1Division of Infectious Diseases, San Giuseppe Moscati Hospital, Avellino, Italy
Received date: December 12, 2016; Accepted date: December 13, 2016; Published date: December 15, 2016
Citation: Leone S, Masiello A, Fiore M, et al. (2016) Sepsis in People Living with HIV Infection: A Negligible Issue? J Heart Health Cir 1:1.
Copyright: © 2016 Leone S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The widespread use of combination antiretroviral therapy (cART) has substantially improved the prognosis of patients infected with HIV . However, despite cART, HIV-infected patients are at greater risk of death compared to general uninfected population. As a consequence of the increase in survival, non-AIDS-related diseases now are a leading cause of death . A large national cohort study from England and Wales found that AIDS- and non-AIDS related deaths accounted for 58% and 42% of cases, respectively. Furthermore, the analysis found that the mortality due to non- AIDS defining infections among HIV-infected patients is significantly higher than that of the general population (standardised mortality ratio 11; 95% confidence interval [CI] 9.8 to 12) .
HIV infection is associated with an increased risk of severe bacterial infections, including pneumonia, skin and soft tissue infections, and infective endocarditis [4-6]. However, few data have been published on the characteristics and outcome of sepsis in patients with HIV infection.
Overall, sepsis is associated with high morbidity and mortality in critically ill HIV-uninfected and HIV-infected patients [7,8]. In Euro SIDA cohort, sepsis in HIV-infected patients occurred at an incidence rate of 1.14 cases (95%CI 0.82 to 1.55) per 1000 person-years of follow-up (PYFU) with an increased risk in patients with advanced HIV disease (CD4+ cell count of <200 cells/μL) . Sepsis accounts for a large share of critically ill HIV-positive patients admitted to the Intensive Care Units (ICUs) .
The etiology of sepsis in HIV-infected patients depends on many factors including age, CD4+ cell count, clinical setting (community-acquired [CA] or hospital-acquired [HA] infection) and geographic area (developed or developing countries) . On this point, in a systematic review, Huson et al. found that non-typhoid salmonellae (36.6%), Streptococcus pneumoniae (30.4%), Escherichia coli (7.5%), and Staphylococcus aureus (7.0%) are the most common pathogens of CA-bacterial bloodstream infections in HIV-infected patients. Furthermore, compared to HIV-uninfected patients, HIV-infected patients had an increased risk to develop non-typhoid salmonellae bloodstream infections (odds ratio [OR] 6.59; 95%CI 3.70 to 11.71). However, when are analyzed only the causative pathogens in adult HIV-infected patients living in developed countries, S. pneumoniae is the leading cause of sepsis accounting 22.8% of all isolates, followed by S. aureus (19.6%), Salmonella spp. (10.8%), and E. coli (10.5%) . Moreover, over the last decade, methicillin-resistant S. aureus (MRSA) strains have emerged as serious pathogens in the nosocomial (HA-MRSA) and community (CA-MRSA) setting [13-15].
Septic HIV-infected patients admitted to the ICU have a worse prognosis than patients without HIV infection. On this point, Mrus et al. observed that HIV-infected patients admitted to the ICU for severe sepsis had an increased likelihood of death than HIV-uninfected patients (OR 2.41; 95%CI 2.23 to 2.61) . Moreover, an observational study on critically ill patients admitted to the ICU showed that severe sepsis independently affected the short- and long-term mortality of HIV population (adjusted hazard ratios [HRs] for 30-day and 6- month mortality were 3.13 [95%CI 1.21 to 8.07] and 3.35 [95%CI 1.42 to 7.86], respectively) .
Finally, although debated by some authors, cART appears to be a major determinant of outcome in HIV-infected patients admitted to the ICU [17-19]. In a retrospective study Morquin, et al. found that the introduction of the cART in untreated patients is associated with a better long-term outcome (HR 0.166; 95%CI 0.043 to 0.642) . Similarly Amancio, et al., in a observational cohort study including HIV-infected patients admitted to a Brazilian ICU, observed that cART is associated with a lower in-ICU mortality (OR 0.19; 95%CI 0.05 to 0.77) . On the other hand, Meybeck no found benefit of cART on survival of HIV-infected patients, while observed that the administration of cART during ICU stay is associated with higher incidence of antiretroviral resistance after ICU stay . In conclusion, despite the decrease in HIV-associated morbidity and mortality with the advent of cART, sepsis is yet a concern in HIV population. Further investigations to better characterize the role of cART as an independent prognostic factor for ICU survival are needed.