Introduction
Materials and methods
Study population
Data collection and definitions
Statistical analysis
Results
Demographic and clinical characteristics
Characteristics | 135 patients |
---|---|
Median age (years)
| 39 (31-50) |
Male sex
| 123 (91.1) |
Race/ethnicity
| |
Taiwanese | 133 (98.5) |
other Asians | 2 (1.5) |
HIV risk factor
| |
Homosexual | 53 (39.3) |
Bisexual | 7 (5.2) |
Injecting drug use | 16 (11.9) |
Transfusion-related | 3 (2.2) |
Heterosexual/other/unknown | 56 (41.5) |
HIV-related characteristics
| |
Newly diagnosed HIV infection | 60 (44.4) |
Time since HIV diagnosis (month) | 1.23 (0-36) |
Time since AIDS diagnosis (month) | 0.73 (0-26) |
Prior HAART at hospital admission | 49 (36.3) |
Duration of HAART for patients on prior HAART (month)
a
| 13 (6-48) |
HAART initiated during ICU stay | 12 (8.9) |
HAART use in ICU | 82 (60.7) |
HIV viral load (copies/ml)
b
| 217,000 (34,500-631,500) |
CD4 lymphocyte count (cells/mm3)
c
| 30 (13-103) |
Organ failure status
| |
Mechanical ventilator use | 106 (78.5) |
Shock (use of vasopressors > 24 hours) | 49 (36.3) |
Renal replacement therapy | 11 (8.1) |
Time from hospitalization to ICU admission (days)
| 2 (0-9.0) |
Laboratory data
| |
Albumin (g/dL)
d
| 2.83 (2.40-3.40) |
LDH (units/L)
e
| 966.5 (686.5-1446.25) |
APACHE II score
| 19 (15-25) |
in-ICU mortality
| 50 (37.0) |
in-hospital mortality
| 66 (48.9) |
Diagnoses of ICU admissions
Admission diagnosis | Number (%) of admissions |
---|---|
Respiratory failure
| 60 (44.4) |
Interstitial pneumonitis with ground glass opacity | 51 (37.8) |
Pneumocystosis | 11 (8.1) |
CMV (pathology-proven) | 9 (6.7) |
Interstitial pneumonitis of unknown etiology | 35 (25.9) |
Others | 11 (8.1) |
Sepsis (including bacteria pneumonia)
| 45 (33.3) |
Neurological disease
| 16 (11.9) |
Postoperative care
| 5 (3.7) |
Trauma
| 3 (2.2) |
Metabolic disturbance
| 2 (1.5) |
Cardiac disease
| 2 (1.5) |
Gastrointestinal bleeding
| 2 (1.5) |
Drug overdose
| 1 (0.7) |
Miscellaneous
| 3 (2.2) |
Predictors of in-ICU and in-hospital mortality
Characteristics | Univariable analysis | Multivariable analysis | ||
---|---|---|---|---|
Odds ratio (95% CI) |
P
value | Odds ratio (95% CI) |
P
value | |
Age (per 10-year increase)
| 1.15 (0.88-1.51) | 0.3 | ||
Male
| 2.03 (0.58-7.10) | 0.27 | ||
HIV risk factor
| 0.8 | |||
MSM | reference | |||
Bisexual | 0.78 (0.16-3.82) | 0.8 | ||
Injecting drug use | 0.62 (0.20-1.96) | 0.4 | ||
Transfusion-related | 2.08 (0.18-24.31) | 0.6 | ||
Heterosexual/other/unknown | 1.12 (0.53-2.37) | 0.8 | ||
HIV-related characteristics
| ||||
Newly diagnosed HIV infection | 1.56 (0.79-3.08) | 0.205 | ||
Prior HAART at hospital admission | 0.78 (0.39-1.57) | 0.5 | ||
HAART initiated during ICU stay | 1.05 (0.32-3.44) | 0.9 | ||
HAART use in ICU | 1.12 (0.56-2.24) | 0.7 | ||
HIV viral load (per 1-log copies/ml increase)
a
| 1.025 (0.83-1.26) | 0.8 | ||
CD4 lymphocyte count (per 10-cells/mm3 decrease)
b
| 1.033 (1.004-1.063) | 0.027 | 1.036 (1.003-1.069) | 0.033 |
Admission diagnosis
| ||||
Respiratory failure | 0.99 (0.50-1.95) | 1.0 | ||
Interstitial pneumonitis with ground glass opacity | 0.78 (0.39-1.57) | 0.5 | ||
Sepsis (including bacterial pneumonia) | 2.25 (1.08-4.69) | 0.03 | 2.91 (1.11-7.62) | 0.029 |
Hospitalization to ICU admission > 24 hours
| 2.72 (1.23-6.01) | 0.013 | 2.21 (0.90-5.47) | 0.085 |
