Early Predictors of Mortality from Pneumocystis jirovecii Pneumonia in HIV‐Infected Patients: 1985–2006
1Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, 2Centre for Sexual Health and HIV Research, Department of Primary Care and Population Sciences, University College London, and 3Department of Genitourinary Medicine, Mortimer Market Centre, Camden Primary Care Trust, London, United Kingdom; and 4Research Service, Veterans Affairs Medical Center and 5Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
Background.
Pneumocystis jirovecii pneumonia (PCP) remains the leading cause of opportunistic infection among human immunodeficiency virus (HIV)–infected persons. Previous studies of PCP that identified case‐fatality risk factors involved small numbers of patients, were performed over few years, and often focused on patients who were admitted to the intensive care unit.
Objective.The objective of this study was to identify case‐fatality risk factors present at or soon after hospitalization among adult HIV‐infected patients admitted to University College London Hospitals (London, United Kingdom) from June 1985 through June 2006.
Patients and Methods.We performed a review of case notes for 494 consecutive patients with 547 episodes of laboratory‐confirmed PCP.
Results.Overall mortality was 13.5%. Mortality was 10.1% for the period from 1985 through 1989, 16.9% for the period from 1990 through June 1996, and 9.7% for the period from July 1996 through 2006 (
). Multivariate analysis identified factors associated with risk of death, including increasing patient age (adjusted odds ratio [AOR], 1.54; 95% confidence interval [CI], 1.11–2.23; 
), subsequent episode of PCP (AOR, 2.27; 95% CI, 1.14–4.52; 
), low hemoglobin level at hospital admission (AOR, 0.70; 95% CI, 0.60–0.83; 
), low partial pressure of oxygen breathing room air at hospital admission (AOR, 0.70; 95% CI, 0.60–0.81; 
), presence of medical comorbidity (AOR, 3.93; 95% CI, 1.77–8.72; 
), and pulmonary Kaposi sarcoma (AOR, 6.95; 95% CI, 2.26–21.37; 
). Patients with a first episode of PCP were sicker (mean partial pressure of oxygen at admission ± standard deviation, 
kPa) than those with a second or third episode of PCP (mean partial pressure of oxygen at admission ± standard deviation, 
kPa; 
), but mortality among patients with a first episode of PCP (12.5%) was lower than mortality among patients with subsequent episodes of PCP (22.5%) (
). No patient was receiving highly active antiretroviral therapy before presentation with PCP, and none began highly active antiretroviral therapy during treatment of PCP.
Conclusions.Mortality risk factors for PCP were identifiable at or soon after hospitalization. The trend towards improved outcome after June 1996 occurred in the absence of highly active antiretroviral therapy.
Received 19 June 2007; accepted 7 October 2007; electronically published 10 January 2008.
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(See the editorial commentary by Morris on pages 634–6)
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