Improved Outcome of Pneumocystis Carinii Pneumonia in AIDS Patients: A Multifactorial Treatment Effect

Factors determining the outcome of an episode of Pneumocystis carinii pneumonia (PCP) in 149 AIDS patients treated at St Mary's Hospital were identified and their importance on improved survival evaluated between 1984 and 1989. The proportion of fatal episodes of PCP decreased over time. Fatal compared with non-fatal episodes had lower mean alveolar-arterial oxygen gradient (82.5 mmHg vs 53.8 mmHg, P<0.001), mean haemoglobin level (11.2g/dl vs 12.1 g/dl, P=0.01), mean lymphocyte count (0.68 times 109/l vs 0.92 times 109/l, P=0.05) and more coinfections (31% vs 5%, P<0.001). Over time, the most significant change which occurred was a reduction in alveolar-arterial oxygen gradient at time of first presentation with PCP (r=−0.37, P<0.001). Mean alveolar-arterial oxygen gradient declined from 79.9 mmHg in 1984 to 45.3 mmHg in 1989 (r= −0.88, P=0.02), independently of zidovudine therapy or PCP prophylaxis. Patients were being treated at an earlier stage in their disease course as indicated by their reduced alveolar arterial oxygen gradient. This is due either to earlier patient presentation, earlier medical diagnosis or both. The widespread introduction of zidovudine and PCP prophylaxis may further contribute to improve morbidity and mortality patterns in the future.

Download Full-text

Empirically Treated Pneumocystis Carinii Pneumonia in London, 1983–1989

International Journal of STD & AIDS ◽

10.1177/095646249200300411 ◽

1992 ◽

Vol 3 (4) ◽

pp. 285-287 ◽

Cited By ~ 5

Author(s):

E J Beck ◽

P D French ◽

M H Helbert ◽

D S Robinson ◽

F M Moss ◽

...

Keyword(s):

Pneumocystis Carinii Pneumonia ◽

Lymphocyte Count ◽

Severe Disease ◽

Pneumocystis Carinii ◽

Fatal Outcome ◽

Case Fatality ◽

Medical Intervention ◽

Arterial Oxygen ◽

Oxygen Gradient ◽

Over Time

For 227 episodes of Pneumocystis carinii pneumonia (PCP) treated at St Mary's between 1983 and 1989, factors predictive of fatal outcome were age, haemoglobin levels, peripheral lymphocyte count and alveolar-arterial oxygen gradient. Case fatality for the 47 empirically-treated episodes was significantly higher compared with the 180 cytologically proven episodes (55% vs 18%, χ2 = 25.7, P<0.0001). Case fatality for episodes which could not be bronchoscoped was significantly higher compared with bronchoscopy negative cases (66% vs 25%, χ2 = 4.5, P<0.05). Predictive factors for fatal outcome differed significantly for cases which could not be bronchoscoped and cytologically proven cases: haemoglobin level (10.7 g/dl vs 12.0 g/dl, P<0.001), lymphocyte count (0.64 × 109/l vs 0.87×109/l, P=0.05) and oxygen gradient (77.7 mmHg vs 58.9 mmHg, P<0.02). Such differences were not observed between bronchoscopy negative and cytologically proven cases. Case fatality decreased significantly over time ( b = –0.39, SE=0.14, P<0.05). Total and non-fatal first time episodes displayed an inverse relationship between oxygen gradient and time ( r = −0.22, P<0.006 and r = −0.24, P<0.01, respectively). Mean oxygen gradient of fatal episodes for sequential years increased significantly from 73 mmHg in 1983 to 102 mmHg in 1989 ( r = 0.92, P<0.01). This suggests that medical intervention as well as presentation with less severe disease both contributed to improved case fatality over time.

Download Full-text

Adjuvant Corticosteroid Therapy for Pneumocystis Carinii Pneumonia in Aids Patients

Annals of Pharmacotherapy ◽

10.1177/106002809202600915 ◽

1992 ◽

Vol 26 (9) ◽

pp. 1127-1133 ◽

Cited By ~ 13

Author(s):

Catherine J. Sistek ◽

Cindy J. Wordell ◽

Stephen P. Hauptman

Keyword(s):

Sample Size ◽

Outcome Measures ◽

Corticosteroid Therapy ◽

Pneumocystis Carinii Pneumonia ◽

Expert Panel ◽

Pneumocystis Carinii ◽

National Institutes Of Health ◽

Arterial Oxygen ◽

Aids Patients ◽

Systemic Corticosteroids

OBJECTIVE: To review published abstracts, case reports, and journal articles and evaluate data examining the use of systemic corticosteroids as adjuvant treatment for Pneumocystis carinii pneumonia (PCP) in patients with AIDS. DATA SOURCES: Computerized online databases, peer-reviewed journals from January 1986 through September 1991, and personal communication with a National Institutes of Health correspondent. STUDY SELECTION: The authors identified 13 reports pertinent to this review. By author consensus, five studies were selected for analysis based on sample size, controlled study design, and clinical outcome measures. Recommendations of an expert panel from the National Institutes of Health and the University of California also are discussed. DATA EXTRACTION: Data are presented based on the methodologic strength of the studies reviewed. Studies are assessed on sample size, inclusion criteria, comparative cohort populations, specific patient outcome measures, and statistical analysis. DATA SYNTHESIS: Results of the study analysis support the use of systemic corticosteroids as early adjunctive therapy for AIDS patients with moderate-to-severe PCP who have an initial arterial oxygen partial pressure of <70 mm Hg or an alveolar-arterial gradient >35 mm Hg on room air. Improved outcomes included decreased mortality, respiratory failure, and deterioration of oxygenation. Data evaluated have shown that adjuvant corticosteroid therapy is most effective when initiated within 72 hours of beginning specific antipneumocystis therapy. A small, but sometimes significant, increased rate of infection in steroid-treated patients was noted. CONCLUSIONS: Based on the literature reviewed, early systemic adjuvant corticosteroid therapy can benefit patients with moderate-to-severe AIDS-related PCP. The steroid regimen used in the largest controlled trial and recommended by the expert panel is prednisone 40 mg bid (days 1–5), then 40 mg/d (days 6–10), then 20 mg/d (days 1–21).

Download Full-text