scholarly journals 1171. Lower Mortality with Adjuvant Corticosteroid Therapy in non-HIV Infected Patients with pneumocystis jirovecii pneumonia: A Single US Cohort Study and a Proposed Novel Mechanism of Corticosteroids

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S610-S611
Author(s):  
William Mundo ◽  
Carlos Franco-Paredes ◽  
Steven C Johnson ◽  
Leland Shapiro ◽  
Andres Henao-Martinez
Keyword(s):  
Corticosteroid Therapy ◽  
Multivariable Analysis ◽  
Solid Organ Transplantation ◽  
Pneumocystis Jirovecii ◽  
Lower Mortality ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Solid Organ ◽  
Hiv Status ◽  
Predictors Of Mortality ◽  
Hiv Negative

Abstract Background Pneumocystis jirovecii pneumonia (PJP) remains a cause of mortality in HIV-negative patients. The clinical benefit of adjuvant corticosteroids given at the time of PJP antimicrobial therapy in these patients is uncertain. This study aimed to determine if corticosteroids reduced mortality in a cohort of HIV-negative PJP patients, and to propose a novel mechanism explaining corticosteroid benefit in patients regardless of HIV status. Methods We examined a retrospective case series of patients diagnosed with PJP at the University of Colorado Hospital between 1995-2019. Data were collected in 71 PJP-infected patients. Twenty-eight patients were HIV-negative, and 43 were infected with HIV. We performed bivariate and forward, stepwise multivariable logistic regressions to identify predictors of mortality. Results Underlying conditions in HIV-negative patients were hematologic malignancies (28.6%), autoimmune disorders (25.9%), or solid organ transplantation (10.7%). Compared to HIV-positive patients, HIV-negative patients had higher rates and duration of mechanical ventilation and ICU stay. Survival was significantly increased in HIV-negative patients receiving adjunct corticosteroids, with 100% mortality in patients not receiving corticosteroids vs 60% mortality in patients receiving corticosteroids (p=0.034). In an adjusted multivariable model, corticosteroids were associated with lower mortality (OR 13.5, 95% CI: 1.1-158.5, p= 0.039) regardless of HIV status. In a novel model of adjunct corticosteroid benefit, we propose corticosteroids reduce immune-mediated lysis of Pneumocystis organisms that curtails the surfactant-disabling effect of PJP internal contents. Table 1. Multivariable Analysis of Predictors of Mortality in patients with PJP Figure 1. Mortality differences by HIV status and use of steroids in PJP Conclusion We found substantial mortality among HIV-negative patients with PJP and adjunct corticosteroid use was associated with decreased mortality. Adjunct corticosteroid mortality-lowering effect is best explained by suppressing pneumocystis lysis. This reduces surfactant disruption resulting from pneumocystis internal substances. Figure 2. Proposed mechanism of action for benefits of adjunct exogenous corticosteroid therapy during PJP Disclosures All Authors: No reported disclosures

scholarly journals Lower Mortality Associated With Adjuvant Corticosteroid Therapy in Non-HIV-Infected Patients With Pneumocystis jirovecii Pneumonia: A Single-Institution Retrospective US Cohort Study

2020 ◽  
Vol 7 (9) ◽  
Author(s):  
William Mundo ◽  
Louis Morales-Shnaider ◽  
Selam Tewahade ◽  
Eric Wagner ◽  
Solana Archuleta ◽  
...  
Keyword(s):  
Solid Organ Transplantation ◽  
Case Series ◽  
Hematologic Malignancies ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Solid Organ ◽  
Retrospective Case ◽  
University Of Colorado ◽  
Beneficial Response ◽  
Hiv Negative

Abstract Background Pneumocystis jirovecii pneumonia (PJP) remains a cause of mortality in HIV-negative patients. The clinical benefit of adjuvant corticosteroids in these patients is uncertain. This study aimed to determine if corticosteroids would reduce mortality in a cohort of HIV-negative PJP patients. Methods We examined a retrospective case series of patients diagnosed with PJP at the University of Colorado Hospital between 1995 and 2019. Data were collected in 71 PJP-infected patients. Twenty-eight patients were HIV-negative, and 43 were infected with HIV. We performed bivariate and forward, stepwise multivariable logistic regressions to identify mortality predictors. Results Common underlying conditions in HIV-negative patients were hematologic malignancies (28.6%), autoimmune disorders (25.9%), and solid organ transplantation (10.7%). HIV-negative patients had higher rates and durations of mechanical ventilation and intensive care unit stay. Survival was significantly increased in HIV-negative patients receiving adjuvant corticosteroids, with 100% mortality in patients not receiving corticosteroids vs 60% mortality in patients receiving corticosteroids (P = .034). In an adjusted multivariable model, no adjuvant corticosteroid use was associated with higher mortality (odds ratio, 13.5; 95% CI, 1.1–158.5; P = .039) regardless of HIV status. Conclusions We found substantial mortality among HIV-negative patients with PJP, and adjuvant corticosteroid use was associated with decreased mortality. Response to corticosteroids is best established in HIV-infected patients, but emerging reports suggest a similar beneficial response in PJP patients without HIV infection. Further prospective studies may establish a more definitive role of the addition of corticosteroids among HIV-negative patients with PJP.

