Both pneumococcal and influenza vaccines should be routinely given to this group of patients to decrease the morbidity and mortality from respiratory disease. Unfortunately, the patient with AIDS does not respond well to vaccination; therefore, early detection and aggressive treatment of infection are the most reasonable avenues to pursue. One possible mode of therapy to consider in adult AIDS patients with recurrent bacterial infections is the use of monthly intravenous 7-globulin infusions. It appears to markedly decrease the incidence of bacterial infections in pediatric patients with AIDS and ARC.
It was unclear from the study by Austrian and Gold as to what caused their early death rate.
Nosocomial strep pneumonia, the fourth leading type of hospital-acquired pneumonia, occurred in two AIDS patients and one patient without HIV infection in this study. These three patients were elderly or had a humoral immunodeficiency (AIDS), both of which factors predispose to strep pneumonia pulmonary infection. Two patients survived and one AIDS patient with nonobstructive jaundice died. Unlike our patients, most noisocomial pneumonias are secondary to Gram-negative bacillary infection and have a greater than 50 percent mortality rate. Most of these Gram-negative bacillary nosocomial pneumonias occur in patients with respiratory assist devices. None of these three patients had a respiratory support device when the pneumonia occurred.
Bacteremic pneumococcal pneumonia mortality in the AIDS population has a time frame similar to that in the non-HIV-infected patients. Six of eight patients died of septic shock. Five of six patients in septic shock also died within five days. Initial penicillin therapy was given to 37.5 percent of AIDS patients who died and 33 percent of patients who survived. Again, when mortality is evaluated only in patients who survived more than five days of antibiotic therapy, there were only three deaths (33.3 percent mortality). This is a reduced mortality that is still five times the mortality rate in patients without HIV infection.
The five patients with strep pneumonia and the six patients with Hemophilus influenzae pneumonia survived. One other case report noted two patients, one with strep pneumonia and one with H influenzae pneumonia, who had an AIDS-like clinical and immunologic profile. Both patients developed a fulminant pneumonia requiring mechanical respiratory support and each survived with aggressive treatment.
Finally, in AIDS, there is partial or complete loss of both T cell-dependent and T cell-independent B-cell stimulation. Therefore, AIDS patients have lost most of their ability to direct an appropriate B-cell response to invading antigens (bacterial pathogens) and are much more prone to bacterial infections. This is despite the fact that there is a nonspecific polyclonal activation of B cells and often hypergammaglobulinemia, which may actually hinder a de novo antibody response. In ARC there is still some B cell-directed antibody response to antigen as well as residual protective antibody from previous antigen exposures.
Studies have shown that HIV infections cause a graded impairment of antibody response depending on the progression of disease. Clinical HIV infection ranges from asymptomatic to an acute infectious mononucleosis-like syndrome, to AIDS-related complex (ARC), often associated with generalized lymphadenopathy, oral thrush, or wasting, and AIDS. Asymptomatic HJV-infected individuals have a good antibody response to both the trivalent influenza vaccine (T cell-dependent B-cell stimulator) and the 23-valent pneumococcal vaccine (T cell-independent B-cell stimulator).
Of the six surviving AIDS patients, three received cephalosporins, two received penicillin, and one received clindamycin with aminoglycosides.
Of the six non-HIV-infected patients who died, three received cephalosporins, two received penicillin, and one was not treated. Thirteen patients in the group of 18 survivors received penicillin, three received cephalosporins, one received erythromycin, and one received clindamycin.
Mortality: Patients without HIV Infection
All six patients died of septic shock in this group. Patients 1, 2, 15, and 22 all died within the first 24 h of hospitalization despite antibiotic therapy. Interestingly (Table 2), patients 1, 2, and 15 had liver disease and all four patients were heavy drinkers. Patient 10, a heavy drinker, died in 14 days despite antibiotic therapy. Patient 12, a known smoker, was admitted to the hospital for hemoptysis with known Mycobacterium tuberculosis who was receiving antituberculous therapy. He died of septic shock after five days and was never treated for his pneumococcal pneumonia. Five of six patients were heavy drinkers and three of six patients were heavy smokers.
Six of the eight patients died of septic shock and two died of respiratory failure. Of the six patients with septic shock (five of six intubated, one of six designated “do not resuscitate” and not intubated), five died in five days or less (average, 2.8 days). One patient in septic shock was hospitalized for 31 days for jaundice and developed a nosocomial pneumonia and subsequently died. The two patients with respiratory failure (1 and 7) had an average hospital stay of 31 days. Patient 1 had combined PCP and strep pneumonia, and the other patient had pneumonia complicated by a spontaneous pneumothorax and death.
After resolution of PCP patient 3 developed a fever, new infiltrate, tod strep pneumonia in blood cultures and was treated for a hospital-acquired pneumonia. The third AIDS patient with a bilateral interstitial pneumonia had suspected PCP and refused bronchoscopy. He was treated with trimethoprim-suifamethoxazole and died in septic shock a few days later with strep pneumonia. If these three AIDS patients with PCP (and bilateral infiltrates) are excluded from the statistical analysis, there is no difference between the occurrence of unilateral and bilateral pneumonia. A strong smoking history was present in five of 14 AIDS patients, 18 of 24 non-HIV-infected patients, and six of 11 HIV-infected non-AIDS patients. Two of 14 AIDS patients, 12 of 24 non-HIV-infected patients, and two of 11 HIV-infected non-AIDS patients were heavy drinkers.