4.2 Characteristics of the HIV group
Among 25 patients infected by HIV, 9 (36.0%) were diagnosed previously and only 1 (4.0%) regularly used ART and had a suppressed viral load. Sixteen (64.0%) patients were admitted with an opportunistic infection and the median of the CD4+ T-cell count was 33.0 (interquartile range, 9.5–107.5) cells/mm3.
4.3 Reasons for ICU admission
Respiratory conditions were the most common cause of ICU admission (42.9%) and they were more frequent in the HIV group (60.0% vs 34.6%, P = .035). Neurological disorders were the reason for 16.9% of ICU admissions. The most common diseases present at ICU admission among HIV-positive individuals were Pneumocystis jirovecii (36.0%) and bacterial pneumonia (16.0%), while those in the non-HIV group were tetanus (17.3%), influenza (15.4%), and pneumonia (11.5%).
4.4 Thirty-day mortality after the first HAI episode
There was a high 30-day mortality rate after the first HAI episode and there was no statistically significant difference between the groups (HIV, 52.0% vs non-HIV, 53.8%, P = .812). There was no difference in the 30-day survival after HAI between HIV and non-HIV patients in the univariate analysis (P = .81), after adjusting for age, diabetes mellitus (DM), SOFA score on the day of the first HAI, and MDRO infection (P = .67; Table 2). Age was the only independent risk factor associated with 30-day death (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.01–1.1, P = .017), and DM (OR 3.64, 95% CI 0.84–15.8, P = .085) and SOFA score (OR 1.16, 95% CI 0.99–1.37, P = .071) showed a trend toward association with death.
4.5 Description of HAI
Among 106 HAIs, 31 occurred in HIV patients and 75 occurred in non-HIV patients, and most were associated with devices (Table 1). CA-BSI was the most frequent HAI among all individuals (39.6%) and no difference was observed in the frequency of this infection among the groups (Table 1). The most frequent HAI in the HIV group was VAP despite the similar periods of mechanical ventilation (Table 1). A low frequency of CA-UTI was observed in both groups (Table 1). Although we have observed a high frequency of HAI caused by MDRO, no difference in frequency was found between the groups (Table 1).
There was a predominance of Gram-positive bacteria as causative agents of CA-BSI in HIV patients (60.0%), and Enterococcus faecalis was the most frequent agent with 3 isolates (30.0%), 1 (33.3%) of which was VRE, followed by 2 Staphylococcus aureus (20.0%), both of which were MRSA. Gram-negative organisms were the predominant cause of CA-BSI in the non-HIV group (78.1%), with 9 Klebsiella pneumoniae (28.1%) and 4 (12.5%) of both Serratia marcescens and Acinetobacter baumannii, which were the most common agents. Seven K pneumoniae (77.8%) and 2 A baumannii (50.0%) were resistant to carbapenems in this group. One (3.1%) S aureus, which was methicillin resistant, was observed as a causative agent of CA-BSI in non-HIV patients, and among the 3 E faecalis (9.4%), 2 (66.7%) were vancomycin resistant. In the non-HIV group, 6 (18.8%) episodes of CA-BSI were caused by Candida species (50.0% albicans and 50.0% non-albicans), whereas catheter associated-candidemia was not observed in the HIV group.
There was a predominance of Gram-negative organisms as causative agents of VAP in both groups (HIV, 92.9% vs non-HIV, 70.0%). In HIV patients, A baumannii and K pneumoniae comprised 5 isolates (35.7%) each and they were the most frequent causative agents of VAP; all of them were resistant to carbapenem and 2 (40.0%) K pneumoniae isolates were colistin-resistant. No Gram-positive organism was observed as a causative agent of VAP in the HIV group. Seven Pseudomonas aeruginosa (35.0%) and 5 A baumannii (25.0%) were the predominant Gram-negative causative agents of VAP in non-HIV patients, and 5 (71.4%) P aeruginosa and 4 A baumannii were resistant to carbapenems. Moreover, 6 VAP episodes (30.0%) were caused by S aureus in this group, and 4 (66.7%) of them were MRSA.
There were 2 CA-UTI in the HIV group, and one of them was caused by a carbapenem and colistin-resistant K pneumoniae, and the other was caused by 2 agents, which were an isolate of K pneumoniae that was susceptible to multiple antimicrobial classes and a vancomycin-resistant Enterococcus faecium. In the non-HIV group, there were 6 episodes of CA-UTI. The predominant agents were 4 Escherichia coli (66.7%), all of which were susceptible to multiple antimicrobial classes, and 4 K pneumoniae (66.7%), one of which was resistant to carbapenems and colistin. There were 2 (33.3%) Candida albicans and 1 (16.7%) E faecalis that were susceptible to multiple antimicrobial classes. Table 3 shows the number of each organism that was isolated for each type of device-associated infection.