scholarly journals Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Benjamin Jean Gaborit ◽  
Benoit Tessoulin ◽  
Rose-Anne Lavergne ◽  
Florent Morio ◽  
Christine Sagan ◽  
...  
Keyword(s):  
Diagnostic Criteria ◽  
Sofa Score ◽  
Invasive Mechanical Ventilation ◽  
Solid Organ Transplantation ◽  
Older Age ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Solid Organ ◽  
Pathophysiological Mechanism ◽  
Hypoxemic Acute Respiratory Failure

Abstract Background Pneumocystis jirovecii pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lavage fluid cytology profiles at diagnosis. Methods We prospectively enrolled all patients meeting pre-defined diagnostic criteria for PJP admitted at Nantes university hospital, France, from January 2012 to January 2017. Diagnostic criteria for PJP were typical clinical features with microbiological confirmation of P. jirovecii cysts by direct examination or a positive specific quantitative real-time polymerase chain reaction (PCR) assay. Severe PJP was defined as hypoxemic acute respiratory failure requiring high-flow nasal oxygen with at least 50% FiO2, non-invasive ventilation, or MV. Results Of 2446 respiratory samples investigated during the study period, 514 from 430 patients were positive for P. jirovecii. Of these 430 patients, 107 met criteria for PJP and were included in the study, 53 (49.5%) patients had severe PJP, including 30 who required MV. All patients were immunocompromised with haematological malignancy ranking first (n = 37, 35%), followed by solid organ transplantation (n = 27, 25%), HIV-infection (n = 21, 20%), systemic diseases (n = 13, 12%), solid tumors (n = 12, 11%) and primary immunodeficiency (n = 6, 8%). By multivariate analysis, factors independently associated with severity were older age (OR, 3.36; 95% CI 1.4–8.5; p < 0.05), a P. jirovecii microscopy-positive result from bronchoalveolar lavage (BAL) (OR, 1.3; 95% CI 1.54–9.3; p < 0.05); and absence of a BAL fluid alveolitis profile (OR, 3.2; 95% CI 1.27–8.8; p < 0.04). The 90-day mortality rate was 27%, increasing to 50% in the severe PJP group. Factors independently associated with 90-day mortality were worse SOFA score on day 1 (OR, 1.05; 95% CI 1.02–1.09; p < 0.001) whereas alveolitis at BAL was protective (OR, 0.79; 95% CI 0.65–0.96; p < 0.05). In the subgroup of HIV-negative patients, similar findings were obtained, then viral co-infection were independently associated with higher 90-day mortality (OR, 1.25; 95% CI 1.02–1.55; p < 0.05). Conclusions Older age and P. jirovecii oocysts at microscopic examination of BAL were independently associated with severe PJP. Both initial PJP severity as evaluated by the SOFA score and viral co-infection predicted 90-day mortality. Alveolitis at BAL examination was associated with less severe PJP. The pathophysiological mechanism underlying this observation deserves further investigation.

Prophylaxis and treatment of Pneumocystis Jirovecii pneumonia after solid organ transplantation

2018 ◽  
Vol 134 ◽  
pp. 61-67 ◽  
Author(s):  
Susanne Brakemeier ◽  
Anja Pfau ◽  
Bianca Zukunft ◽  
Klemens Budde ◽  
Peter Nickel
Keyword(s):  
Organ Transplantation ◽  
Solid Organ Transplantation ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Solid Organ

scholarly journals Herpes Zoster in Solid Organ Transplantation: Incidence and Risk Factors

2021 ◽  
Vol 12 ◽  
Author(s):  
Marcia M. L. Kho ◽  
Stefan Roest ◽  
Dominique M. Bovée ◽  
Herold J. Metselaar ◽  
Rogier A. S. Hoek ◽  
...  
Keyword(s):  
Risk Factors ◽  
Herpes Zoster ◽  
Multivariable Analysis ◽  
Solid Organ Transplantation ◽  
Organ Transplant ◽  
Clinical Signs ◽  
Significant Risk ◽  
Solid Organ ◽  
Disseminated Disease ◽  
Cmv Prophylaxis

