Global Trends in Extracorporeal Membranous Oxygenation Use and Survival of Patients With Influenza-Associated Illness.

OBJECTIVES: To determine the overall use of extracorporeal membranous oxygenation for influenza-associated illness and describe risk factors associated with mortality in these patients. DESIGN: Retrospective multicenter cohort analysis. SETTING: The international Extracorporeal Life Support Organization database was queried for patients with influenza-associated illness on extracorporeal membranous oxygenation from 1992 to 2014. PATIENTS: In total, 1,654 patients with influenza-associated illness on extracorporeal membranous oxygenation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical data collected included age, type of support, duration of support, type of microbial codetection, complications, and survival status at discharge. The primary outcome of interest was survival to hospital discharge. From 1992 to 2014, 1,688 (3%) of the 61,336 extracorporeal membranous oxygenation runs were due to influenza-associated illness reflecting 1,654 unique patients: 30 (2%) were neonates, 521 (31%) were pediatric patients, and 1,103 (67%) were adults. Extracorporeal membranous oxygenation use for influenza-associated illness increased from 1992 to 2014, with a marked increase in use after the 2009 H1N1 pandemic. Survival to hospital discharge of patients with influenza-associated illness on extracorporeal membranous oxygenation was 63% and was not affected by bacterial codetection. However, when patients with Staphylococcus aureus codetection were compared with those with another bacterial codetection, their survival to hospital discharge was significantly lower (52% vs 67%; p < 0.01). In a logistic regression model, the effect of S. aureus on in-hospital mortality varied by age group, with younger patients with S. aureus having increased in-hospital mortality. CONCLUSIONS: Extracorporeal membranous oxygenation use for individuals with influenza increased over time, particularly after the 2009 H1N1 pandemic, most notably among older adults. Survival to hospital discharge for patients with influenza on extracorporeal membranous oxygenation was slightly higher than survival to hospital discharge for respiratory illness due to any cause. Bacterial codetection was common among patients with influenza on extracorporeal membranous oxygenation and was associated with increased days on extracorporeal membranous oxygenation but not increased mortality. Only S. aureus codetection in children was associated with increased in-hospital mortality.

Association of ongoing drug and alcohol use with non-adherence to antiretroviral therapy and higher risk of AIDS and death: results from ACTG 362.

Drug and alcohol use have been associated with a worse prognosis in short-term and cross-sectional analyses of HIV-infected populations, but longitudinal effects on adherence to antiretroviral therapy (ART) and clinical outcomes in advanced AIDS are less well characterized. We assessed self-reported drug and alcohol use in AIDS patients, and examined their association with non-adherence and death or disease progression in a multicenter observational study. We defined non-adherence as reporting missed ART doses in the 48 hours before study visits. The association between drug use and ART non-adherence was evaluated using repeated measures generalized estimating equation (GEE) models. The association between drug and alcohol use and time to new AIDS diagnosis or death was evaluated via Cox regression models, controlling for covariates including ART adherence. Of 643 participants enrolled between 1997 and 1999 and followed through 2007, at entry 39% reported ever using cocaine, 24% amphetamines, and 10% heroin. Ongoing drug use during study follow-up was reported by 9% using cocaine, 4% amphetamines, and 1% heroin. Hard drug (cocaine, amphetamines, or heroin) users had 2.1 times higher odds (p=0.001) of ART non-adherence in GEE models and 2.5 times higher risk (p=0.04) of AIDS progression or death in Cox models. Use of hard drugs was attenuated as a risk factor for AIDS progression or death after controlling for non-adherence during follow-up (HR = 2.11, p=0.08), but was still suggestive of a possible adherence-independent mechanism of harm. This study highlights the need to continuously screen and treat patients for drug use as a part of ongoing HIV care.