Bacteremic Pneumococcal Pneumonia in HIV-Seropositive and HIV-Seronegative Adults

doi:10.1378/chest.116.1.107

Chest

Volume 116, Issue 1, July 1999, Pages 107-114

https://doi.org/10.1378/chest.116.1.107 Get rights and content

Study objectives

To compare the demographic, clinical, laboratory, and microbiological data, and the hospital course and outcome of HIV-seropositive and HIV-seronegative adults with bacteremic pneumococcal pneumonia.

Design

Retrospective observation study conducted over a 2-year period.

Setting

Academic teaching hospital attached to the University of the Witwatersrand, Johannesburg, South Africa.

Patients

Consecutive patients with bacteremic pneumococcal pneumonia were identified on the basis of positive blood culture results.

Interventions

All available demographic, clinical, routine laboratory, radiographic, and microbiological data were recorded retrospectively for each of the patients, and the combined data for the HIV-seropositive patients were compared with those of the HIV-seronegative patients.

Measurement and results

A total of 112 patients (31 HIV-seropositive and 81 HIV-seronegative patients) were entered into the study. The HIV-seropositive patients were significantly younger than the HIV-seronegative patients (32.8 vs 39.6 years old) and had lower admission hemoglobin (11.8 vs 13.4 g/dL), WBC count (10.3 vs 14.3 × 10⁹/L), serum albumin (31 vs 36 g/L), sodium (129 vs 132 mmol/L), and potassium (3.0 vs 3.5 mmol/L), respectively. Although the HIV-seropositive patients appeared to have more multilobar pulmonary consolidation on the chest radiograph than the HIV-seronegative patients (60% vs 34%), this did not quite reach statistical significance. In addition, the HIV-seropositive patients had significantly more infections (48.4% vs 20.8%) with pneumococcal serogroups/serotypes (serogroups 6, 19, 23, and serotype 14) that are found more commonly in children, and they also had more penicillin-resistant isolates (13% vs 2.5%) than the HIV-seronegative patients, respectively. Similarly, it was noted that when these data were analyzed according to gender (irrespective of HIV status), women had significantly more infections than men (47% vs 21%) with serogroups/serotypes that are usually found in children, more penicillin-resistant isolates (15% vs 1%), and more co-trimoxazole-resistant isolates (21% vs 5%), respectively. There were no differences noted in any of the other parameters, including initial APACHE (acute physiology and chronic health evaluation) II score, Pao₂/fraction of inspired oxygen ratio, duration of temperature, duration of IV therapy, duration of hospitalization, complications, and outcome, when comparing HIV-seropositive and HIV-seronegative patients. Two patients in each group died.

Conclusions

The clinical features of bacteremic pneumococcal pneumonia are similar in HIV-seropositive and HIV-seronegative patients. Although differences are noted in various laboratory and microbiological parameters, they do not appear to have an impact on outcome.

Section snippets

Materials and Methods

In this study, consecutive adult patients with bacteremic pneumococcal pneumonia admitted over a 2-year period to the Hillbrow Hospital in Johannesburg were recruited prospectively. Permission to conduct the study was obtained from the Committee for Research on Human Subjects of the University of the Witwatersrand, with the requirement of verbal informed consent from each patient. All patients received pretest and posttest counseling for HIV infection as was appropriate. The patients who were

Results

A total of 112 patients were enrolled in the study: 81 were HIV seronegative and 31 were HIV seropositive. None of the patients in this study had received prior immunization with the pneumococcal vaccine, and none were known to be HIV seropositive prior to this episode of pneumococcal bacteremia. Eleven HIV-seronegative patients and 1 HIV-seropositive patient had underlying disorders other than HIV infection that may have predisposed them to pneumococcal bacteremia. In the HIV-seronegative

Discussion

In this comparative study of HIV-seronegative and HIV-seropositive patients with bacteremic pneumococcal pneumonia, we noted few differences in the clinical presentation of the patients. A number of significant differences were noted in routine laboratory data, as well as in the microbiological parameters. With regard to the microbiology, more infections were noted with serogroups/serotypes that are more commonly noted in children (serogroups 6, 19, 23, and serotype 14), and significantly more

Conclusion

In conclusion, we have noted that bacteremic pneumococcal pneumonia remains an important disease among both HIV-seronegative and HIV-seropositive patients. While the clinical picture in these two groups of patients is very similar, a number of significant differences are noted in the routine laboratory and microbiological data. These differences do not seem to impact on the outcome of the cases, which is very similar, and even infections with organisms of intermediate susceptibility to

