Trends in mortality and antibiotic resistance among HIV‐infected patients with invasive pneumococcal disease

Abstract

Objectives The aim of the study was to describe trends and risk factors for mortality and changes in antibiotic resistance, serotypes and clones among HIV‐infected patients with invasive pneumococcal disease (IPD). Methods A prospective study of 199 episodes of IPD occurring in a cohort of 4011 HIV‐infected patients was carried out. Predictors of mortality included clinical and microbiological data. The 7‐valent pneumococcal conjugate vaccine (PCV7) for children was introduced in late 2001. Time periods were classified for mortality studies as pre‐ (1986–1996), early (1997–2001) and late (2002–2007) highly active antiretroviral therapy (HAART) era, and for serotype studies as pre‐PCV7 (1986–2001) and PCV7 (2002–2007) era. Results Of 199 IPD episodes, 71 (36%) occurred in HIV‐infected patients with associated comorbidities (mainly liver cirrhosis; 52 of 71), which increased in recent years. The incidence of IPD decreased from the pre‐HAART era to the early HAART era and then remained stable in the late HAART era (24.1, 8.4 and 7.4 episodes per 1000 patient‐years, respectively). Rates of 30‐day mortality have risen over the three periods (8, 19 and 25%, respectively; P=0.017). In multiple logistic regression analysis, predictors of mortality were shock at presentation [odds ratio (OR) 7.01; 95% confidence interval (CI) 2.05–23.87] and associated comorbidities (OR 4.27; 95% CI 1.53–11.92). In the PCV7 era, IPD caused by non‐PCV7 serotypes increased, and resistance to betalactams decreased. The most frequent genotypes were Spain9V‐ST156, Spain23F‐ST81, ST8819F, Sweden1‐ST304 and Spain6B‐ST90. Conclusions In the late HAART era, the incidence of IPD has not significantly decreased. Mortality from IPD has risen in association with an increase in comorbidities such as liver cirrhosis. New vaccination strategies are needed to diminish the burden of IPD in the HIV‐infected population.

Actualités dans les infections invasives à pneumocoque chez le patient infecté par le VIH

“…Depuis la généralisation des traitements, le taux de mortalité des IIP reste élevé, évalué à 25 % environ [1,9]. De façon paradoxale, il semblerait même qu'il soit relativement plus élevé qu'avant les trithérapies, probablement parce que les patients VIH+ présentant des IIP souffrent actuellement plus souvent de comorbidités, et notamment de cirrhose, que les patients présentant des IIP dans la période pré-ART [18].…”

“…Le vaccin a ainsi permis de diminuer l'exposition des pneumocoques à la pression de sélection antibiotique et donc d'une façon indirecte de réduire le portage de souches de pneumocoques résistants. Chez les patients infectés par le VIH, la résistance des pneumocoques est en baisse comme dans la population générale [18]. Des données récentes de notre équipe retrouvent toujours une discrète augmentation du risque d'infection par des PSDP [33].…”

AIDS and Opportunistic Infections

“…However, in a recent report, no obvious difference in pneumococci resistance patterns has been found between HIV-positive and negative patients (Stephan et al, 2009). Also, in a study in which the trend of S. pneumoniae antibiotic resistance has been evaluated, a near significant decrease in penicillin-resistant strains in the late-HAART compared with of pre and early-HAART era has been found (Grau et al, 2009). Patients on TMP-SMX prophylaxis for Pneumocystis pneumonia may be more likely to have penicillin and TMP-SMX resistant S. pneumoniae.…”

Immunization of HIV-infected adult patients — French recommendations

“…28 Such infections are associated with high mortality. 29 The primary risk factor for pneumococcal infection in HIV-infected patients is immunodeficiency. Other risk factors include smoking, intravenous drug addiction and uncontrolled HIV replication (>500 copies/mL).…”