BackgroundStudies on herpes zoster (HZ) incidence in solid organ transplant (SOT) recipients report widely varying numbers. We investigated HZ incidence, severity, and risk factors in recipients of four different SOTs, with a follow-up time of 6–14 years.MethodsRecords of 1,033 transplant recipients after first heart (HTx: n = 211), lung (LuTx: n = 121), liver (LiTx: n = 258) and kidney (KTx: n = 443) transplantation between 2000 and 2014 were analyzed for VZV-PCR, clinical signs of HZ, and complications.ResultsHZ was diagnosed in 108 of 1,033 patients (10.5%): 36 HTx, 17 LuTx, 15 LiTx, and 40 KTx recipients. Overall HZ incidence rate after HTx (30.7 cases/1,000 person–years (PY)), LuTx (38.8 cases/1,000 PY), LiTx (22.7 cases/1,000 PY) and KTx (14.5 cases/1,000 PY) was significantly higher than in the general 50–70 year population. Multivariable analysis demonstrated age ≥50 years at transplantation (p = 0.038, RR 1.536), type of organ transplant (overall p = 0.002; LuTx p = 0.393; RR 1.314; LiTx p = 0.011, RR 0.444; KTx p = 0.034, RR 0.575), CMV prophylaxis (p = 0.043, RR 0.631) and type of anti-rejection therapy (overall p = 0.020; methylprednisolone p = 0.008, RR 0.475; r-ATG p = 0.64, RR1.194) as significant risk factors. Complications occurred in 33 of 108 (31%) patients (39% of HTx, 47% of LuTx, 20% of LiTx, 20% of KTx): post-herpetic neuralgia, disseminated disease, and cranial nerve involvement.ConclusionHZ incidence and severity in SOT recipients are most pronounced after heart and lung transplantation, in older patients, and when CMV prophylaxis is lacking.

scholarly journals 423. Self-Reported Screening for Rectal Sexually Transmitted Infections Among Men Who Have Sex with Men

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S212-S213
Author(s):  
Timothy William. Menza ◽  
Lauren Lipira ◽  
Amisha Bhattarai ◽  
Joseph Ramirez ◽  
Roberto Orellana
Keyword(s):  
Sexually Transmitted Infections ◽  
Multivariable Analysis ◽  
Prevalence Ratio ◽  
Hiv Positive ◽  
Sexually Active ◽  
Hiv Status ◽  
Sexually Transmitted ◽  
Sex With Men ◽  
Hiv Negative ◽  
Hiv Positive Men

Abstract Background Rectal gonorrhea and Chlamydia are common and predict HIV acquisition among men who have sex with men (MSM); however, screening for rectal sexually transmitted infections (STIs) is not routine. Methods In 2017, we recruited sexually-active MSM in the Portland, Oregon metropolitan area through venue-based sampling. Our outcome of interest was self-reported rectal STI screening in the prior 12 months. Stratified by HIV status, we assessed the prevalence and demographic, healthcare, clinical, and behavioral predictors of screening. Results Of 448 participants, 168 (37.5%) reported rectal STI screening. One hundred twenty-seven (35.8%) of 355 HIV-negative men, 41 (58.6%) of 70 HIV-positive men, and none of 23 men who did not know their HIV status reported screening. Among HIV-negative men, having a healthcare provider who offered HIV testing (adjusted prevalence ratio [aPR]=2.09; 95% confidence interval [CI]: 1.43, 3.04), a syphilis diagnosis (aPR=1.32; 95% CI: 1.03, 1.69), use of pre-exposure prophylaxis (aPR=1.57; 95% CI 1.21, 2.04), and condomless anal sex with casual partners in the prior 12 months (aPR=1.74; 95% CI: 1.36, 2.22) independently predicted screening for rectal STI in multivariable analysis. HIV-positive men who reported having a provider who always or often initiates conversations about sex were significantly more likely to report screening compared with men who did not have such a provider (aPR=1.48; 95% CI: 1.06, 2.06). Conclusion Rectal STI screening is not universal in a venue-based sample of sexually-active MSM. Implementing innovative, acceptable, and accessible screening practices and improving provider comfort with talking about sex are paramount to increasing rectal STI screening. Disclosures All authors: No reported disclosures.

scholarly journals Factors Associated With Ventriculoperitoneal Shunt Placement in Patients With Cryptococcal Meningitis

2019 ◽  
Vol 6 (6) ◽  
Author(s):  
John W Baddley ◽  
George R Thompson ◽  
Kristen O Riley ◽  
Mary K Moore ◽  
Stephen A Moser ◽  
...  
Keyword(s):  
Cryptococcal Meningitis ◽  
Multivariable Analysis ◽  
Solid Organ Transplantation ◽  
Categorical Variables ◽  
Stepwise Logistic Regression ◽  
Fisher Exact Test ◽  
Solid Organ ◽  
Vp Shunt ◽  
Factors Associated ◽  
Shunt Placement

