Journal of Infection (2014) xx, 1e8
www.elsevierhealth.com/journals/jinf
Prognostic factors of Pneumocystis jirovecii pneumonia in patients without HIV infection Soo Jung Kim a,b,c, Jinwoo Lee a,b, Young-Jae Cho a,c, Young Sik Park a,b, Chang-Hoon Lee a,b, Ho Il Yoon a,c, Sang-Min Lee a,b, Jae-Joon Yim a,b, Jae Ho Lee a,c, Chul-Gyu Yoo a,b, Choon-Taek Lee a,c, Young Whan Kim a,b, Sung Koo Han a,b, Hong Bin Kim a,d, Jong Sun Park a,c,* a
Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea b Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea c Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea d Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea Accepted 23 February 2014 Available online - - -
KEYWORDS Pneumocystis jirovecii pneumonia; Immunocompromised patients; Prognostic factor
Summary Objectives: The incidence of Pneumocystis jirovecii pneumonia (PCP) in patients without HIV infection (non-HIV PCP) has been increasing along with the increased use of chemotherapeutic agents and immunosuppressants, but the prognostic factors of non-HIV PCP remain unclear. This study aimed to identify the prognostic factors of non-HIV PCP. Methods: Immunocompromised patients without HIV infection who were diagnosed and treated for PCP were included. The PCP diagnosis was based on positive direct fluorescent antibody (DFA) or polymerase chain reaction (PCR) results and compatible clinical symptoms and radiological findings. Results: In total, 372 non-HIV patients with positive PCP DFA or PCR findings were screened and 173 were included. Univariate analysis indicated that age, smoking, chronic lung disease or hematologic malignancy, chemotherapeutic agents, high alveolarearterial oxygen gradient (D [Aea]O2), C-reactive protein, albumin, blood urea nitrogen (BUN), CMV antigenemia, combined bacteremia, high percentage of neutrophils and rate of co-infection in BAL fluid, and
* Corresponding author. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Republic of Korea. Tel.: þ82 31 787 7054; fax: þ82 31 787 4052. E-mail address: [email protected] (J.S. Park). 0163-4453/$36 ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jinf.2014.02.015 Please cite this article in press as: Kim SJ, et al., Prognostic factors of Pneumocystis jirovecii pneumonia in patients without HIV infection, J Infect (2014), http://dx.doi.org/10.1016/j.jinf.2014.02.015
2
S.J. Kim et al. mechanical ventilator care were related to the prognosis of non-HIV PCP. Multivariate analysis revealed that high D(Aea)O2, combined bacteremia, increased BUN and preexisting lung disease were indicators of a poor prognosis. Conclusions: High D(Aea)O2, combined bacteremia, increased BUN and preexisting lung disease were independent factors of poor prognosis in non-HIV PCP patients. ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
Introduction Pneumocystis jirovecii pneumonia (PCP), a pulmonary infection caused by P. jirovecii, remains one of the most prevalent opportunistic infection in immunosuppressed patients. Effective prophylaxis of PCP and the availability of highly active antiretroviral therapy have reduced the morbidity and mortality of PCP in patients with HIV infection (HIV PCP). However, the risk and incidence of PCP in patients without HIV infection (non-HIV PCP) has increased as the number of patients receiving chemotherapy or immunosuppressive agents has been growing rapidly.1 Previous studies reported that non-HIV PCP has a more acute and severe course than HIV PCP. Non-HIV PCP presents as an acute fulminant pneumonia with abrupt onset of respiratory failure, whereas HIV patients experience a more insidious course.2 HIV-negative status has also been shown to be independently associated with mortality in ICU-admitted PCP patients.3 In addition, the PCP mortality rate is higher in patients without AIDS than in those with AIDS. Previous studies have reported a PCP mortality rate of 35e55% in patients without AIDS compared to 10e20% among those with AIDS.4 Prognostic factors for HIV PCP have been well-established. In HIV PCP, frequently reported markers of poor prognosis either at the time of diagnosis or during treatment are age, low serum albumin and bilirubin, high LDH levels, hypoxemia
