Pneumocystis carinii pneumonia requiring intensive care management: Survival and prognostic study in 110 patients with human immunodeficiency virus

Objective: To perform a descriptive study of patients with acute respirator y failure secondary to acquired immunodeficiency syndrome-related Pneumocys tis carinii pneumonia and to identify variables that are predictive of deat h within 3 months. Design:Case series study. etting. Infectious disease intensive care unit (ICU) in a university hospit al. Patients: Detailed clinical, laboratory, and ventilatory data were collecte d prospectively within 48 hrs of admission and during the ICU stay in 110 c onsecutive human immunodeficiency virus-infected patients requiring ICU man agement with or without mechanical ventilation for P. carinii pneumonia-rel ated acute respiratory failure. Measurements and Main Results: Continuous positive airway pressure was used initially in 66 (60%) patients. Among the 34 patients (31%) who required m echanical ventilation, including 12 at admission and 22 after failure of co ntinuous positive airway pressure, 76% died. The 3-month mortality rate aft er ICU admission was estimated at 34.6% (95% confidence interval [CI], 25%- 44%). The l-yr survival rate was estimated at 47% (95% CI, 36%-58%). With s uccessive multiple logistic regression models analyzing the relative progno stic importance of baseline clinical and laboratory tests variables, ventil ation variables, and events in the ICU, only delayed mechanical ventilation after 3 days (odd ratio [OR], 6.7; 95% CI, 1.9-23.9), duration of mechanic al ventilation of greater than or equal to 5 days (OR, 2.8; 95% CI, 1.1-6.9 ), nosocomial infection (OR, 5.2; 95% CI, 2.1-12.9), and pneumothorax (OR, 5; 95% CI, 1.7-14.7) were predictive of death within 3 months of ICU admiss ion. Among patients with delayed mechanical ventilation on day 3 or later a nd with a pneumothorax associated or not associated with a nosocomial infec tion, the predicted probability of 3-month death was close to 100%. Conclusions: Our data suggest that the most significant predictive factors of death were identifiable during the course of P. carinii pneumonia-relate d acute respiratory failure rather than at admission and can help in bedsid e decisions to withdraw intensive care support in such patients.