Predicting mortality from HIV-associated Pneumocystis pneumonia at illness presentation: an observational cohort study

Abstract

Background: Although the use of antiretroviral therapy has led to dramatic declines in AIDS-associated mortality, Pneumocystis pneumonia (PCP) remains a leading cause of death in HIV-infected patients. Objectives: To measure mortality, identify predictors of mortality at time of illness presentation and derive a PCP mortality prediction rule that stratifies patients by risk for mortality. Methods: An observational cohort study with case note review of all HIV-infected persons with a laboratory diagnosis of PCP at San Francisco General Hospital from 1997 to 2006. Results: 451 patients were diagnosed with PCP on 524 occasions. In-hospital mortality was 10.3%. Multivariate analysis identified five significant predictors of mortality: age (adjusted odds ratio (AOR) per 10-year increase, 1.69; 95% CI 1.08 to 2.65; p = 0.02); recent injection drug use (AOR 2.86; 95% CI 1.28 to 6.42; p = 0.01); total bilirubin .0.6 mg/dl (AOR 2.59; 95% CI 1.19 to 5.62; p = 0.02); serum albumin ,3 g/dl (AOR 3.63; 95% CI 1.72-7.66; p = 0.001); and alveolar-arterial oxygen gradient >50 mm Hg (AOR 3.02; 95% CI 1.41 to 6.47; p = 0.004). Using these five predictors, a six-point PCP mortality prediction rule was derived that stratifies patients according to increasing risk of mortality: score 0-1, 4%; score 2-3, 12%; score 4-5, 48%. Conclusions: The PCP mortality prediction rule stratifies patients by mortality risk at the time of illness presentation and should be validated as a clinical tool.

Pulmonary infections in HIV-infected patients: an update in the 21st century

“…The degree of hypoxaemia at presentation is strongly related to the prognosis of PCP: the case fatality rate is ,10% in patients with mild to moderate disease, whereas it is .20% in patients with marked abnormalities in gas exchange [162,163]. Other factors include older age, presence of comorbidities, malnourishment, injection drug use, prior episodes of PCP, high LDH levels, marked neutrophilia in BAL, low haemoglobin level and high bilirubin level at hospital admission, the presence of cytomegalovirus in BAL fluid and a CD4 count ,50 cells per mm 3 [14,68,161,164]. Improved survival has been described in the era of HAART among the subgroup of patients with severe PCP admitted to the ICU.…”

Pulmonary Manifestations of HIV Disease

“…The overall in hospital mortality of this illness is in the region of 10-13%. Among the factors that have been associated with death in patients with PcP include older age, recent injection drug use, total bilirubin of greater than 0.6 mg/dl, serum albumin of less than 3 g/dl, alveolararterial oxygen gradient of equal or greater than 50 mm Hg, failure of cotrimoxazole treatment and the presence of co-morbidities such as bacterial pneumonia, Kaposis sarcoma and TB 55,56,57 . Patients who need to be admitted to the intensive care unit may suffer very high rates of deaths that could reach 80% within the ICU and up to 34 % three months post ICU admission 58 .…”

Impact of an Intravenous Trimethoprim/Sulfamethoxazole Shortage on Treatment Outcomes Among HIV-Infected Patients with Pneumocystis jirovecii Pneumonia

“…The mortality rate in both groups was 16.7%, which is similar to a recently published observational study examining PJP treatment outcomes in the era of HAART. 9 Patients with PJP in a study of PJP treatment outcomes by Fei et al (2009) had a median LOS of 8 days. 10 This number is comparable with patients in PRE, but patients in POST had a longer median LOS, especially patients who experienced WCS.…”

“…9 Patients with PJP in a study of PJP treatment outcomes by Fei et al (2009) had a median LOS of 8 days. 10 This number is comparable with patients in PRE, but patients in POST had a longer median LOS, especially patients who experienced WCS. When examined together, these data suggest that the lack of IV TMP/SMX may have led to a temporary increase in PJP-related morbidity and LOS but not necessarily an increase in PJP-related mortality.…”