Management Of Pneumonia In Hiv Patients

Deterrence And Patient Education

To prevent pneumonia in immunocompromised individuals, the following are recommended:

• Immunization against influenza and Pneumococcus. Vaccination against other encapsulated bacteria such as H. influenzae should also be done. Live attenuated vaccines are to be avoided, which include the intranasal influenza vaccine.
• Avoidance of unnecessary immunosuppression, e.g., avoiding unnecessary glucocorticoid use
• HIV-infected individuals should adhere to their antiretroviral therapy regimen.
• Compliance and adherence to antimicrobial prophylaxis
• Regular follow-up with a physician so that any abnormality may be caught early on.
• Maintain a healthy diet and lifestyle

Serratia Marcescens Pneumonia In An Hiv

For 3 days, a 45-year-old woman with HIV infection who was noncompliant with her antiretroviral medications had cough, yellowish sputum, fever, and dyspnea. She denied hemoptysis, weight loss, or recent hospitalization. She had a long history of heavy smoking and alcohol and intravenous drug abuse.

For 3 days, a 45-year-old woman with HIV infection who was noncompliant with her antiretroviral medications had cough, yellowish sputum, fever, and dyspnea. She denied hemoptysis, weight loss, or recent hospitalization. She had a long history of heavy smoking and alcohol and intravenous drug abuse.

The patient had a high fever, tachycardia, tachypnea, and inspiratory rales in both lung fields but no evidence of hypoxia. White blood cell count was 23,500/L, with 84% neutrophils. CD4+ cell count was 679/L . A chest radiograph revealed bibasilar patchy infiltrate .

Therapy with intravenous ceftriaxone and azithromycin was started for presumed community-acquired pneumonia, and the patient was isolated as a precaution. Her clinical condition did not improve with antibiotic and supportive treatment. No acidfast bacilli were isolated from sputum samples. A CT scan of the

chest showed extensive bilateral basilar pneumonitis . Multiple small cavities in both lungs were also noted. A subsequent bronchoscopy with lavage and bronchial washing isolated Serratia marcescens.

The patient responded well to intravenous imipenem. After 10 days, she was discharged.

Bacterial Pneumonia Risk In Hiv Patients Reduced By Quitting Smoking

Bacterial pneumonia risk in HIV patients is seen to be reduced by quitting smoking. Bacterial pneumonia is a common condition, which affects HIV patients, and among those who smoke, the risk of developing bacterial pneumonia is doubled.

The research conducted a meta-analysis of data on several thousand HIV patients taken from 14 different studies in different countries. Current smoking was associated with a 70 to 100 percent increase in bacterial pneumonia, when compared with non-smokers. But the researchers found that quitting smoking reduced the risk by one-third.

Study lead Prof. Paul Aveyard said, Antiretroviral treatment means that people with HIV can have a normal life expectancy. However, they still have substantially increased health risks compared to the general population, including risk of pneumonia. Our results show that smokers with HIV have twice the risk of bacterial pneumonia, but that stopping smoking can reduce this risk. In order to prevent this potentially life-threatening lung disease, we believe that smoking cessation programs should be promoted as part of HIV treatment.

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Enhancing Healthcare Team Outcomes

Patients with weakened immune defenses are particularly susceptible to developing pneumonia rapidly. It is for this reason that high clinical suspicion and detailed history taking are required at the initial evaluation. An interprofessional team approach is needed in the management of pneumonia in immunocompromised patients.

The most valuable treatment outcome for patients is treating the underlying infection. Close follow-up as an outpatient with treatment plan compliance is essential in preventing recurrence. For transplant patients, close monitoring and re-evaluation of immunosuppressive drugs are essential. Close coordination with a respiratory therapist is essential to ensure optimal oxygen delivery. Nursing care is just as important and can prevent unnecessary complications like pressure ulcers. These patients also need dietary consult and physical therapy to maintain a healthy muscle mass and maintain some degree of immunity.

With evaluation across multiple disciplines, a team approach, and early intervention, positive outcomes can be achieved.

