Current antimicrobial management of community-acquired pneumonia in HIV-infected children

ABSTRACT

Introduction: Community-acquired pneumonia is a leading cause of morbidity and mortality amongst HIV-infected infants and children. Polymicrobial infection is common and, due to the difficulties in confirming the etiology of pneumonia, empiric broad-spectrum antimicrobial therapy is frequently used.

Areas covered: The author based this article on literature identified from PubMed. The author’s search terms included: pneumonia, community-acquired pneumonia, HIV, children. The articles reviewed included original studies, recent review articles and current guidelines on the management of pneumonia in HIV-infected children. The microbiological etiology and the empiric and pathogen-specific antimicrobial therapy of community-acquired pneumonia in HIV-infected and HIV-exposed infants and children are also discussed.

Expert opinion: There are many changing epidemiological factors impacting antimicrobial management of community-acquired pneumonia in the context of HIV infection in infants and children. These include vaccination strategies, antimicrobial prophylaxis, emerging drug-resistant pathogens, and recognition of the importance of viruses and tuberculosis in the etiology of community-acquired pneumonia. Further research is needed on optimal amtimicrobial management strategies in HIV-exposed uninfected children, and HIV-infected children receiving antiretroviral therapy.

KEYWORDS:

• Children
• antimicrobial
• HIV
• pneumonia
• community-acquired

Article highlights

• HIV infection is a significant risk factor for death in children <5 years of age with pneumonia and the vast majority of deaths due to HIV-associated pneumonia occur in Africa.

• Establishing an etiological diagnosis of pneumonia in young children is difficult as a result of overlapping and non-specific clinical features, limited availability of diagnostic tests, and challenges in the interpretation of microbiological isolates from respiratory specimens due to high rates of polymicrobial infection and colonization.

• Rapid initiation of broad-spectrum, first-line empirical antimicrobial therapy including ampicillin and gentamicin (directed primarily at S. pneumoniae & H. influenzae), cotrimoxazole in combination with corticosteroids (directed at Pneumocystis jirovecii) and ganciclovir (directed at Cytomegalovirus) is recommended for HIV-infected infants and children who are not yet established on antiretroviral therapy and presenting with community-acquired pneumonia, particularly if hypoxic.

• In the context of decreasing rates of mother-to-child transmission of HIV infection, there are increasing numbers of HIV-exposed, uninfected infants and young children, and also older HIV-infected children who started antiretroviral therapy and who may be stable on treatment, have interrupted treatment or are failing treatment and present with community-acquired pneumonia and for whom antimicrobial treatment considerations may be different.

• The role and prevalence of bacterial, mycobacterial, fungal and viral infections that are resistant to first-line antimicrobials used in treating community-acquired pneumonia needs ongoing evaluation and surveillance.

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Declaration of interest

J Nuttall has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.