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
Management In Patients With Pulmonary Infections Receiving Art
When the infection occurs within 12 weeks of starting ART, many cases can represent unmasking IRISs treatment of the infection should be started and ART should be continued . When the infection occurs > 12 weeks after initiation of ART, despite complete virological suppression, therapy for the infection should be initiated and ART should be continued if the CD4 responses has been suboptimal, modification of the ART regimen could be considered . When the infection occurs in the setting of virological failure, infection therapy should be started and the ART regimen should be modified to achieve better virological control .
Determination Of The Antibiotic Sensitivity Pattern Of Streptococcus Pneumoniae Isolates
The antibiotic sensitivity pattern of the Streptococcus pneumoniae isolates was determined using the modified Kirby-Bauer disc diffusion technique as described by Bauer, et al. and Cheesbrough . With the aid of Standard Interpretative Chart, the zones sizes of each antibiotic was interpreted and the isolate reported as either ‘Resistant’ or ‘Susceptible’.
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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.
Assessing Severity Of Disease And Treatment Location
Therefore, in general, validated clinical prediction scores for prognosis can be used in patients with HIV in conjunction with clinical judgement to guide treatment location for CAP. Low risk patients for whom there are no other concerns regarding adherence or complicating factors can be treated as outpatients. Patients with severe CAP, including those presenting with shock or respiratory failure, usually require a higher level of care, typically ICU admission. Additionally, severe CAP criteria can include PSI risk class of III or IV or CURB-65 scores â¥3. Patients with â¥3 of the ATS/IDSA minor severity criteria for CAP57 often require ICU or higher level of care as well.
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Whatever Happened To Pcp
One of the things that happened to PCP is that it changed its name and should now properly be called PJP. Pneumocystis pneumonia is caused by the fungus Pneumocystis jirovecii, with the carinii species now only infecting other animals. This ubiquitous fungus is probably transmitted through airborne routes early in life two-thirds of healthy children have antibody to P. jirovecii by the age of four. Colonisation of the respiratory tract of healthy people generally causes no ill effects. Infections appear with severe suppression of the immune system about 90% of cases occur in people with CD4 counts below 200 cells/mm3.
PCP is seared into the collective memory of the HIV community in the resource-rich world because it was such a common and fatal condition early in the epidemic. According to the US Centers for Disease Control and Prevention, PCP occurred in 70 to 80% of people with AIDS, and even with treatment, the disease led to death in 20 to 40% of cases.25 Rates of PCP dropped to about 2 to 3 cases per 100 people a year among people with AIDS in Western Europe and the US with the use of effective treatments, prophylaxis and with the advent of effective HIV treatment.
Special Consideration With Regards To Starting Art
If not already started, ART should be initiated in patients, when possible, within 2 weeks of diagnosis of PCP . In a randomized controlled trial of 282 patients with opportunistic infections other than TB, 63% of whom had definite or presumptive PCP, the incidence of AIDS progression or death was significantly lower among participants who initiated ART early than among those who delayed ART .100 Of note, none of the participants with PCP enrolled in the study had respiratory failure requiring intubation 100 initiating ART in such patients is problematic given the lack of parenteral preparations and unpredictble absorption of oral medications, as well as potential drug interactions with agents commonly used in the ICU.101
Paradoxical immune reconstitution inflammatory syndrome following an episode of PCP is rare but has been reported.102,103 Most cases occurred within weeks of the episode of PCP symptoms included fever and recurrence or exacerbation of pulmonary symptoms including cough and shortness of breath, as well as worsening of a previously improving chest radiograph. Although IRIS in the setting of PCP has only rarely been life-threatening,104 patients should be closely followed for recurrence of symptoms after initiation of ART. Management of PCP-associated IRIS is not well defined some experts recommend use of corticosteroids in patients with respiratory deterioration if other causes are ruled out.
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Pneumonia Can Be Caused By Bacterial Viral Or Fungal Infections
Pneumonia is a type of lung infection that causes the air sacs in the lungs to fill with liquid.
There are different types of pneumonia. In most cases, pneumonia is caused by a bacterial or viral infection. In rarer cases, pneumonia can be caused by inhaling fluid into the lungs, or from a fungal infection.
However, healthcare providers arent always able to identify a cause for pneumonia: one study found that in up to 62% of pneumonia cases no pathogen like a virus, bacteria, or fungus is identified.
