Community-acquired bacterial pneumonia in human immunodeficiency virus-infected patients - Validation of severity criteria

Severity criteria for community-acquired pneumonia (CAP) have always exclud ed patients with human immunodeficiency virus (HIV) infection. A 1-yr, mult icenter, prospective observational study of HIV-infected patients with bact erial CAP was done to validate the criteria used in the American Thoracic: Society (ATS) guidelines for CAP, and to determine the prognosis-associated factors in the HIV-infected population with bacterial CAP. Overall, 355 ca ses were included, with an attributable mortality of 9.3%. Patients who met the ATS criteria had a longer hospital stay (p = 0.01), longer duration of fever (p < 0.001), and higher attributable mortality (13.1% versus 3.5%, p = 0.02) than those who did not. Three factors were independently related t o mortality: CD4(+) cell count < 100/mul, radiologic progression of disease , and shock. Pleural effusion, cavities, and/or multilobar infiltrates at a dmission were independently associated with radiologic progression. A progn ostic rule based on the five criteria of shock, CD4(+) cell count < 100/<mu >l, pleural effusion, cavities, and multilobar infiltrates had a high negat ive predictive value for mortality (97.1%). The attributable mortality for severe pneumonia was 11.3%, as compared with 1.3% for nonsevere disease (p = 0.008). The ATS severity criteria are valid in HIV-infected patients with bacterial CAP. Our study provides the basis for identification of patients who may require hospitalization determined by clinical judgment and the-fi ve clinical criteria of shock, a CD4(+) cell count < 100/<mu>l, pleural eff usion, cavities, and multilobar involvement. These prognostic factors shoul d be validated in independent cohort studies.