Chest

Chest

Volume 135, Issue 1, January 2009, Pages 11-17
Journal home page for Chest

Original Research
Critical Care Medicine
Survival for Patients With HIV Admitted to the ICU Continues to Improve in the Current Era of Combination Antiretroviral Therapy

https://doi.org/10.1378/chest.08-0980Get rights and content

Background

The combination antiretroviral therapy (ART) era (1996 to the present) has been associated with improved survival among HIV-infected outpatients, but ICU data from 2000 to the present are limited.

Methods

We conducted a retrospective study of HIV-infected adults who had been admitted to the ICU at San Francisco General Hospital (from 2000 to 2004). The primary outcome was survival to hospital discharge.

Results

During the 5-year study period, there were 311 ICU admissions for 281 patients. Respiratory failure remained the most common indication for ICU admission (42% overall), but the proportion of patients with respiratory failure decreased each year from 52 to 34% (p = 0.02). Hospital survival ratios significantly increased during the 5-year period (p = 0.001). ART use at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts, lower plasma HIV RNA levels, higher serum albumin levels, and lower proportions with AIDS-associated ICU admission diagnoses and with Pneumocystis pneumonia. In a multivariate analysis, a higher serum albumin level (adjusted odds ratio [AOR], 2.08; 95% confidence interval [CI], 1.41 to 3.06; p = 0.002) and the absence of mechanical ventilation (AOR, 6.11; 95% CI, 2.73 to 13.72; p < 0.001) were associated with survival.

Conclusions

In this sixth in a series of consecutive studies started in 1981, we found that the epidemiology of ICU admission diagnoses continues to change. Our study also found that survival for critically ill HIV-infected patients continues to improve in the current era of ART. Although ART use was not associated with survival, it was associated with predictors that were associated with survival in a multivariate analysis.

Section snippets

Study Design and Subjects

We conducted a retrospective cohort study of all HIV-infected adults who had been admitted to the ICU at SFGH from 2000 through 2004. SFGH is an urban public hospital, with 375 beds and 30 ICU beds. A computerized search of SFGH ICU admissions using the International Classification of Diseases, ninth revision, diagnostic code for HIV (042) identified patients with HIV who had been admitted to the ICU. The University of California, San Francisco, Committee on Human Research approved the study

Results

There were 311 ICU admissions for 281 patients. Twenty-five patients (9%) had more than one ICU admission during the 5-year study period. Because few patients had repeat ICU admissions, each ICU admission that occurred during a subsequent hospitalization was treated as a separate event. The predictors of survival identified from the multivariate analysis were unchanged if these repeat patient admissions were excluded.

Discussion

This study is notable in that it is the sixth in a series of consecutive studies that was started in 1981 to examine the critical care provided to HIV-infected patients at SFGH.2, 9, 12, 13, 17 In addition, our study is among the few studies to examine HIV patients who have been admitted to the ICU since the year 2000, and we have noted several important trends. Our study shows that in the current era of ART respiratory failure remains the most common indication for ICU admission, although the

References (27)

  • M Narasimhan et al.

    Intensive care in patients with HIV infection in the era of highly active antiretroviral therapy

    Chest

    (2004)
  • VA De Palo et al.

    Outcome of intensive care in patients with HIV infection

    Chest

    (1995)
  • FJ Palella et al.

    Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection: HIV Outpatient Study Investigators

    N Engl J Med

    (1998)
  • A Morris et al.

    Intensive care of human immunodeficiency virus-infected patients during the era of highly active antiretroviral therapy

    Am J Respir Crit Care Med

    (2002)
  • A Morris et al.

    Improved survival with highly active antiretroviral therapy in HIV-infected patients with severe Pneumocystis carinii pneumonia

    AIDS

    (2003)
  • H Khouli et al.

    Outcome of critically ill human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy

    J Intensive Care Med

    (2005)
  • RF Miller et al.

    Improved survival for HIV infected patients with severe Pneumocystis jirovecii pneumonia is independent of highly active antiretroviral therapy

    Thorax

    (2006)
  • SJ Dickson et al.

    Survival of HIV-infected patients in the intensive care unit in the era of highly active antiretroviral therapy

    Thorax

    (2007)
  • L Huang et al.

    Intensive care of patients with HIV infection

    N Engl J Med

    (2006)
  • RM Wachter et al.

    Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization

    Am Rev Respir Dis

    (1986)
  • PL Rogers et al.

    Admission of AIDS patients to a medical intensive care unit: causes and outcome

    Crit Care Med

    (1989)
  • JM Luce et al.

    Intensive care for patients with the acquired immunodeficiency syndrome

    Intensive Care Med

    (1989)
  • RM Wachter et al.

    Pneumocystis carinii pneumonia and respiratory failure in AIDS: improved outcomes and increased use of intensive care units

    Am Rev Respir Dis

    (1991)

    • Cited by (0)

    The contents of this study are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources of the National Institutes of Health. Information on the National Center for Research Resources is available at http://www.ncrr.nih.gov/. Information on Re-engineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp.

    This research was funded by NIH grants 1F32HL088990 (J.L.D.), 1R01HL090339 (A.M.), 5K24HL087713 (L.H.), and 1R01HL090335 (L.H.). This project was also supported by grant No. 1 UL1 RR024131–01 from the National Center for Research Resources, a component of the NIH, and by the NIH Roadmap for Medical Research.

    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text
    Copyright © 2009 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.