Abstract Objective Increased intracranial pressure (ICP) is an important complication of cryptococcal meningitis (CM) and impacts morbidity and mortality. Factors associated with permanent ventriculoperitoneal (VP) shunt placement are poorly characterized. Method We conducted a retrospective cohort study of patients with CM at the University of Alabama at Birmingham from 1996 through 2015. Characteristics of patients at time of CM diagnosis who did and did not receive a VP shunt were compared with use of the 2-group chi-square test or Fisher exact test for categorical variables and the 2-group t test for continuous variables. Stepwise logistic regression analysis was used to determine predictors of shunt placement. Results Of 422 patients with cryptococcosis, 257 (60.9%) had CM. Mean age was 47.7 years, 71.6% were male, and 44.4% were African American. The most common underlying conditions were HIV (42.4%), solid organ transplantation (29.6%), and corticosteroid use (34.2%). Forty-four (17.1%) received a VP shunt a median of 17 days (range, 1–320 days) post-diagnosis. By multivariable analysis, baseline opening pressure &gt;30 cm H2O (OR, 9.4; 95% CI, 3.0, 28.8; P &lt; .0001), being a normal host (OR, 6.3; 95% CI, 1.5, 26.1; P = .011) and hydrocephalus (OR, 4.9, 95% CI, 1.3, 17.9); P = .017) were associated with increased odds of shunting (Table 2). In contrast, age (OR, 0.96; 95% CI, 0.92, 0.99; P = .037) and male gender (OR, 0.18; 95% CI, 0.06, 0.55; P = .023) were associated with decreased odds of shunting. Conclusions Identification of factors at time of CM diagnosis associated with need for permanent VP shunt placement may allow for earlier, more aggressive treatment and potentially improve outcomes associated with increased ICP from cryptococcal meningitis.

scholarly journals Pneumocystis jirovecii Pneumonia in Patients with Nephrotic Syndrome: Application of Lymphocyte Subset Analysis in Predicting Clinical Outcomes

2020 ◽  
Vol 2020 ◽  
pp. 1-8
Author(s):  
Yang Liu ◽  
Ke Zheng ◽  
Yecheng Liu ◽  
Huadong Zhu
Keyword(s):  
Nephrotic Syndrome ◽  
T Lymphocyte ◽  
Lymphocyte Count ◽  
Clinical Manifestations ◽  
Multivariate Logistic Regression Analysis ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Confirmatory Tests ◽  
Life Threatening ◽  
Hiv Negative

Purpose. With immunosuppressants being widely used, Pneumocystis jirovecii pneumonia (PCP) has been increasing and could be life-threatening among HIV-negative patients. This study aimed at identifying prognostic factors of PCP in patients with nephrotic syndrome. Methods. We retrospectively investigated patients with nephrotic syndrome who were diagnosed with PCP. The diagnosis of PCP was based on clinical manifestations, radiological findings, and microbiological confirmatory tests. Predictors of outcome were determined with multivariate logistic regression analysis. Results. A total of 57 patients were included in this study. The PCP mortality was 33.3%, which increased to 48.6% if ICU admission was required and to 60% when mechanical ventilation was needed. The T lymphocyte count and CD4/CD8 ratio independently predicted the outcome of PCP, so did the CD4+ T lymphocyte count (OR, 0.981; 95% CI, 0.967–0.996; p=0.001). The cut-off value of 71 cells/μl for the CD4+ T lymphocyte count was determined to identify patients with poor prognosis. No association was found between PCP mortality and the type of immunosuppressant used. Conclusions. PCP is a fatal complication among nephrotic syndrome patients receiving immunosuppressive therapy. The CD4+ T lymphocyte count is suggested as an independent predictor of prognosis, which can be used clinically to identify patients with high risk of unfavorable outcomes.

scholarly journals No Recurrence of Pneumocystis jirovecii Pneumonia after Solid Organ Transplantation Regardless of Secondary Prophylaxis

2012 ◽  
Vol 56 (11) ◽  
pp. 6041-6043 ◽  
Author(s):  
Tark Kim ◽  
Heungsup Sung ◽  
Yu-Mi Lee ◽  
Hyo-Lim Hong ◽  
Sung-Han Kim ◽  
...  
Keyword(s):  
Cohort Study ◽  
Organ Transplantation ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Solid Organ Transplantation ◽  
Secondary Prophylaxis ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Solid Organ ◽  
Content Type

ABSTRACTThere are no data on the efficacy of secondary prophylaxis againstPneumocystispneumonia after solid organ transplantation. Therefore, we investigated the rate of recurrence ofPneumocystispneumonia after solid organ transplantation in a retrospective cohort study. Between 2005 and 2011, a total of 41 recipients recovered fromPneumocystispneumonia. Of these, 22 (53.7%) received secondary prophylaxis. None of the 41 recipients experienced recurrence ofPneumocystispneumonia during the follow-up, regardless of secondary prophylaxis.

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