Pneumonia in HIV‐infected patients in the HAART era: Incidence, risk, and impact of the pneumococcal vaccination

Abstract

The objective of this study was to assess the factors implicated in an increased or decreased risk of pneumonia, with particular attention to the response to highly active antiretroviral therapy (HAART) and the effect of the polysaccharide 23-valent pneumococcal vaccination in 300 human immunodeficiency virus (HIV)-infected adults followed-up for a median of 35.6 months. Pneumococcal pneumonia occurred in 12 patients and all bacterial pneumonia (pneumonia caused by Streptococcus pneumoniae or other bacteria, as well as those with negative cultures but presumably bacterial in origin) in 40 patients. In the univariate analysis, immunodepressed patients (defined as those with less than 200 CD4+ T cell/microl), those without immunological response to HAART (defined as an increase of 25% of CD4+ T lymphocyte count), patients with previous admissions to hospital and those with cotrimoxazole or Mycobacterium avium intracellulare prophylaxis showed a higher incidence of both pneumococcal and all bacterial pneumonia. Multivariate analysis demonstrated that the presence of pneumococcal pneumonia was associated with a CD4+ lymphocyte count at the time of HIV diagnosis <200 cells/microl. The multivariate model that was more valid for prediction of all bacterial pneumonia included a CD4+ T cell count <200 cells/microl and absence of immunological response to HAART. Only in patients with a baseline CD4+ T cell count lower than 200/microl and immunological response to HAART, a near significant lower incidence of all bacterial pneumonia was observed after vaccination. Thus, these results do not support an important additional protective effect of 23-valent pneumococcal vaccine in HIV-patients with immunological response to HAART.

The effectiveness of pneumococcal polysaccharide vaccination in HIV-infected adults: a systematic review

“…1c) [16,17]. Studies finding no vaccine effect were the previously mentioned randomized trial [14,35] and the study by Ló pez-Palomo et al [39]. In the latter study, details of the multivariate analysis of vaccine effectiveness were not reported, but it did show an effect of PPV-23 on allcause pneumonia.…”

“…Two found no significant effect [35,39], three found a protective effect [19,32,36], and two found a protective effect in subgroups with high CD4 cell counts at the time of immunization (Fig. 1c) [16,17].…”

“…Three studies found no significant effect of PPV-23 immunization [19,37,38], four found a protective effect [18,30,39,40], and the Uganda trial reported a harmful effect (Fig. 1b).…”

“…Two studies found a significant protective effect [6,15] and the others found no significant effect of PPV-23 in preventing IPD (Fig. 1d) [4,19,34,35,39]. Two of these studies included fewer than 10 incidences and therefore had limited power to detect significant risk differences.…”

Pulmonary Manifestations of HIV Disease

“…The 23 valent polysaccharide vaccine appears to be effective in HIV infected persons in North America for reducing all cause pneumonia but those with plasma viral load of greater than 100,000 may not benefit 180 , 181 , 182 , but the results of clinical trials have not always been consistent 183 . On the other hand African patients have not been documented to benefit from the 23 valent pneumoccal vaccine, 184 , 185 .…”