Intensive Care Usage by HIV-Positive Patients in the HAART Era

Abstract

In the 1980s the outlook for patients with the acquired immunodeficiency syndrome (AIDS) and critical illness was poor. Since then several studies of outcome of HIV+ patients on ICU have shown improving prognosis, with anti-retroviral therapy playing a large part. We retrospectively examined intensive care (ICU) admissions in a large HIV unit in London. Between April 2001 and April 2006 43 patients were admitted to the ICU. The mean age of patients was 44 years and 74% were male. Fifty-six percent of admissions were receiving anti-retroviral therapy and 44% had an AIDS defining diagnosis. The median CD4 count was 128 cells/mL and the median APACHE II score was 21. The commonest diagnostic ICU admission category was respiratory disease. This group experienced higher mortality despite slightly lower APACHE II scores, though this did not achieve statistical significance. The follow up period was one year or until April 2007, when data were censored. ICU mortality was 33%, in hospital mortality was 51% and overall mortality at the end of the study period was 67%. Median survival was 1008 days. The CD4 count did not predict long-term survival, although the sample size was too small for this to be conclusive.

Etiology and Outcome of Patients with HIV Infection and Respiratory Failure Admitted to the Intensive Care Unit

“…This result contradicted data from other studies, where elevated APACHE-II scores were prognostic of adverse outcomes in these patients [5, 9, 10, 12]. Interesting is the high number of patients who received mechanical ventilation in this study, outweighing results from other reports [9–11, 13, 14, 20, 23, 28]. However, our patients' length of stay in ICU is comparable to figures shown previously [11, 14, 18, 27].…”

“…Although comparable to results from other similar studies [12, 14, 27], the median CD 4 cell count in our patients was higher than those reported in other series [9, 10, 13, 28]. A large proportion of our HIV-infected population is known for poor adherence to antiretrovirals and ongoing substance abuse.…”

“…The overall hospital survival rate in this report is comparable to data previously published [10–12]. Although the reported overall hospital mortality rate in this study was lower than in other series [6, 13, 14], our ICU survival rate was remarkably lower when compared with similar studies [5, 9, 11, 13–15]. Majority of our patients were receiving antiretroviral therapy at the time of death.…”

“…The substandard treatment responses to HAART in our patients may be due to the presence of transmitted drug resistance of the HIV strains, poor adherence to HAART that may result in emergence of antiretroviral drug resistance mutations, and suboptimal or nonimmunological response. The median APACHE-II score in our patients was lower than reported in previous studies [10, 14, 18, 21], and we found no significant difference in the APACHE-II score of survivors and nonsurvivors. This result contradicted data from other studies, where elevated APACHE-II scores were prognostic of adverse outcomes in these patients [5, 9, 10, 12].…”

Invasive Diagnostic Strategies in Immunosuppressed Patients with Acute Respiratory Distress Syndrome

“…97,98 Acute respiratory failure has remained the most common cause for ICU admissions in patients with HIV, and pneumonia is the overall leading cause of ARDS. [99][100][101] Streptococcus pneumonia is the most frequent bacteria isolated, followed by Hemophilus influenzae and Staphylococcus aureus. 102 In addition, Pseudomonas aeruginosa and Enterobacteriaceae spp are important considerations.…”