Abstract
The aim of the study was to compare a retrospective case note review of all cases of Pneumocystis carinii (now Pneumocystis jirovecii) pneumonia (PJP) over the period 1997–2004 at North Manchester General Hospital with a previous audit covering the years 1986–1995. During 1986–1995, 777 patients were diagnosed with HIV. One hundred and eighty-one were also diagnosed with PJP. Of these, 11 patients required ventilation with a mortality rate of 100%. For the current review during 1997–2004, 210 patients were diagnosed with PJP, and 64 with severe PJP. Median age was 39 years (interquartile range [IQR] 22–61). Twenty-four patients had a prior diagnosis of HIV (median 43 months, IQR 6–72 months), and for 38 patients this was the presenting diagnosis of HIV. Median CD4 was 34 cells/L (IQR of 12–80 cells/L). Median viral load was 3.5 × 105 copies/mL (IQR 1–5.8 × 105 copies/mL). Eighteen patients required intubation during this period. Nine (50%) were alive at 30 days postextubation. We believe that the 50% reduction in mortality seen between 1997–2004 in intubated patients with severe PJP is due to the improvement in intensive care management of severe respiratory failure rather than changes in the specific management of PJP. The necessity of ventilation in HIV patients is no longer a mandatory death sentence.
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INTRODUCTION
In a previously published retrospective review of intensive care management of patients at our unit with Pneumocystis jirovecii pneumonia (PJP) during 1986–1995, 1,2 11 patients required mechanical ventilation, with a 100% mortality rate. However, it is our perception that outcomes have improved over the recent years among ventilated patients with severe PJP. We therefore conducted a review of the patients presenting to the unit with severe PJP in order to compare trends in outcome and mortality.
METHODS
A retrospective case note review was performed looking at all cases of PJP admitted over the period 1997–2004 at our unit in North Manchester General Hospital. In order to compare results with the previous audit 1986–1995, we kept our definition of severe PJP the same. We used 3 dyspnoea at rest, persistent fever, cough, the extent of radiographic changes, high lactate dehydrogenase level and admission PaO2<8 kPa (60 mmHg).
RESULTS
In the initial period 1986–1995, 777 patients were diagnosed with HIV in our unit. One hundred and eighty-one were also diagnosed with PJP, and 48 with severe PJP. Twenty-one of these required either non-invasive ventilation or intubation. Of the 11 patients intubated there was a mortality rate of 100%.
For the current review during 1997–2004, 210 patients were diagnosed with PJP; 64 with severe PJP. The median age was 39 years (IQR 22–61). PJP predominantly occurred in men – 59 (92%) and only five (8%) cases were in women. Twenty-four patients had a diagnosis of HIV prior to presentation (median 43 months, IQR 6–72 months) and for 38 patients this was the presenting diagnosis of HIV.
The majority of patients (53) had not been on co-trimoxazole prophylaxis including 15 patients who had previously been diagnosed as HIV-positive. Data were missing for two patients. Of those who had been on prophylaxis, eight were on co-trimoxazole (three for less than one month) and one had been on atovaquone. Five cases of ‘co-trimoxazole failures’ were suspected.
CD4 at presentation with PJP was 34 cells/L (IQR 12–80). Median viral load was 3.5 × 105 copies/mL (IQR 1–5.8 × 105 copies/mL).
Eight patients were on highly active antiretroviral therapy (HAART) at presentation with PJP (median 30 days, IQR 30–1001).
Eighteen patients required intubation during this period. Nine (50%) were alive at 30 days postextubation. At one year, seven patients remained alive. One patient died as a complication of PJP, and one patient later died from lymphoma. For all survivors this was the first episode of PJP.
Nine intubated patients received prior continuous positive airway pressure (CPAP). The median number of days for prior CPAP was 1.5 (IQR 1–3). Of those who received prior CPAP, five were still alive 30 days after intubation. Only one patient who received CPAP did not require intubation.
The median time to intubation was 8.5 days (IQR 3–13). In the group that survived, the median time was six days and in the group that died, median time was 15 days (non-significant). Seven patients had a tracheostomy postintubation; five in the alive group and two in the group who died.
Rates of complications were similar in survivors and non-survivors with pneumothoraces occurring in three patients who died, and three who survived.
CONCLUSIONS
PJP is still a significant cause of death in HIV-positive people. The mortality rate of severe PJP is declining, with a mortality rate of 71% in the pre-1995 era, and 17% between 1997 and 2004. The definition of severe PJP has not changed, so it is unlikely that this reduction can be accounted for by a decline in the severity of PJP. Importantly, the mortality rate of those patients requiring intubation has fallen from 100% to 50%. This is not due to the advent of HAART, as the current practice is to start patients on HAART after the acute phase of PJP is over.
Past studies have shown that survival increases with the experience of the centre treating PJP 4 and HIV. 5 Previously, there was a perceived reluctance to intubate patients with PJP due to the high mortality. This led to the increased use of non-invasive measures of ventilation, which may have helped some patients. However, increasing experience on the part of intensive care units will have contributed to the reduction in mortality rate. This may have manifested increased positive end-expiratory pressure and permissive hypercapnia from the use of protective ventilation, which involves lower tidal volumes. This in turn may have helped prevent pneumothoraces and earlier tracheostomy. The necessity of ventilation in HIV patients with severe PJP is no longer a mandatory death sentence.