Outcome

Untreated Pneumocystis pneumonia is associated with a mortality of 90% to 100%. In HIV-infected patients with PCP, mortality was found to be 6.6% overall and 50-60% in patients who were intubated. In non-HIV infected immunocompromised patients with PCP, the overall mortality was 39%, and 66% among intubated patients.

What Is Hiv Pneumonia

Pneumonia is an infection of the lung that can occur in any person. It is more likely to affect people with weakened immune systems. HIV infection is one of the rapidly growing causes of a weak immune system. Therefore pneumonia in an HIV-positive patients is sometimes termed HIV pneumonia or more correctly as HIV-associated pneumonia.

It is similar to pneumonia in any other person although sometimes in HIV pneumonia the microorganisms that causes the infection are very rare. When pneumonia occurs in HIV or any other diseases that compromises a persons immune status, there is a high degree of mortality. This means that the chances of death is very likely especially if medical treatment is not rapidly initiated.

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Indication For Primary Prophylaxis

Adults and adolescents with HIV, including pregnant women and those on ART, with CD4 counts < 200 cells/mm3 should receive chemoprophylaxis against PCP.12,13,41 Persons who have a CD4 cell percentage < 14% should also be considered for PCP prophylaxis .12,13,41 If ART initiation must be delayed and frequent monitoring of CD4 counts is impossible, some experts recommend starting PCP chemoprophylaxis at CD4 counts â¥200 cells/mm3 to â¤250 cells/mm3.13 Patients receiving pyrimethamine-sulfadiazine for treatment or suppression of toxoplasmosis do not require additional prophylaxis for PCP .42

For patients who cannot tolerate TMP-SMX, alternative prophylactic regimens include dapsone ,43 dapsone plus pyrimethamine plus leucovorin ,51-53 aerosolized pentamidine administered with the Respirgard II nebulizer ,44 and atovaquone .54,55 Atovaquone is as effective as aerosolized pentamidine54 or dapsone55 but substantially more expensive than the other regimens. For patients seropositive for Toxoplasma gondii who cannot tolerate TMP-SMX, recommended alternatives for prophylaxis against both PCP and toxoplasmosis include dapsone plus pyrimethamine plus leucovorin ,51-53 or atovaquone, with or without pyrimethamine, plus leucovorin .

The following regimens cannot be recommended as alternatives to TMP-SMX because data regarding their efficacy for PCP prophylaxis are insufficient:

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Beware: There Are Other Diseases That Can Mimic Pneumonia

The differential diagnosis of respiratory symptoms in an HIV-positive patient includes several conditions that are seen in the general population, as follows:

• Pulmonary embolus : The clinical manifestations of PE are highly nonspecific. The classic presentation includes acute onset of dyspnea, hypoxemia, pleuritic chest pain, and sinus tachycardia with or without hemoptysis. Pleural effusion is common. Massive embolus may precipitate acute hypoxemic respiratory failure or hemodynamic collapse. Risk factors include immobility, recent surgery, thrombophilia, or underlying malignancy.

• Cardiogenic pulmonary edema: Pulmonary edema presents with dyspnea and occasionally cough. The primary physical exam findings are pulmonary crackles in concert with other signs of heart failure, including lower extremity edema, an elevated jugular venous pressure, an S3 or S4, or a cardiac murmur. The chest radiograph may show ground glass opacities, Kerley B and A lines, and pleural effusions.

HIV is specifically associated with a number of noninfectious pulmonary conditions, as follows:

Substance abuse, which remains common in the HIV-positive population, may predispose the patient to a number of pulmonary conditions. A careful substance history may suggest one of the following conditions:

Diagnosis Of Pulmonary Infections In Patients With Hiv Infection

There is no consensus on a diagnostic algorithm of pulmonary infections in HIV patients. Some investigators have recommended an empirical approach based on clinical features and local epidemiology. They have also suggested that diagnostic techniques should only be considered for patients in whom empirical therapy fails . Other authors think that the aim should always be to achieve an aetiological diagnosis by means of noninvasive specimens initially, followed by invasive techniques if these specimens are non-diagnostic . A study showed that not having an aetiological diagnosis was associated with increased mortality . In this way, it is important to remember that while it is always appealing to make a single diagnosis and initiate therapy, multiple simultaneous processes are common in HIV patients, particularly in those with a lower CD4 count . The occurrence of multiple simultaneous infections can delay and complicate appropriate therapy. Additionally, it must be taken into account that the differential diagnosis of pulmonary infiltrates in HIV patients includes both infectious and non-infectious conditions.

