Pneumonia in HIV-infected Persons

Abstract

Rationale: Bacterial pneumonia is a major cause of morbidity for HIVinfected persons and contributes to excess mortality in this population. Objectives: To evaluate the frequency and risk factors for occurrence of bacterial pneumonia in the present era of potent antiretroviral therapy. Methods: We evaluated data from a randomized trial of episodic antiretroviral therapy. The study, Strategies for Management of Antiretroviral Therapy, enrolled 5,472 participants at 318 sites in 33 countries. Study patients had more than 350 CD4 cells at baseline. Diagnosis of bacterial pneumonia was confirmed by a blinded clinical-events committee. Measurements and Main Results: During a mean follow-up of 16 months, 116 participants (2.2%) developed at least one episode of bacterial pneumonia. Patients randomized to receive episodic antiretroviral therapy were significantly more likely to develop pneumonia than patients randomized to receive continuous antiretroviral therapy (hazard ratio, 1.55; 95% confidence interval, 1.07-2.25; P 5 0.02). Cigarette smoking was a major risk factor: Current-smokers had more than an 80% higher risk of pneumonia compared with never-smokers (hazard ratio, 1.82; 95% confidence interval, 1.09-3.04; P 5 0.02). Participants who were on continuous HIV treatment and were current smokers were three times more likely to develop bacterial pneumonia than nonsmokers. Current smoking status was significant, but a past history of smoking was not. Conclusions: Bacterial pneumonia is a major source of morbidity, even for persons on potent antiretroviral therapy, including those with high CD4 cells. Efforts to reduce this illness should stress the importance of uninterrupted antiretroviral therapy and attainment and/or maintenance of nonsmoking status. Clinical trial registered with www.clinicaltrials.gov (NCT 00027352).

Tobacco Use and Cessation in HIV-Infected Individuals

“…Bacterial pneumonia is closely linked to cigarette smoking and studies in both the pre-ART and ART eras have demonstrated a greatly increased risk of bacterial pneumonia in HIV-infected smokers [6, 13-15]. Furthermore, evidence now exists that cigarette smoking has become the single most important clinical risk factor for bacterial pneumonia in the HIV-infected population [14, 15]. Smoking effects on lung host defense, including adverse effects on alveolar macrophage function and chemotactic properties, may be an important contributing mechanism [16-18].…”

Cigarette Smoking and HIV: More Evidence for Action

“…Both HIV and smoking are risk factors for suppression of local lung defenses and pulmonary diseases including a variety of bacterial pneumonias, acute bronchitis, and tuberculosis (Burns et al, 1996; Conley et al, 1996; Gordin et al, 2008; Hajjeh et al, 1999; Marrie, 1999; Miguez-Burbano et al, 2005; Nuorti et al, 2000; Tumbarello et al, 1998). Evidence exists that the lungs of HIV-positive individuals are especially susceptible to the damaging effects of cigarette smoke with reduction in pulmonary diffusing capacity and increased susceptibility to early development of emphysema (Crothers et al, 2006; Diaz, King, Wewers, et al, 2000; Diaz, King, Pacht, et al, 2000; Diaz et al, 1999; Diaz et al, 2003; Petrache et al, 2008).…”

Bacterial Pneumonia among HIV-Infected Patients: Decreased Risk After Tobacco Smoking Cessation. ANRS CO3 Aquitaine Cohort, 2000–2007

“…Among HIV-infected patients, the prevalence of tobacco smoking is very high, generally reported around 50% in European HIV cohorts [5], [6], compared to 27% in the general population of comparable age and gender [7]. Recent studies have confirmed the effect of tobacco smoking on respiratory tract infections in HIV-infected patients [8], [9], [10], and promoted tobacco smoking withdrawal as a priority. However, the benefit of tobacco withdrawal on the risk of bacterial pneumonia has not been quantified in such populations, exposed to other important risk factors such as HIV-related immunodeficiency [11].…”