www.elsevierhealth.com/journals/jinf
Prognostic factors of Pneumocystis jirovecii pneumonia in patients without HIV infection Soo Jung Kim a,b,c, Jinwoo Lee a,b, Young-Jae Cho a,c, Young Sik Park a,b, Chang-Hoon Lee a,b, Ho Il Yoon a,c, Sang-Min Lee a,b, Jae-Joon Yim a,b, Jae Ho Lee a,c, Chul-Gyu Yoo a,b, Choon-Taek Lee a,c, Young Whan Kim a,b, Sung Koo Han a,b, Hong Bin Kim a,d, Jong Sun Park a,c,* a
Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea b Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea c Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea d Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea Accepted 23 February 2014 Available online - - -
KEYWORDS Pneumocystis jirovecii pneumonia; Immunocompromised patients; Prognostic factor
Summary Objectives: The incidence of Pneumocystis jirovecii pneumonia (PCP) in patients without HIV infection (non-HIV PCP) has been increasing along with the increased use of chemotherapeutic agents and immunosuppressants, but the prognostic factors of non-HIV PCP remain unclear. This study aimed to identify the prognostic factors of non-HIV PCP. Methods: Immunocompromised patients without HIV infection who were diagnosed and treated for PCP were included. The PCP diagnosis was based on positive direct fluorescent antibody (DFA) or polymerase chain reaction (PCR) results and compatible clinical symptoms and radiological findings. Results: In total, 372 non-HIV patients with positive PCP DFA or PCR findings were screened and 173 were included. Univariate analysis indicated that age, smoking, chronic lung disease or hematologic malignancy, chemotherapeutic agents, high alveolarearterial oxygen gradient (D [Aea]O2), C-reactive protein, albumin, blood urea nitrogen (BUN), CMV antigenemia, combined bacteremia, high percentage of neutrophils and rate of co-infection in BAL fluid, and
* Corresponding author. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Republic of Korea. Tel.: þ82 31 787 7054; fax: þ82 31 787 4052. E-mail address: [email protected] (J.S. Park). 0163-4453/$36 ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jinf.2014.02.015 Please cite this article in press as: Kim SJ, et al., Prognostic factors of Pneumocystis jirovecii pneumonia in patients without HIV infection, J Infect (2014), http://dx.doi.org/10.1016/j.jinf.2014.02.015
2
S.J. Kim et al. mechanical ventilator care were related to the prognosis of non-HIV PCP. Multivariate analysis revealed that high D(Aea)O2, combined bacteremia, increased BUN and preexisting lung disease were indicators of a poor prognosis. Conclusions: High D(Aea)O2, combined bacteremia, increased BUN and preexisting lung disease were independent factors of poor prognosis in non-HIV PCP patients. ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
Introduction Pneumocystis jirovecii pneumonia (PCP), a pulmonary infection caused by P. jirovecii, remains one of the most prevalent opportunistic infection in immunosuppressed patients. Effective prophylaxis of PCP and the availability of highly active antiretroviral therapy have reduced the morbidity and mortality of PCP in patients with HIV infection (HIV PCP). However, the risk and incidence of PCP in patients without HIV infection (non-HIV PCP) has increased as the number of patients receiving chemotherapy or immunosuppressive agents has been growing rapidly.1 Previous studies reported that non-HIV PCP has a more acute and severe course than HIV PCP. Non-HIV PCP presents as an acute fulminant pneumonia with abrupt onset of respiratory failure, whereas HIV patients experience a more insidious course.2 HIV-negative status has also been shown to be independently associated with mortality in ICU-admitted PCP patients.3 In addition, the PCP mortality rate is higher in patients without AIDS than in those with AIDS. Previous studies have reported a PCP mortality rate of 35e55% in patients without AIDS compared to 10e20% among those with AIDS.4 Prognostic factors for HIV PCP have been well-established. In HIV PCP, frequently reported markers of poor prognosis either at the time of diagnosis or during treatment are age, low serum albumin and bilirubin, high LDH levels, hypoxemia