The initial approach to the diagnosis of pulmonary infections in HIV-infected patients begins with an adequate clinical history and physical examination. Since the differential diagnosis is broad, historical clues may be useful in narrowing the possibilities, and selecting initial empiric therapy.

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When To Restart Primary Or Secondary Prophylaxis

Primary or secondary PCP prophylaxis should be reintroduced if the patientâs CD4 count decreases to < 100 cells/mm3 regardless of the HIV plasma viral load. Prophylaxis should also be reintroduced for patients with CD4 counts of 100 cells/mm3 to 200 cells/mm3 with HIV plasma viral load above detection limits of the assay used . Based on results from the COHERE study, primary or secondary PCP prophylaxis may not need to be restarted in patients with CD4 counts of 100 cells/mm3 to 200 cells/mm3 who have had HIV plasma RNA levels below limits of detection for â¥3 to 6 months .16,66

If an episode of PCP occurs at a CD4 count > 200 cells/mm3 while a patient is on ART, it would be prudent for the patient to continue PCP prophylaxis for life, regardless of how high their CD4 cell count rises as a consequence of ART . For patients in whom PCP occurs at a CD4 count > 200 cells/mm3 while not on ART, discontinuation of prophylaxis can be considered once HIV plasma RNA levels are suppressed to below limits of detection for â¥3 to 6 months, although there are no data to support recommendations in this setting .

Intensive Care Of Hiv

Since the beginning of the AIDS epidemic, respiratory failure has been the most common indication for intensive care unit admission among patients with HIV infection . In the early years of the HIV pandemic, respiratory failure due to PCP was by far the most common disorder that prompted ICU admission and outcomes were uniformly dismal . ICU care was perceived as futile by physicians. Since then, the proportion of ICU admissions caused by respiratory failure has declined, but respiratory failure remains the most common indication for ICU admission in the current era of HAART bacterial pneumonia and PCP are the leading causes of acute respiratory failure, but the proportion of PCP has decreased . Survival for critically ill HIV-infected patients continues to improve in the current era and could be comparable to the overall survival in non-HIV ICU patients . Consequently, clinicians should no longer consider HIV infection as the driving factor for determining outcome in patients with HIV infection and respiratory failure .

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Tb And Other Mycobacteriosis

The coincidence of TB and HIV epidemics has created a devastating international public health crisis. At least one-third of HIV-infected persons worldwide are infected with Mycobacterium tuberculosis, and HIV infection is, in global terms, the largest risk factor for developing TB disease . Additionally, TB is a leading cause of death for people living with HIV in low- and middle-income countries . HIV-infected persons have a substantially greater risk of progressing from latent TB infection to active TB compared with persons without HIV infection . The use of HAART has been found to be associated with a notable reduction in the risk of TB, but incidence rates remain higher than in the general population . In a study of patients initiating HAART over a follow-up period of 4.5 yrs, the risk of TB only decreased when the CD4 threshold was > 500 cells per mm3 .

Africa is experiencing the worst TB epidemic since the advent of antibiotics, with rates increasing sharply in the past two decades . Conversely, in the USA and Western Europe, a decline in the incidence of TB in HIV-infected patients has been observed in the last decades however, remarkable regional differences have been found in Europe, with rates four to seven times higher in southwest Europe than in other European regions .

Pneumocystis Pneumonia Diagnosis And Tests

A technician will use a microscope to look for traces of the fungus in fluid or tissue from your lungs. Your doctor will help you cough up fluid. Or they might use a special tool called a bronchoscope, which goes through your mouth and into your airways, to take a sample. They could also do a biopsy, using a needle or a knife to remove a tiny amount of cells from your lung.

A test called PCR makes copies of specific pieces of DNA so it can find smaller amounts of the fungus in samples.