When people discuss types of pneumonia, they also consider how severe the infection is. For example, walking pneumonia is a nonmedical term thats used to refer to a mild case of pneumonia, where the patient can still be up and walking around. People also distinguish pneumonia cases by where they were picked up: for example, hospital-acquired pneumonia or community-acquired pneumonia.
Epidemiology Of Pulmonary Infections In Hiv
Few studies have systematically described the full spectrum of HIV-associated pulmonary infections . Most investigators have focused on pneumonias of specific aetiologies. Therefore, there is no consensus on any diagnostic algorithm of pulmonary infections in HIV patients. The diagnostic decision should be different depending on the epidemiological features in a specific geographical area . Thus, the incidence of TB in HIV patients varies considerably in different geographical areas, depending on the prevalence of disease in the general population. In Africa, TB could be the most common pulmonary complication of HIV, followed by community-acquired pneumonia . However, PCP is uncommon in Africa, although the incidence seems to be increasing . It remains speculative whether this trend denotes a true increase in the prevalence of PCP or whether the early reports underestimated the actual prevalence . In Western Europe in the 1990s, PCP was the commonest AIDS-defining illness, whereas pulmonary TB was more common in Eastern Europe. Within Western Europe, TB remains more common in the south than in the north . Endemic fungi are common in HIV patients who live in endemic areas, but are exceptional in patients that have never resided in or travelled to endemic regions .
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Which Individuals Are Of Greater Risk Of Developing Pneumonia
The risk of developing pneumonia from various organisms will vary with the CD4 count and with the use of appropriate prophylactic therapy and antiretroviral therapy . Bacterial pneumonia may develop at any CD4 count, though the risk is lower when the patient is on combination ART and increases with degree of immune suppression. Similarly, as the CD4 cell count declines, the incidence of TB increases, but TB can present at any CD4 count. The diseases that are associated with various CD4 counts are summarized in Table II.
|Pneumocystis jirovecii pneumonia Cryptococcal pneumoniaExtrapulmonary tuberculosisBlastomycosis|
|< 50100||Toxoplasmosis Histoplasmosis, coccidiomycosis, penicillosisCytomegalovirusMycobacterium avium, Mycobacterium kansasiiInvasive aspergillosisRhodococcus equi|
CD, cluster of differentiation SMX, sulfamethoxazole TMP, trimethoprim.
A general principle is that prior infection with any opportunistic infection is associated with increased risk of recurrence.
Injection drug use and cigarette smoking increase the risk of bacterial pneumonia.
Emerging data suggest that risk of methicillin-resistant S. aureus colonization is increased in HIV-positive individuals, particularly intravenous drug users, men who have sex with men, and those with low CD4 cell counts. MRSA may be a pathogen in pneumonia.
Chronic corticosteroid use increases the risk of PCP.
Exposure to domestic cats or eating undercooked meats increases risk for toxoplasmosis.
Baseline Sociodemographic Characteristics Of The Child And Parents Or Childs Caregiver Information
In this study, among HIV-infected children on ART from January 1, 2013 to December 30, 2020, a total of 356 medical records of children were retrieved. Of these, 14 charts were excluded due to the exclusion criteria and the remaining 342 charts of the children were included in this study. Among those children, slightly more than half of the children were male. Majority of the children were in the age group of 5 to 9 years. The median age of the participants at the ART initiation was 8 years . The highest proportion of pneumonia was seen among the 10 to 14 year age group and among children living in urban areas .
Table 1 Baseline Sociodemographic Characteristics of HIV-Infected Children at Public Health Institutions in Bahir Dar City, Northwest Ethiopia from January 1, 2013 to December 30, 2020
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When To Stop Secondary Prophylaxis
Secondary prophylaxis should be discontinued in adult and adolescent patients whose CD4 counts have increased from < 200 cells/mm3 to > 200 cells/mm3 for > 3 months as a result of ART . Reports from observational studies57,63,111,112 and from two randomized trials64,113 and a combined analysis of European cohorts being followed prospectively66,114 support this recommendation. In these studies, patients responded to ART with an increase in CD4 counts to â¥200 cells/mm3 for > 3 months. At the time secondary PCP prophylaxis was discontinued, the median CD4 count was > 300 cells/mm3 and most patients had a CD4 cell percentage > 14%. Most patients had sustained suppression of plasma HIV RNA levels below the limits of detection for the assay employed the longest follow-up was 40 months. Based on results from the COHERE study, secondary prophylaxis in patients with CD4 counts of 100 cells/mm3 to 200 cells/mm3 can potentially be discontinued if HIV plasma RNA levels remain below limits of detection for â¥3 months to 6 months .66
Are You Sure Your Patient With Human Immunodeficiency Virus Has Pneumonia What Should You Expect To Find
Patients with pneumonia typically present with a number of cardinal symptoms and signs, which are listed below. The presentation may vary depending on the degree of immunosuppression or the organism causing the pneumonia some organisms may even present with a normal physical exam.