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Cette étude rétrospective chez des patients infectés par le VIH a comparé 94 cas de tuberculose pulmonaire à microscopie positive à 78 cas de pneumopathies aiguës communautaires bactériennes.
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Ce score diagnostique pourrait améliorer la prise en charge des pneumopathies aiguës communautaires bactériennes en zone d’endémie tuberculeuse.
Immunodepression induced by the human immunodeficiency virus (HIV) modifies the clinical, radiological and microbiological manifestations of pulmonary tuberculosis; leading to similarities between pulmonary tuberculosis and acute community-acquired bacterial pneumonia. A consequence is the high proportion of discordant pre- and post-mortem diagnoses of pneumonia. The aim of our study was to contribute to the improvement in the diagnosis of acute bacterial pneumonia in HIV positive patients in areas where tuberculosis is endemic.
This retrospective study in HIV positive patients has compared 94 cases of positive smear cases pulmonary tuberculosis and 78 cases of acute community-acquired bacterial pneumonia.
Using logistic regression, the following features were positively associated with bacterial pneumonia: the sudden onset of signs (OR = 8.48 [CI 95% 2.50–28.74]), a delay in the evolution of symptoms of less than 15 days (OR = 3.70 [CI 95% 1.11–12.35]), chest pain (OR = 2.81 [CI 95% 1.10–7.18]), radiological alveolar shadowing (OR = 12.98 [CI 95% 4.66–36.12) and high leukocytosis (OR = 3.52 [CI 95% 1.19–10.44]). These five variables allowed us to establish a diagnostic score for bacterial pneumonia ranging from 0 to 5. The area under the ROC curve was 0.886 [CI 95% 0.84–0.94, P < 0.001]). Its specificity was > 96.8% for a score of greater than or equal to 4.
The diagnostic score for acute community-acquired pneumonia may improve the management of bacterial pneumonia in areas where tuberculosis is endemic.
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Citation Excerpt :
One area that has been particularly controversial, both in all-cause CAP and specifically in pneumococcal pneumonia, is whether the outcome is worse in HIV-infected versus HIV-uninfected persons.1 Some studies have suggested that the outcome is no different,1,77–79 whereas more recent studies in both all-cause CAP and pneumococcal pneumonia have suggested that the mortality rate for CAP is higher in HIV-infected patients.1,35,68 In one of these studies, which was in patients with bacteremic pneumococcal pneumonia, when cases were stratified according to age and severity of illness, HIV-infected patients had a higher mortality rate with a significant trend for increasing mortality in those with lower CD4 cell counts.35,68
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Les pneumonies communautaires (PC) sont la deuxième cause d’hospitalisation dans les services de pneumologie à Abidjan, après la tuberculose. Fréquemment associées à l’infection par le VIH, elles présentent une mortalité élevée de l’ordre de 20 à 30 %. L’objectif de cette étude est d’identifier les spécificités et les facteurs de gravité associés au devenir des PC bactérienne (PCB) chez les sujets VIH positifs.
Nous avons réalisé une étude préliminaire prospective et comparative entre deux groupes de patients : 29 patients présentant une PCB infectés par le VIH, 21 patients présentant une PCB non infectés par le VIH, tous hospitalisés pour une PCB grave selon les scores habituels de sévérité.
Les caractéristiques sociodémographiques, cliniques, paracliniques étaient superposables dans les deux groupes. Les échecs et les décès étaient plus fréquents en cas d’infection par le VIH. Ce sont surtout les patients infectés par le VIH avec un indice de masse corporelle inférieur à 18,5 et un taux de lymphocyte T CD4 inférieur à 200 par millimètre cube, qui présentaient le plus d’évolution défavorable.
Une étude plus importante devrait permettre de définir des critères propres de sévérité des PCB associés à l’infection par le VIH.
Community-acquired pneumonia (CAP) is the second leading cause of hospitalization in the respirology department in Abidjan after tuberculosis. Frequently associated with HIV infection, it has a high mortality rate of about 20% to 30%. The aim of this study is to identify the specificities and severity factors associated with bacterial CAP (BCAP) outcome in HIV-positive patients.
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Chest

Clinical InvestigationsPneumoniaBacteremic Pneumococcal Pneumonia in HIV-Seropositive and HIV-Seronegative Adults

Study objectives

Design

Setting

Patients

Interventions

Measurement and results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Chest

Chest

Chest

Chest

Lancet

Int J Infect Dis

Chest

Chest

Streptococcus pneumoniae

Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP)

MMWR (Morb Mortal Wkly Rep)

Pneumococcal disease during HIV infection

Ann Intern Med

Bacterial pneumonia in persons infected with the human immunodeficiency virus

N Engl J Med

Fourth national HIV survey of women attending antenatal clinics, South Africa, October/November, 1993

Epidemiol Comments

Fifth national HIV survey in women attending antenatal clinics of the public health services in South Africa, October/November 1994

Epidemiol Comments

Clinical Investigations
Pneumonia
Bacteremic Pneumococcal Pneumonia in HIV-Seropositive and HIV-Seronegative Adults