recommended, and these patients had a higher mortality risk (HR 1.80 (95% CI 1.10–3.44), p = 0.02).ConclusionsPcP remains a life-threatening disease among immunocompromised patients. About half of patients with PcP do not have HIV infection. Initial LDH values might serve as a stratifying tool to identify those patients at high risk of death among patients with HIV and without HIV infection.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2221-8) contains supplementary material, which is available to authorized users.

Hydroxychloroquine may reduce risk of Pneumocystis pneumonia in lupus patients: a Nationwide, population-based case-control study

“…Pneumocystis pneumonia (PCP), caused by Pneumocystis jirovecii, is a potentially life-threatening infection and is increasingly diagnosed in the immunocompromised patient without human immunodeficiency virus infection, including transplant recipients and the patient with malignancies or autoimmune diseases [1,2]. Glucocorticoids (GC) and a number of immunosuppressants, mainly cyclophosphamide, and have been identified to be associated with an increased risk for PCP in patients with systemic lupus erythematosus (SLE) [3].…”

Pneumocystis jirovecii Pneumonia in Patients with Nephrotic Syndrome: Application of Lymphocyte Subset Analysis in Predicting Clinical Outcomes

“…ICU admission and mechanical ventilation are frequently reported to be associated with a poor prognosis of PCP [5,33]. In HIV-negative patients, ICU admission rate was reported to be 41.7% and 60% in two studies [33,34]; the in-ICU mortality of 53% was reported in another recent study [7]. With regard to mechanical ventilation, it occurred to 40-54% of HIV-negative patients [34,35], and the mortality rate increased to 69.3% compared with the overall mortality of 35.8% in one report [32].…”

“…In HIV-negative patients, ICU admission rate was reported to be 41.7% and 60% in two studies [33,34]; the in-ICU mortality of 53% was reported in another recent study [7]. With regard to mechanical ventilation, it occurred to 40-54% of HIV-negative patients [34,35], and the mortality rate increased to 69.3% compared with the overall mortality of 35.8% in one report [32]. In comparison, among nephrotic syndrome patients who developed PCP, the rates of ICU admission and in-ICU mortality were 64.9% and 48.6%, respectively.…”

Predicting the Prognosis of Patients with Pneumocystis Pneumonia by the (1,3)-β-D-Glucan Test Change

“…The independent risk factors of death in this study is different from that of other studies. The other risk factors including low FiO2 (13)(14)(15)(16)(17)(18), high level of serum LDH (15,16,(19)(20)(21), co-infection of other pathogens (15,19), admission to the ICU (14,22,23), mechanical ventilation (19,24,25), low level of serum albumin (15)(16)(17)24), high level of serum CRP (18,22), high APACHE score (26), elder (15,22), female (21), high ECOG score (22), elevated neutrophils in alveolar lavage fluid (28), underlying disease (22), failure of initial anti-PCP treatment (29), basic lung disease (30), and high P (A-a) O 2 (30).…”