CoughCough is one of the most common indicators of pneumonia and may be productive or nonproductive, depending on the organism.
DyspneaDyspnea is frequently present in pneumonia, ranging from mild exertional shortness of breath to severe dyspnea at rest. The onset is typically progressive and may be subacute and insidious in the case of fungal pneumonia or Pneumocystis pneumonia . Acute onset of severe dyspnea should raise concern for another process, such as myocardial infarction, pulmonary embolus, or cardiogenic edema.
Chest painPleuritic chest pain may accompany pneumonia, particularly in the case of a necrotizing process or an associated pleural effusion or empyema. Musculoskeletal chest pain may develop in the setting of relentless cough. Severe chest pain in the absence of radiographic abnormalities should raise concern for pulmonary embolus or cardiac process.
FeverFever typically accompanies pneumonia, but may not be present in a patient with severe immunosuppression.
HypoxemiaOxygen saturation may be assessed rapidly with pulse oximetry decreased saturations correlate with more severe disease.
Typical presentations of respiratory pathogens
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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.
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.
Hiv And The Respiratory System
Lung is a major target organ for HIV infection that has been shown to be present in T and B lymphocytes, pulmonary fibroblasts, macrophages, Natural Killer cells, eosinophils, monocytes and dendritic cells. As a consequence, progressive quantitative and functional depression within the CD4 lymphocytes and other immunological subsets occur and render the patient more prone to a wide array of infectious and non-infectious complications.
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Monitoring Of Response To Pneumocystis Pneumonia Therapy And Adverse Events
Careful monitoring during PCP therapy is important to evaluate response to treatment and to detect toxicity as soon as possible. Follow-up after therapy includes assessment for early relapse, especially if therapy has been with an agent other than TMP-SMX or was shortened because of toxicity.
In patients with HIV, rates of adverse reaction to TMP-SMX are high .70,71,83,85,89,105-109 Common adverse effects are rash , fever , leukopenia , thrombocytopenia , azotemia , hepatitis , and hyperkalemia. Supportive care for common adverse effects should be attempted before TMP-SMX is discontinued . Rashes often can be âtreated throughâ with antihistamines, nausea can be controlled with antiemetics, and fever can be managed with antipyretics.
The most common adverse effects of alternative therapies include methemoglobinemia and hemolysis with dapsone or primaquine rash and fever with dapsone 71,83 azotemia, pancreatitis, hypoglycemia or hyperglycemia, leukopenia, electrolyte abnormalities, and cardiac dysrhythmia with pentamidine 87-89,108 anemia, rash, fever, and diarrhea with primaquine and clindamycin 71,84,85 and headache, nausea, diarrhea, rash, and transaminase elevations with atovaquone.70,107
Incidence Of Pneumonia During Follow
The study participants were followed for a minimum of 0.96 months and a maximum of 86.3 months. The total person month of the cohort was 15,300.067 child-months of observation and the total person year of the cohort was also 1256.679 child-years of observation. From 342 study participants, 70 developed pneumonia and the remaining 272 were censored observation. Of these, 60 pneumonia cases were bacterial pneumonia and the remaining were pneumocystis pneumonia.
From all participants followed, about 59.9%, 3.8% and 14.6% were alive beyond the study period, deceased and transferred out, respectively . This study found that the incidence of pneumonia among HIV-infected children was 5.57 per 100 child-years of observation. As this study indicated, the incidence of pneumonia among HIV-infected children within the first year was 8.5 per 100 child-years of observation.
Figure 1 Outcome status of HIV-infected children at public health institutions in Bahir Dar city, Northwest Ethiopia from January 1, 2013 to December 30, 2020 .
The overall pneumonia-free probability among HIV-infected children remained 68% and survival was above the median .
Figure 2 Overall KaplanMeier curve of pneumonia-free survival probability of HIV-infected children at public health institutions in Bahir Dar city, from January 1, 2013 to December 30, 2020 .
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