Treating bacterial pneumonia in people living with HIV

ABSTRACT

Introduction: Bacterial pneumonia remains an important cause of morbidity and mortality in people living with HIV (PLWH) in the antiretroviral therapy (ART) era. In addition to being immunocompromised, as reflected by low CD4 cell counts and elevated HIV viral loads, PLWH often have other behaviors associated with an increased risk of pneumonia including smoking and injected drug use. As PLWH are aging, comorbid conditions such as chronic obstructive pulmonary disease (COPD), cancers, and cardiovascular, renal and liver diseases are emerging as additional risk factors for pneumonia. Pathogens are often similar to those in HIV-uninfected individuals; however, PLWH are at risk for unusual and/or multi-drug resistant organisms causing bacterial pneumonia based, in part, on their CD4 cell counts and other exposures.

Areas covered: In this review, we focus on the recognition and management of bacterial community-acquired pneumonia (CAP) in PLWH. Along with antimicrobial treatment, we discuss prevention strategies such as vaccination and smoking cessation.

Expert opinion: Early initiation of ART after HIV infection can decrease the risk of pneumonia. Improved efforts at vaccination, smoking cessation, and reduction of other substance use are urgently needed in PLWH to decrease the risk for bacterial pneumonia. As PLWH are aging, comorbidities are additional risk factors for bacterial CAP.

KEYWORDS:

• Bacterial pneumonia
• HIV
• pneumonia risk
• treating pneumonia
• vaccination
• pneumonia pathogens
• smoking HIV

Article Highlights

• Bacterial pneumonia remains an important cause of morbidity and mortality in people living with HIV (PLWH) in the antiretroviral therapy (ART) era, even in those with well-controlled HIV.

• Initial evaluation of PLWH should include a focused history that identifies the level of immunosuppression and HIV disease control (prior CD4 cell counts, HIV viral load, use of ART and antimicrobial prophylaxis, if indicated), risk for endemic organisms including tuberculosis, fungi, as well as opportunistic infections and multi-drug resistant organisms.

• Pneumonia severity indexes, though mainly validated in HIV-uninfected individuals, may be utilized as a part of the decision-making process in determining inpatient or outpatient treatment location.

• In PLWH with well-controlled HIV and CD4 cell counts over 200–350 cells/µL, treatment for bacterial community-acquired pneumonia (CAP) is generally the same as in HIV-uninfected individuals. In these patients, beta-lactam monotherapy should be used for individuals treated as outpatients and those with mild disease. Hospitalized patients should be treated with beta-lactam/macrolide combination therapy or fluoroquinolone monotherapy. Macrolides or fluoroquinolones should be added to beta-lactams for treatment of severe pneumonia (Pneumonia Severity Index of IV or greater).

• Individuals with risks for multi-drug resistant organisms should be covered empirically while awaiting results of the microbiologic evaluation.

• All PLWH should receive pneumococcal vaccination and annual influenza vaccination per the US Advisory Committee on Immunization Practices (ACIP) recommendations.

Declaration of interest

The authors have 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.

Reviewers Disclosure

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

Additional information

Funding

This paper was not funded.