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Open Access Highly Accessed Research

Critical care management and outcome of severe Pneumocystis pneumonia in patients with and without HIV infection

Xavier Monnet12*, Emmanuelle Vidal-Petiot12, David Osman12, Olfa Hamzaoui12, Antoine Durrbach3, Cécile Goujard45, Corinne Miceli56, Patrice Bourée27 and Christian Richard12

Author Affiliations

1 AP-HP, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France

2 Univ Paris-Sud, Faculté de médecine Paris-Sud, EA 4046, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France

3 AP-HP, Hôpital de Bicêtre, service de néphrologie, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France

4 AP-HP, Hôpital de Bicêtre, service de médecine interne, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France

5 Univ Paris-Sud, INSERM, UMR_S 802, 78, rue du Général Leclerc, Le Kremlin Bicêtre, F-94270, France

6 AP-HP, Hôpital de Bicêtre, service de rhumatologie, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France

7 AP-HP, Hôpital de Bicêtre, unité des maladies parasitaires, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France

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Critical Care 2008, 12:R28  doi:10.1186/cc6806

Published: 25 January 2008

Abstract

Background

Little is known about the most severe forms of Pneumocystis jiroveci pneumonia (PCP) in HIV-negative as compared with HIV-positive patients. Improved knowledge about the differential characteristics and management modalities could guide treatment based on HIV status.

Methods

We retrospectively compared 72 patients (73 cases, 46 HIV-positive) admitted for PCP from 1993 to 2006 in the intensive care unit (ICU) of a university hospital.

Results

The yearly incidence of ICU admissions for PCP in HIV-negative patients increased from 1993 (0%) to 2006 (6.5%). At admission, all but one non-HIV patient were receiving corticosteroids. Twenty-three (85%) HIV-negative patients were receiving an additional immunosuppressive treatment. At admission, HIV-negative patients were significantly older than HIV-positive patients (64 [18 to 82] versus 37 [28 to 56] years old) and had a significantly higher Simplified Acute Physiology Score (SAPS) II (38 [13 to 90] versus 27 [11 to 112]) but had a similar PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio (160 [61 to 322] versus 183 [38 to 380] mm Hg). Ventilatory support was required in a similar proportion of HIV-negative and HIV-positive cases (78% versus 61%), with a similar proportion of first-line non-invasive ventilation (NIV) (67% versus 54%). NIV failed in 71% of HIV-negative and in 13% of HIV-positive patients (p < 0.01). Mortality was significantly higher in HIV-negative than HIV-positive cases (48% versus 17%). The HIV-negative status (odds ratio 3.73, 95% confidence interval 1.10 to 12.60) and SAPS II (odds ratio 1.07, 95% confidence interval 1.02 to 1.12) were independently associated with mortality at multivariate analysis.

Conclusion

The yearly incidence of ICU admissions for PCP in HIV-negative patients in our unit increased from 1993 to 2006. The course of the disease and the outcome were worse in HIV-negative patients. NIV often failed in HIV-negative cases, suggesting that NIV must be watched closely in this population.