Albumin (per 1 g/dl decrease)
c
| 1.69 (1.04-2.74) | 0.034 | 1.31 (0.74-2.34) | 0.36 |
Discussion
City [reference] | San Francisco [8] | San Francisco [16] | New York [20] | Paris [18] | Mexico [14] | São Paulo [15] | Rio de Janeiro [19] | Taipei |
---|---|---|---|---|---|---|---|---|
Study year
| 1996-1999 | 2000-2004 | 1997-1999 | 1996-2005 | 1996-2006 | 1996-2006 | 2006-2008 | 2001-2010 |
HIV-related characteristics
| ||||||||
Newly diagnosed HIV (%) | 5.6 | - | - | 19.7
a
| 26 | 38 | 28 | 44.4 |
Median CD4 count (cells/mm3) | 64 | 109 | 85 | - | - | 39 | 75 | 30 |
ICU admission diagnosis (%)
| ||||||||
Respiratory failure (%) | 40.7 | 42.3 | 30.0 | 58.8 | 51.0 | 33.1 | 29 | 44.4 |
pneumocystosis (%) | 10.7 | 13.8 | - | 18.7 | - | 23.2 | - | 8.1
b
|
Sepsis (%) | 11.9 | 20.3 | 13.0 | 23.9 | 26.0 | 31.2 | 20.5 | 33.3 |
Neurological disease (%) | 12.4 | 16.3 | 18.0 | 32 | 15.0 | 19.4 | 22.7 | 11.9 |
Others (%) | 35.0 | 21.1 | 39.0 | - | 21.0 | 16.2 | 27.3 | 13.3 |
Mortality predictors
| ||||||||
ART use | No prior HAART univariably increased hospital mortality, 1.8 (1.02-3.2), but not significantly in multivariable analysis | No association | No association | No association | No prior HAART independently increased ICU mortality, 3.33 (1.43-10.0)
c
| No ART use in ICU independently increased 6-month mortality, 2.00 (1.41-2.86) | No association | No association |
CD4 count (cells/mm3) | - | - | CD4 < 200 univariably increased hospital mortality, 2.24 (1.16-4.31), but not significantly in multivariable analysis | No association | - | CD4 < 50 independently increased ICU mortality, 2.10 (1.17-3.76) | No association | CD4 (per 10-cells/mm3 decrease) independently increased hospital mortality, 1.036 (1.003-1.069) |
Admission diagnosis of sepsis | - | No significant difference between with sepsis and respiratory failure | - | Severe sepsis independently increased ICU mortality, 3.67 (1.53-8.80) | Septic shock independently increased ICU mortality, 2.4 (1.1-5.2)
c
| Sepsis independently increased ICU mortality, 3.16 (1.65-6.06) | Severe sepsis/septic shock independently increased 28-day mortality, 3.13 (1.21-8.07)
c
| Sepsis independently increased hospital mortality, 2.91 (1.11-7.62) |
Hospital-to-ICU interval | - | - | - | Delayed ICU admission independently increased ICU mortality, 3.04 (1.29-7.71) | - | - | - | Hospital-to-ICU interval > 24 hours univariably increased hospital mortality, 2.72 (1.23-6.01), but not significantly in multivariable analysis |
Serum albumin level (g/dL) | Serum albumin < 2.6 independently increased hospital mortality, 3.5 (1.8-6.6) | Lower serum albumin (per 1-g/dl decrease) independently increased hospital mortality, 2.08 (1.41-3.06) | - | - | No association | No association | - | Lower serum albumin (per 1-g/dl decrease) univariably increased hospital mortality, 1.69 (1.04-2.74), but not significantly in multivariable analysis |
Conclusions
Key messages
-
Respiratory failure is the most common cause of ICU admission for HIV-infected patients in the era of HAART, followed by sepsis and neurological disease.
-
The hospital mortality of HIV-infected patients who are admitted to the ICU is associated with low CD4 lymphocyte count and the diagnosis of sepsis.
-
Low serum albumin level and delayed ICU admission are associated with poor outcome.