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Lack of ART Tied to Tripled Mortality in
Veterans With Community-Acquired Pneumonia
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IDWeek, October 2-6, 2013, San Francisco
Mark Mascolini
Not taking antiretroviral therapy (ART) prolonged hospital stays and tripled chances of death in a large study of older US veterans with community-acquired pneumonia (CAP) [1]. Compared with HIV-negative veterans with CAP, HIV-positive veterans with CAP had almost a 50% higher VACS Index score, and every 5-point higher score boosted chances of death 20% in veterans with HIV.
Although CAP is a leading cause of death in people without HIV infection, its impact on morbidity and mortality in HIV-positive people remains poorly understood. To further that understanding, Yale University researchers and colleagues at other institutions explored associations between CAP and three health outcomes in male veterans older than 49 in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC): 30-day mortality, hospital readmission within 30 days of discharge, and length of hospital stay.
The investigators studied veterans admitted to the hospital between October 2002 and August 2010. All men were at least 50 years old when hospitalized with CAP. The researchers calculated each veteran's VACS Index score, a cumulative tally considering CD4 count, viral load, anemia, liver injury, renal injury, and hepatitis C infection [2]. The VACS Index score predicts mortality better than CD4 count or viral load alone when antiretroviral therapy begins [2].
The analysis focused on 1203 veterans with a CAP diagnosis and complete data available; 670 (56%) had HIV and 533 did not. The HIV-positive group included a significantly lower proportion who were 65 or older (10.4% versus 21.0%, P < 0.001) and a significantly higher proportion of nonwhites (59.0% versus 53.3%, P = 0.049). The HIV group included a higher proportion of smokers, but this difference lacked statistical significance (66.9% versus 62.3%, P = 0.162). Pulmonary comorbidity was less prevalent in veterans with HIV (9.6% versus 13.3%, P = 0.04). A somewhat lower proportion of veterans with HIV had an alcohol-related diagnosis in the year before admission (16.1% versus 20.1%, P = 0.075), but a significantly higher proportion of HIV-positive veterans had a drug-related diagnosis in the previous year (19.7% versus 14.6%, P = 0.021).
Veterans with HIV had a significantly higher (worse) average VACS Index score than veterans without HIV (60.1, standard deviation 25.1, versus 42.3, SD 19.6, P < 0.001). HIV-positive and negative veterans did not differ significantly in 30-day mortality (5.5% and 5.1%), average length of stay (7.1 and 7.5 days), or readmission within 30 days (14.3% and 11.8%).
Regression models to identify predictors of 30-day mortality, length of hospital stay, and readmission within 30 days adjusted for race, smoking status, pulmonary disease, VACS Index score, and alcohol- and drug-related diagnoses in the year before admission.
Sixty-four of 1203 veterans (5.3%) died within 30 days of admission. Every 5-point higher (worse) VACS Index score translated into a 17% higher risk of 30-day mortality (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.12 to 1.23, P < 0.001) and an 8% higher risk of readmission (HR 1.08, 95% CI 1.05 to 1.12, P < 0.001).
Among HIV-positive veterans, every 5-point higher VACS Index score meant a 20% higher risk of death (HR 1.20, 95% CI 1.13 to 1.28, P < 0.001) and a 7% higher risk of readmission (HR 1.07, 95% CI 1.02 to 1.12, P = 0.003). In veterans with HIV infection, lack of antiretroviral therapy was associated with more than a 3-fold increase in 30-day mortality (HR 3.22, 95% CI 1.63 to 6.36, P < 0.001) and with a 2.7-day longer hospital stay (beta 2.73, P = 0.008) but not with hospital readmission.
The researchers believe this is the largest cohort analysis of CAP clinical outcomes in older people with HIV. They noted that their analysis is limited by its restriction to male veterans and to patients admitted to the hospital. They may have missed veterans readmitted to a hospital outside the Veterans Administration system. And they had limited data on clinical variables such as prophylaxis for opportunistic infections and relevant vaccinations.
With those caveats in mind, the investigators think their findings highlight the prognostic value of the VACS Index score and the value of antiretroviral therapy in older HIV-positive people with CAP.
References
1. Barakat L, Juthani-Mehta M, Allore H, et al. Comparing clinical outcomes of HIV-infected to HIV-uninfected older adults hospitalized with community-acquired pneumonia. IDWeek 2013. October 2-6, 2013. San Francisco. Abstract 1506.
2. Tate JP, Justice AC. The VACS Index. Veterans Aging Study Cohort Project Team. www.vacohort.org/welcome/75_158724_VACS_Index_Handout_19Nov10.pdf
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