Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa.
PLoS One. 2018 Aug 2;13(8):e0201733. doi: 10.1371/journal.pone.0201733. eCollection 2018.
HIV-associated pneumocystis pneumonia (PCP) is increasingly recognized as an important cause of severe respiratory illness in sub-Saharan Africa. Outcomes of HIV-infected patients with PCP, especially those requiring intensive care unit (ICU) admission, have not been adequately studied in sub-Saharan Africa. The aim of this study was to describe the clinical phenotype and outcomes of HIV-associated PCP in a group of hospitalized South African patients, and to identify predictors of mortality. We conducted a retrospective record review at an academic referral center in Cape Town. HIV-infected patients over the age of 18 years with definite (any positive laboratory test) or probable PCP (defined according to the WHO/CDC clinical case definition) were included. The primary outcome measure was 90-day mortality. Logistic regression and Cox proportional hazards models were constructed to identify factors associated with mortality. We screened 562 test requests between 1 May 2004 and 31 April 2015; 124 PCP cases (68 confirmed and 56 probable) were included in the analysis. Median age was 34 years (interquartile range, IQR, 29 to 41), 89 (72%) were female, and median CD4 cell count was 26 cells/mm3 (IQR 12 to 70). Patients admitted to the ICU (n = 42) had more severe impairment of gas exchange (median ratio of arterial to inspired oxygen (PaO2:FiO2) 158 mmHg vs. 243 mmHg, p < 0.0001), and increased markers of systemic inflammation compared to those admitted to the ward (n = 82). Twenty-nine (23.6%) patients were newly-diagnosed with tuberculosis during their admission. Twenty-six (61.9%) patients admitted to ICU and 21 (25.9%) admitted to the ward had died at 90-days post-admission. Significant predictors of 90-day mortality included PaO2:FiO2 ratio (aOR 3.7; 95% CI, 1.1 to 12.9 for every 50 mgHg decrease), serum LDH (aOR 2.1; 95% CI, 1.1 to 4.1 for every 500 U/L increase), and concomitant antituberculosis therapy (aOR 82; 95% CI, 1.9 to 3525.4; P = 0.021). PaO2:FiO2 < 100 mmHg was significantly associated with inpatient death (aHR 3.8; 95% CI, 1.6 to 8.9; P = 0.003). HIV-associated PCP was associated with a severe clinical phenotype and high rates of tuberculosis co-infection. Mortality was high, particularly in patients admitted to the ICU, but was comparable to other settings. Prognostic indictors could be used to inform ICU admission policy for patients with this condition.
HIV 相关的卡氏肺孢子虫肺炎（PCP）在撒哈拉以南非洲日益被认为是严重呼吸道疾病的重要原因。HIV 感染患者，特别是需要入住重症监护病房（ICU）的患者，其 PCP 的结局在撒哈拉以南非洲尚未得到充分研究。本研究的目的是描述一组南非住院患者的 HIV 相关 PCP 的临床表型和结局，并确定死亡率的预测因素。我们在开普敦的一家学术转诊中心进行了回顾性病历审查。纳入年龄在 18 岁以上、有明确（任何阳性实验室检测）或可能的 PCP（根据世界卫生组织/CDC 临床病例定义定义）的 HIV 感染者。主要结局指标为 90 天死亡率。构建逻辑回归和 Cox 比例风险模型以确定与死亡率相关的因素。我们在 2004 年 5 月 1 日至 2015 年 4 月 31 日之间筛查了 562 项检测请求；124 例 PCP 病例（68 例确诊和 56 例可能）被纳入分析。中位年龄为 34 岁（四分位距，IQR，29 至 41），89 例（72%）为女性，中位 CD4 细胞计数为 26 个细胞/mm3（IQR 12 至 70）。入住 ICU（n = 42）的患者的气体交换严重受损（中位动脉血氧分压与吸入氧比值（PaO2:FiO2）为 158mmHg 与 243mmHg，p < 0.0001），与入住病房的患者相比，全身炎症标志物增加（n = 82）。29 例（23.6%）患者在住院期间新诊断为结核病。入住 ICU 的 26 例（61.9%）和入住病房的 21 例（25.9%）患者在入院后 90 天死亡。90 天死亡率的显著预测因素包括 PaO2:FiO2 比值（优势比 3.7；每下降 50mgHg，95%CI，1.1 至 12.9）、血清 LDH（优势比 2.1；每增加 500U/L，95%CI，1.1 至 4.1）和同时接受抗结核治疗（优势比 82；95%CI，1.9 至 3525.4；P = 0.021）。PaO2:FiO2 < 100mmHg 与住院死亡显著相关（危险比 3.8；95%CI，1.6 至 8.9；P = 0.003）。HIV 相关的 PCP 与严重的临床表型和高结核合并感染率相关。死亡率很高，特别是在入住 ICU 的患者中，但与其他环境相当。预后指标可用于为该疾病患者的 ICU 入院政策提供信息。