There was no difference in 30-day mortality between HIV-infected and non-infected patients who acquired HAI during an ICU stay. Age was the only independent risk factor that was associated with outcome in our study. These findings are similar to a prospective single-center study that was conducted in a high-income country, which aimed to evaluate mortality and risk of acquiring a HAI caused by a MDRO, and they did not find a difference between HIV and non-HIV groups for both outcomes. In our study, most HIV patients were recently diagnosed, had an uncontrolled disease, and were admitted for an opportunistic infection, which are considered to be factors for a poor prognosis[4,5]; however, we observed a high mortality rate in both groups, with no significant difference. These findings reinforce the evidence of high mortality associated with HAI, which is independent of other comorbidities and has a large social impact.[15,16]
There is no consensus in the literature about the impact of HIV infection on mortality of ICU patients. Some studies have observed a higher mortality rate in HIV patients admitted to the ICU.[32,33] However, a prospective study showed that HIV infection has little impact on mortality, which is consistent with the results of our study. These studies evaluated patients with sepsis and none addressed HAI.[32–34]
The most common HAI observed in HIV patients in our study was VAP and its frequency in this group was higher than in non-HIV individuals, despite similar periods of device use. This could be because HIV patients were admitted more frequently with a respiratory disease or for local pulmonary changes in immune response resulting from a reduction in alveolar macrophage function caused by oxidative stress that is observed in HIV infection.[5,35] Moreover, there is no consensus in the literature about which HAI is the most frequent in HIV patients. Several studies, most of which were not restricted to the ICU setting, reported CA-BSI,[21,25,27] but there are studies that described VAP and CA-UTI as the most frequent HAI in HIV patients.
A high frequency of HAI caused by MDROs was found in our study, but HIV infection did not seem to be a risk factor for this outcome. This finding was similar to that described by Cobos-Trigueros et al, who evaluated HAI caused by MDROs as well as mortality. There are studies that showed a higher frequency of colonization by multidrug resistant bacteria in HIV patients, suggesting possible sexual transmission of these bacteria. Our study did not find a difference between HIV and non-HIV patients in the colonization rate by carbapenem-resistant Enterobacteriaceae in HAI caused by MDROs.
We observed that Gram-positive organisms were the predominant agents of CA-BSI, whereas Gram-negative organisms were the predominant cause of VAP in HIV patients. Studies showed a high frequency of Gram-positive organisms as agents of HAI in HIV patients[21,22] and most of them described these organisms as the most frequent cause of CA-BSI in this patient population. Gram-negative organisms were previously described as the predominant agents in VAP, but Gram-positive organisms were also frequently found in HIV patients. Conversely, our study did not observe any Gram-positive organism as a cause of VAP in HIV patients. However, Candida species were considered to be important agents of CA-BSI in HIV patients,[26,37,38] and we observed catheter-associated candidemia only in non-HIV individuals.
This study has several limitations such as the small sample size and its design; it was based on retrospective data, with possible measurement bias and loss of information. As a retrospective study, it was not possible to evaluate death that was attributable to HAI. We did not observe an HAI outbreak during the study period, and it was not possible to evaluate if there was cross-infection among groups because molecular analysis was not performed. There was a predominance of male patients, so there is a limitation to extrapolate the results to the general population, but a multivariable analysis was performed to reduce possible confounders. There are few studies in the literature about HAI in HIV patients. To the best of our knowledge, this is the first study that evaluated 30-day mortality as a primary outcome in HIV patients after HAI. The epidemiologic and microbiologic profile of HAI in these patients is also described, contributing additional data to this controversial theme.
VAP that was mainly caused by Gram-negative bacteria was the most frequent HAI in HIV patients in our ICU. However, Gram-positive bacteria were the predominant causative agents of CA-BSI in the HIV group. There was a high frequency of HAI caused by MDROs and 30-day mortality after HAI, but there was no statistically significant difference among HIV and non-HIV patients. HIV infection is not a predictive factor that is associated with 30-day mortality of patients with HAI, and age was the only independent factor associated with outcome.
Conceptualization: Victor Augusto Camarinha de Castro-Lima, Igor Carmo Borges, Ho Yeh Li, Silvia Figueiredo Costa, Maria Luisa Nascimento Moura.
Data curation: Victor Augusto Camarinha de Castro-Lima, Igor Carmo Borges, Daniel Joelsons, Vivian Vieira Tenorio Sales, Ho Yeh Li, Thais Guimaraes, Silvia Figueiredo Costa, Maria Luisa Nascimento Moura.
Formal analysis: Victor Augusto Camarinha de Castro-Lima, Igor Carmo Borges, Silvia Figueiredo Costa, Maria Luisa Nascimento Moura.
Investigation: Victor Augusto Camarinha de Castro-Lima, Igor Carmo Borges, Silvia Figueiredo Costa, Maria Luisa Nascimento Moura.
Methodology: Victor Augusto Camarinha de Castro-Lima, Igor Carmo Borges, Silvia Figueiredo Costa, Maria Luisa Nascimento Moura.
Project administration: Victor Augusto Camarinha de Castro-Lima, Maria Luisa Nascimento Moura.
Software: Victor Augusto Camarinha de Castro-Lima.
Visualization: Victor Augusto Camarinha de Castro-Lima.
Writing – original draft: Victor Augusto Camarinha de Castro-Lima, Silvia Figueiredo Costa.
Writing – review & editing: Daniel Joelsons, Vivian Vieira Tenorio Sales, Ho Yeh Li, Thais Guimaraes, Maria Luisa Nascimento Moura.
Supervision: Silvia Figueiredo Costa, Maria Luisa Nascimento Moura.
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Keywords:Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
critical care; health care-associated infections; human immunodeficiency virus infection; infection control; infectious diseases; intensive care units