THE CHANGING FACE OF AIDS

Patients with acquired immunodeficiency syndrome (AIDS) who are admitted to an intensive care unit (ICU) increasingly present with bacterial sepsis rather than with Pneumocystis carinii pneumonia (PCP), according to the authors of an observational cohort study conducted in Washington, DC. AIDS patients who have a sepsis syndrome of unknown etiology should receive broad-spectrum antibacterial therapy.

Rosenberg and colleagues conducted a 2.5-year study of the causes and outcomes of sepsis in 129 consecutive AIDS patients admitted to an ICU. In 102 patients (79%), the primary reason for admission was infection; 46 (45%) of the patients had bacterial infections, with Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus pneumoniae the most commonly isolated organisms. The lung was the most common site of infection. Lung infections were responsible for 66 (65%) of the admissions; PCP, in 27 patients (41%), was the most common cause of pneumonia.

Overall hospital mortality was 54%. It was much higher—68%—among the patients with bacterial sepsis. Eighteen percent of the patients had sepsis, and 73% had septic shock. Mortality correlated significantly with the severity of infection and of sepsis. The most important single clinical predictor of mortality was the admission APACHE III score. Bacterial infections and pneumonia were also predictive of mortality.

The authors suggest that patients who are not receiving or no longer responding to highly active antiretroviral therapies may be at increasing risk for bacterial infections. Thus, greater attention should be paid to bacterial sepsis when evaluating AIDS patients admitted to an ICU.

In an accompanying editorial, Proctor notes that in patients with AIDS, infections may progress from routine to more severe and thus may require ICU admission. In view of the high mortality associated with bacterial sepsis in the study by Rosenberg and colleagues, he recommends that broad-spectrum antibiotics be used in all seriously ill human immunodeficiency virus–infected patients until it becomes possible to exclude infections with pyogenic bacteria.

Proctor adds that combination antibiotic therapy will be needed to treat drug-resistant S aureus and P aeruginosa infections. A more aggressive approach at the onset of antibiotic therapy may reduce mortality.

Rosenberg AL, Seneff MG, Atiyeh L, et al. The importance of bacterial sepsis in intensive care unit patients with acquired immunodeficiency syndrome: implications for future care in the age of increasing antiretroviral resistance. Crit Care Med. 2001;29:548-556.

Proctor RA. Bacterial sepsis in patients with acquired immunodeficiency syndrome [editorial]. Crit Care Med. 2001;29:683-684.

10-DAY STEROID REGIMEN SUPERIOR TO THREE-DAY REGIMEN IN COPD?

In patients with severe exacerbations of chronic obstructive pulmonary disease (COPD), a 10-day course of corticosteroids is superior to a three-day course in terms of outcome but not exacerbation rates, report the authors of a prospective, randomized study from Turkey.

Sayiner et al compared the effectiveness of three- and 10-day courses of methylprednisolone in 36 COPD patients who had experienced exacerbations requiring hospitalization. For the first three days, all patients were treated with methylprednisolone (0.5 mg/kg every six hours). Eighteen patients were then randomized to continue treatment for an additional seven days, during which the dose was tapered and eventually discontinued. The other 18 patients received placebo after the first three days. Seventeen patients in each group completed the study.

Arterial oxygen tension and forced expiratory volume in one second improved significantly in both groups, but more so in patients treated for 10 days. The pH levels normalized in both groups, and the arterial carbon dioxide tension did not change in either group. Forced vital capacity improved only in patients on the 10-day regimen. Both groups reported significant improvement in all symptom scores (dyspnea during the day, at night, and with exertion; cough; and sputum volume), but dyspnea with exertion was significantly more improved in the 10-day group. Hyperglycemia developed in two patients in each group and was controlled by adjusting caloric intake.

During a six-month follow-up, six patients in the three-day group experienced eight exacerbations, and the five patients in the 10-day group had one exacerbation each. These differences were not significant.

Sayiner A, Aytemur ZA, Cirit M, Ünsal I. Systemic glucocorticoids in severe exacerbations of COPD. Chest. 2001;119:726-730.

LOW-DOSE VASOPRESSIN VERSUS HIGH-DOSE CATECHOLAMINES

Low-dose infusions of vasopressin are associated with clinically important increases in blood pressure, systemic vascular resistance, and urinary output in hypotensive patients with vasodilatory septic shock, say the authors of a prospective, case-controlled trial from Japan.

Tsuneyoshi et al studied the cardiovascular and metabolic effects of a continuous intravenous infusion of vasopressin (0.04 U/min for 16 hours) in 16 septic patients with persistent hypotension despite adequate fluid resuscitation and infusions of pharmacologic doses of catecholamines. Vasopressin therapy resulted in significant increases in blood pressure and systemic vascular resistance index, starting with the first measurement at two hours and continuing to the end of treatment. No significant changes were seen in mean pulmonary artery pressure, pulmonary vascular resistance, cardiac index, heart rate, pulmonary artery occlusion pressure, or central venous pressure.

Vasopressin therapy stabilized 14 of the 16 patients. Two remained unstable with persistent hypotension. Overall, there were no significant treatment-related changes from baseline in the metabolic or electrolyte values or in the concentrations of atrial natriuretic peptide, aldosterone, angiotensin II, or renin. Urinary output increased in 10 patients, but not in six patients who were anuric before the start of treatment. The authors noted that this effect may be nonspecific.

Seven patients died, for a mortality rate of 44%. They included the two patients who remained hypotensive despite vasopressin therapy and five patients with multiple organ failure.

Tsuneyoshi I, Yamada H, Kakihana Y, et al. Hemodynamic and metabolic effects of low-dose vasopressin infusions in vasodilatory septic shock. Crit Care Med. 2001;29:487-493.

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