Chronic lung disease and a history of tuberculosis (post-tuberculosis lung disease): Clinical features and in-hospital outcomes in a resource-limited setting with a high HIV burden

Background. Many patients with previous pulmonary tuberculosis (PTB) continue to experience respiratory symptoms long after completion of tuberculosis (TB) therapy, often resulting in numerous hospital visits and admissions.Objectives. To describe the profile of patients with chronic lung disease (CLD) with or without a history of PTB, and their in-hospital outcomes. Methods. We conducted a retrospective review of patients with CLD admitted with respiratory symptoms to Dora Nginza Hospital, Port Elizabeth, South Africa, from 1 April 2016 to 31 October 2016. These patients were divided into two groups: CLD with a history of PTB (CLD-TB) and CLD without a history of PTB. Patients with current culture-positive TB were excluded. Baseline characteristics and clinical outcomes (duration of hospitalisation and in-hospital mortality) were compared between the two groups.Results. During the study period, a total of 4 884 patients were admitted and 242 patients received a diagnosis of CLD. In the CLD patient group, 173 had CLD-TB and 69 had no history of PTB. Patients with CLD-TB presented with respiratory symptoms a median of 41 months (interquartile range (IQR) 101) after completion of TB therapy. CLD-TB patients were predominantly male (59.5%), and compared with patients with no history of PTB were more likely to be HIV-positive (49.7% v. 8.7%; p=0.001) and had had more frequent hospital admissions before the current admission (median 2.0 (IQR 2.0) v. 0; p=0.001) and longer hospital stays (median 5 days (IQR 7) v. 2 (4); p=0.002). However, there was no statistically significant difference in in-hospital mortality between the two groups (17.3% v. 10.1%; p=0.165).Conclusions. In patients with CLD, a history of PTB is associated with numerous hospital admissions and longer hospital stays but not with increased in-hospital mortality. TB therefore continues to be a public health burden long after cure of active disease

HIV-positive patients in the intensive care unit: A retrospective audit

Background. The indications for and outcomes of intensive care unit (ICU) admission of HIV-positive patients in resource-poor settings such as sub-Saharan Africa are unknown.Objective. To identify indications for ICU admission and determine factors associated with high ICU and hospital mortality in HIV-positive patients.Methods. We reviewed case records of HIV-positive patients admitted to the medical and surgical ICUs at Groote Schuur Hospital, Cape Town, South Africa, from 1 January 2012 to 31 December 2012.Results. Seventy-seven HIV-positive patients were admitted to an ICU, of whom two were aged <18 years and were excluded from the final analysis. HIV infection was newly diagnosed in 37.3% of the patients admitted during the study period. HIV-positive patients had a median CD4 count of 232.5 (interquartile range 59 - 459) cells/µL. Respiratory illness, mainly community-acquired pneumonia, accounted for 30.7% of ICU admissions. ICU and hospital mortality rates were 25.3% and 34.7%, respectively. Predictors of ICU mortality included an Acute Physiology and Chronic Health Evaluation ΙΙ (APACHE II) score >13 (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.1 - 1.7; p=0.015), receipt of renal replacement therapy (RRT) (OR 2.2, 95% CI 1.2 - 4.1; p=0.018) and receipt of inotropes (OR 2.3, 95% CI 1.6 - 3.4; p<0.001). Predictors of hospital mortality were severe sepsis on admission (OR 2.8, 95% CI 0.9 - 9.1; p=0.07), receipt of RRT (OR 1.9, 95% CI 1.0 - 3.6; p=0.056) and receipt of inotropic support (OR 2.0, 95% CI 1.4 - 3.2; p<0.001). Use of highly active antiretroviral therapy (HAART), CD4 count, detectable HIV viral load and diagnosis at ICU admission did not predict ICU or hospital mortality.Conclusions. Respiratory illnesses remain the main indication for ICU in HIV-positive patients. HIV infection is often diagnosed late, with patients presenting with life-threatening illnesses. Severity of illness as indicated by a high APACHE ΙΙ score, multiple organ dysfunction requiring inotropic support and RRT, rather than receipt of HAART, CD4 count and diagnosis at ICU admission, are predictors of ICU and hospital mortality