CHEST
Volume 119, Issue 3, March 2001, Pages 844-851
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Clinical Investigations
Prognostic Markers of Short-term Mortality in AIDS-Associated Pneumocystis carinii Pneumonia

https://doi.org/10.1378/chest.119.3.844Get rights and content

Background:

Since 1990, corticosteroids have beenrecommended as adjunctive therapy for patients with AIDS-associatedPneumocystis carinii pneumonia (PCP) and respiratoryfailure. We hypothesized that the natural course of AIDS-associated PCPhas changed in the era of adjunctive corticosteroid therapy.

Objective:

To study variables obtained on hospitaladmission for possible prognostic value of short-term (3-month) outcomeof PCP.

Design and patients:

Prospective observationalstudy of 176 consecutive HIV-1–infected individuals with PCP between1990 and 1999.

Method:

Cox proportional-hazardsregression models.

Results:

Univariate analysis showedthat age, one or more prior episodes of PCP, use of antimicrobialtherapy other than trimethoprim-sulfamethoxazole (TMP-SMZ), use of PCPprophylaxis at diagnosis, and culture of cytomegalovirus (CMV) in BALpredicted progression to death with in 3 months. After adjustment, age(relative risk [RR], 4.1; 95% confidence interval [CI], 1.8 to9.3), initial antimicrobial therapy other than TMP-SMZ (RR, 3.1; 95%CI, 1.2 to 8.5), use of PCP prophylaxis (RR, 5.6; 95% CI, 2.2 to14.4), and culture of CMV in BAL fluid (RR, 2.7; 95% CI, 1.3 to 5.6)remained independent predictors of a poor outcome. In contrast, neitherPo2 nor serum lactate dehydrogenase, which inearlier studies were identified as prognostic markers, were predictorsof mortality.

Conclusion:

Age, initial anti-PCPtherapy, use of PCP prophylaxis, and BAL CMV status may be usefulpredictors of outcome of PCP in patients treated in the era of adjunctive corticosteroid therapy.

Section snippets

Patients

Between June 1, 1990, and January 31, 1999, all episodes of HIV-1-related PCP diagnosed at the Department of Infectious Diseasesat Hvidovre Hospital, Copenhagen, were included in the study. Clinicaland laboratory data were collected prospectively. Outcome was recordedfrom the medical files.

A diagnosis of PCP was established by bronchoscopy with BAL aspreviously described.25 BAL fluid was divided intoaliquots for microbiological and cytologic examination, including aGram's stain and cultures for

Patient Characteristics

During the study period, there were 189 episodes of confirmed PCPin 176 individuals. As shown in Table 1, the majority of patients were male (94%), had had sex with men(70%), and presented with PCP as a first diagnosis of AIDS (88%). Forty-five percent had HIV-1 diagnosed at the same time as theirdiagnosis of PCP. Sixteen patients had a previous diagnosis of PCP. Fewpatients were treated with antiretroviral therapy at the time of PCP(20%).

Laboratory Characteristics at Admission

Measures of Po2 and Pco2, on room air, were 65 mm

Discussion

In this study, we show that age, initial anti-PCP therapy, use of PCP prophylaxis, and BAL CMV status may be useful markers foridentification of patients with a severe prognosis. Surprisingly, classic markers such as Po2 and serumLDH did not have independent prognostic value.

The choice of initial antimicrobial therapy (IV pentamidine) wasassociated with a threefold increased risk of death. Trimetrexate orclindamycin/primaquine was associated with an increased RR of progression to death as well,

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    Supported by grants from the Danish Medical Research Council(Nos. 9400576 and 12–1451-1) and the Danish AIDS Foundation.

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