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Sharp Drop in ICU Mortality After Introduction of HAART in Netherlands
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49th ICAAC (Interscience Conference on Antimicrobial Agents and Chemotherapy), September 12-15, 2009, San Francisco
Mark Mascolini
One- and 5-year mortality fell sharply among 116 HIV-infected people admitted 127 times to a Dutch hospital intensive care unit (ICU) after potent antiretroviral combinations (HAART) arrived in 1996 [1]. The investigators suggest their findings show "there is no reason to restrict ICU care in patients with HIV infection when indicated."
This retrospective chart review by researchers in Utrecht and Arnhem, the Netherlands, involved all HIV-infected people admitted to the ICU from 1991 through 1998, except for those admitted after surgery or for self-induced intoxication. Thus the findings cannot be applied to such patients. The investigators divided the study group into 47 people admitted to the ICU before HAART (1991-1996), 42 admitted in the early HAART era (1996-2003), and 38 admitted in the late HAART era (2003-2008).
Most ICU patients were male (82%) and middle-aged (average 42 years). During the HAART era 36% were taking HAART upon ICU admission and 20% had an undetectable viral load.
Respiratory failure accounted for the bulk of ICU admissions in the pre-HAART era (57%), the early HAART era (62%), and the late HAART era (47%). Admissions for hemodynamic emergencies accounted for 29% of ICU stays in the pre-HAART era, a rate that fell to 4% in the early HAART era then rebounded to 15% in the late HAART era.
Median CD4 count did not differ significantly between the pre-HAART era and the total HAART era (57 versus 80) but did differ significantly between the pre-HAART era and the late HAART era (57 versus 101, P = 0.04). Pre-HAART and HAART patients differed in the need for mechanical ventilation (57% pre-HAART versus 85% HAART, P = 0.001). Equivalent proportions of pre-HAART and HAART patients had AIDS (55% and 50%).
Comparing all HAART patients with pre-HAART patients, the investigators recorded substantial drops in in-ICU mortality (47% to 31%, P = 0.08), in-hospital mortality (60% to 45%, P = 0.1), and 1-year mortality (74% to 49%, statistically significant at P = 0.007). Five-year mortality improved significantly from the pre-HAART era to the early HAART era (91% to 62%, P = 0.002).
Kaplan-Meier analysis determined that overall 5-year survival improved from 20% in pre-HAART days to 70% with HAART.
Reference
1. Wind CM, Van Lelyveld SFL, Van Leeuwen JH, et al. ICU mortality, in hospital mortality as well as long-term follow up outcomes are significantly improved in HIV infected patients admitted to ICU in the HAART era. 49th ICAAC (Interscience Conference on Antimicrobial Agents and Chemotherapy). September 12-15, 2009. San Francisco. Abstract H-1564.
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