Predictors of short- and long-term survival in HIV-infected patients admitted to the ICU.

STUDY OBJECTIVES: To evaluate the prognosis of HIV-infected patients admitted to ICUs and to identify factors predictive of short- and long-term survival. DESIGN: A prospective study from January 1, 1990, to December 31, 1992, including all consecutive HIV-infected patients admitted to our ICU for the first time. ICU survivors were followed up until January 1, 1994. SETTING: An 18-bed infectious diseases ICU in a 1,300-bed university hospital in Paris. PATIENTS: Four hundred twenty-one HIV-related admissions were recorded during the study period (33.5% of 1,258 admissions to ICU); 354 HIV-infected patients were first ICU admissions and were analyzed. MEASUREMENTS AND RESULTS: Predictive factors on univariate and multivariate analyses (logistic regression and Cox model) for short- and long-term mortality were performed. Respiratory failure was the main cause of admission (49.2%), followed by neurologic disorders (26.8%), sepsis (10.2%), heart failure (4.5%), and miscellaneous disorders (9.3%). For these groups, in-ICU and in-hospital mortality rates were as follows: 16.7% and 33.9%; 23.2% and 41.1%; 38.9% and 58.3%; 25% and 68.8%; and 12.1% and 24.2%, respectively. In-ICU and in-hospital mortality rates were significantly different across the groups (p=0.026 and 0.002, respectively). Multivariate analysis showed that the in-hospital outcome was significantly associated with functional status (p=0.05), time since AIDS diagnosis (p=0.04), HIV disease stage (0.016), simplified acute physiology score (SAPS I) (p=0.06), need for mechanical ventilation (p<0.000001), and its duration (p=0.0001). In the 281 patients who were discharged alive from the ICU, cumulative survival rates were 51%+/-38% at 6 months, 28%+/-38% at 12 months, and 18%+/-30% at 24 months. Median and crude mean+/-SD survival times were 199 days and 316+/-343 days. Multivariate analysis showed that the long-term outcome was significantly associated with functional status (p=0.000001), weight loss (p=0.00001), the CD4 count (p=0.00001), the HIV disease stage (p=0.01), the duration of AIDS (p=0.001), the admission cause group (p=0.03), and the SAPS I at admission (p=0.00001). CONCLUSIONS: The short-term (in-ICU and in-hospital) outcome of HIV-infected patients was mainly related to the severity of the acute illness (SAPS I, cause of admission, need for and duration of mechanical ventilation), and to the preadmission health status, based on functional status and weight loss. Some of these parameters, in particular the SAPS I and preadmission health status, also influenced the long-term outcome. Whereas HIV-related variables had little impact on the in-ICU outcome, they were closely related with the in-hospital outcome and even more strikingly with the long-term outcome. Thus, the life expectancy of HIV-infected patients, which depends primarily on the natural history of the HIV infection, is the most powerful determinant of the long-term prognosis. Our results confirm that ICU support for HIV-infected patients should not be considered futile.

[Induced expectoration: its role in the diagnosis of pneumocystis carinii pneumonia]. / Expectorations induites: intérêt pour le diagnostic des pneumocystoses pulmonaires.

OBJECTIVES: The purpose of this retrospective study was to describe the changes and the effect of Pneumocystis carinii pneumonia (PCP) prophylaxis on induced sputum sensitivity during these five last years METHODS: An induced sputum examination was performed in 80 cases of PCP over a 5-year period. RESULTS: The induced sputum were positive in 30 cases (sensitivity = 37.5%). This sensitivity changed very little during these five years. Thirty of these 80 patients (37.5%) received PCP prophylaxis at least for four weeks before PCP diagnosis. Induced sputum sensitivity was 50% in the group with prophylaxis versus 30% in the group without prophylaxis (p = 0.073). CONCLUSION: In our institution, the induced sputum examination remains an interesting diagnostic procedure for PCP. PCP prophylaxis does not seem to have effects on induced sputum sensitivity.

A nosocomial outbreak of multidrug-resistant Mycobacterium bovis among HIV-infected patients. A case-control study.

OBJECTIVE: To identify risk factors in a nosocomial outbreak of multidrug-resistant Mycobacterium bovis (MDRMB) tuberculosis (TB) among HIV-infected patients. DESIGN: We evaluated the study period (from the first to the last MDRMB smear-positive patients hospitalized in the unit) using a case-control study with three control groups. Since MDRMB is extremely rare, we assumed that a single strain was responsible for all six cases. SETTING: A 19-bed infectious diseases unit in Paris, France. PATIENTS: The index case was an AIDS patient who was hospitalized in September 1989 because of MDRMB TB. The cases were five HIV-infected patients who developed MDRMB TB between January 1990 and October 1991. Controls were randomly selected from HIV-infected patients in our unit during the study period (case-control study 1, 15 patients), during the contact period (at least one MDRMB smear-positive patient hospitalized in the unit; case-control study 2,20 patients), and patients matched according to the length of contact (case-control study 3, 24 patients). INTERVENTIONS: After detecting the nosocomial outbreak, we took respiratory isolation precautions for all patients suspected of having active TB. MAIN OUTCOME MEASURES: Risk factors for MDRMB nosocomial transmission, and the occurrence of new cases of MDRMB infection in HIV-infected patients and health-care workers after the introduction of isolation precautions. RESULTS: The most important predictor of nosocomial transmission of MDRMB to HIV-infected patients was the (mean +/- s.d.) length of contact in days [cases, 22 +/- 15.8; study 1 controls, 11.2 +/- 18.9 (P = 0.07); study 2 controls, 14.6 +/- 8.5 (P = 0.043)]. Only one case of MDRMB TB resulted from exposure to MDRMB-smear-positive patient after the introduction of respiratory isolation measures. The incubation period in the single health-care worker who developed MDRMB TB was longer than in the cases. CONCLUSION: In a nosocomial outbreak of MDRMB TB, the contact time was the main risk factor of transmission to HIV-infected patients. Respiratory isolation measures appear to be effective.