Severe pneumonia in HIV-infected and exposed infants in a paediatric ICU

Abstract

Within South Africa (SA) (as in many other countries), HIV infection is a significant cause of morbidity in women and their infants. In SA, 26% of pregnant women are HIV-infected, and in the absence of preventive therapy there is a 15-30% risk of HIV infection in their infants. [1,2] Even children who are part of the prevention of motherto-child transmission (PMTCT) programme have an increased risk of HIV-related infection relative to those who are not exposed, although that risk is substantially reduced. Mortality in HIV-infected children results primarily from respiratory tract infections. [3,4] In children (especially HIV-infected children) with acute severe respiratory disease requiring endotracheal intubation and ventilation, a number of pathogens (including Pneumocystis jiroveci and cytomegalovirus (CMV)) have been isolated. (The term PCP (P. pneumonia) was retained when P. carinii was taxonomically renamed P. jiroveci). Although there has been considerable focus on P. jiroveci as a cause of mortality, [5] CMV infection has been reported to affect nearly 90% of HIV-exposed infants, [6] especially HIVexposed infants with severe pneumonia. Admitting HIV-infected infants with severe pneumonia to an intensive care unit (ICU) in a resource-limited setting has created a number of ethical dilemmas for paediatricians, which have been accentuated by the historically poor outcome for these patients and the pressure on scarce resources. [7] However, previous reports have suggested that severe pneumonia can now be successfully treated when the mode of ventilation and antibiotic therapy is appropriate for all pathogens that may be present. [8] The successful management of PCP requires careful attention to ventilation strategies, fluid restriction and multiple antibiotics. [9] Objective To report on the progress in improving survival of HIV-exposed and-infected infants admitted to a PICU with respiratory failure and acute respiratory distress syndrome (ARDS), and to explore the relationship between therapeutic strategies (which have not changed since the previous study) [9] and patient outcomes. In addition, this follow-up study reports on the use of highly active antiretroviral treatment (HAART) initiated in the PICU. Methods All HIV-exposed infants admitted to the PICU at the Steve Biko Academic Hospital in Pretoria, SA, with respiratory failure were recruited into this study. Patients had to fit the diagnosis of ARDS as described by Bernard et al., [8] the most important criterion being hypoxic acute lower respiratory tract infection with a partial pressure of oxygen in mmHg over fraction of inspired oxygen (P/F) ratio of <200. Each infant was ventilated using a strategy of high positive end expiratory pressure (PEEP) of 10-15 cm of water, a tidal volume of 6-8 mL/kg and a positive inspiratory pressure (PIP) not exceeding 30 cm of water. Tidal volume was read from the ventilator display despite limitations of this technique. [10,11] None of the infants was offered high-frequency oscillation ventilation. Total fluid in...

HIV exposure and its association with paediatric ICU outcomes in children admitted with severe pneumonia at Chris Hani Baragwanath Academic Hospital, South Africa

“…The overall mortality was in keeping with recent studies which have shown an improvement in survival from 32% to 35% in the early 1990s to 82% to 90% in 2009 -2011. [15,[18][19][20] However, although it was still slightly higher than that found in high-income countries where overall PICU mortality averages 6%, it is in keeping with their mortality rates for serious bacterial infections and pneumonia (~17.5% in children). [19][20][21] The median PICU length of stay was 8 days.…”

“…[9][10][11][12][13] As a result, HIV-exposed uninfected (HIV-EU) babies now account for as many as 30% of all births in parts of southern Africa. [9,14,15] However, the effect of HIV exposure on pneumonia morbidity and mortality risk is less well known. They are nevertheless considered a vulnerable population and appear to have an increased morbidity and mortality rate from infections when compared with their HIV-unexposed (HIV-U) counterparts.…”