You might also get a chest X-ray or blood tests to check for low oxygen levels or high levels of something called beta-D-glucan.

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Pneumocystis Pneumonia In People With Hiv

In the late 1980s, before there was medicine to treat HIV, about three-quarters of people who had AIDS got PCP. Antiretroviral therapy now keeps people with HIV from getting AIDS, and not many of them get PCP. But in people who have AIDS, itâs still the most common opportunistic infection — a disease that happens more often or is worse in people with weak immune systems.

You’re most likely to get PCP when your CD4 cell count is less than 200. People who have HIV and get PCP are eight times more likely to need to stay in the hospital than those who get PCP but donât have HIV. Even with treatment, PCP can be deadly for people who have AIDS.

General Approach To Treatment

The basic principles of antibiotic treatment of CAP are the same for patients with HIV as for those who do not have HIV.57 As discussed in the Diagnosis section, if specimens are to be collected for diagnosis, they should preferably be collected before antibiotic therapy is initiated or within 12 hours to 18 hours of antibiotic initiation. However, antibiotic therapy should be administered promptly, without waiting for the results of diagnostic testing. Empiric therapy varies based on geographic region and common pathogens in these regions, and should take into account local resistance patterns, results of MRSA rapid swab testing if done, and individual patient risk factors, including severity of immunocompromise and use of ART.

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Bacterial Pneumonia Symptoms And Risk Factors

Although anyone can develop bacterial pneumonia, there are certain risk factors and groups with a heightened risk. Infants and children, adults over the age of 65, those with weakened immune systems, long-term users of immunosuppressants, patients with COPD or who use inhaled corticosteroids, and smokers are all more likely to develop bacterial pneumonia, compared to the general population.

Symptoms of bacterial pneumonia include:

• A cough with thick yellow, green, or blood mucus
• Chest pains that worsen during breathing or coughing
• Sudden onset of chills
• Confusion
• Loss of appetite

Monitoring Of Response To Therapy And Adverse Events

The clinical response to appropriate antimicrobial therapy for CAP is similar in patients with and without HIV.36,50 A clinical response typically is observed within 48 to 72 hours after initiation of appropriate antimicrobial therapy. A review of patients with CAP found that advanced HIV infection and CD4 count < 100 cells/mm3 were predictors for longer time to clinical stability and that patients who received ART tended to become clinically stable sooner and had better outcomes.89,92 The presence of bacteremia is a significant factor that impacts outcomes. Among those with pneumococcal pneumonia, longer time to clinical stability is more often seen in the setting of bacteremia. As in patients without HIV, radiographic improvement usually lags behind clinical improvement.

Immune reconstitution inflammatory syndrome has been rarely described in association with bacterial CAP and initiation of treatment with ART in patients with HIV. This could be secondary to a number of reasons:

• Patients with recurrent pneumonia have not been included in the study population
• IRIS among participants with bacterial pneumonia has not been specified, or
• This complication has truly not been observed.2,105

Only case reports describe IRIS with pneumonia due to Rhodococcus equii. More commonly IRIS occurs with pneumonia due to Pneumocystis and mycobacterial infections.

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Special Considerations During Pregnancy

The diagnosis of bacterial respiratory tract infections in pregnant women is the same as in those who are not pregnant, with appropriate shielding of the abdomen during radiographic procedures. Bacterial respiratory tract infections should be managed in pregnant women as in women who are not pregnant, with certain exceptions. Among macrolides, clarithromycin is not recommended because of an increased risk of birth defects seen in some animal studies. Two studies, each involving â¥100 women with first-trimester exposure to clarithromycin, did not document a clear increase in or specific pattern of birth defects, although an increased risk of spontaneous abortion was noted in one study.107,108 Azithromycin did not produce birth defects in animal studies, but experience with human use in the first trimester is limited. Azithromycin is recommended when a macrolide is indicated in pregnancy . Arthropathy has been noted in immature animals with in utero exposure to quinolones. Studies evaluating quinolone use in pregnant women did not find an increased risk of birth defects or musculoskeletal abnormalities.109,110 When indicated, quinolones can be used in pregnancy for serious respiratory infections only when a safer alternative is not available .111