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Poorly Controlled HIV Infection Raises Risk of
Pneumococcal Disease in French Study
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52nd ICAAC, September 9-12, 2012, San Francisco
Mark Mascolini
Cumulative AIDS and non-AIDS conditions, a low CD4 count, and a detectable viral load independently raised the risk of invasive pneumococcal disease in a 2000-2011 case-control study in France [1]. Being born outside of France quadrupled the risk of invasive pneumococcal disease.
Streptococcus pneumoniae causes invasive pneumococcal disease, which the CDC defines as bacteremia, meningitis, or infection of other normally sterile sites [2]. US guidelines say "HIV-infected adults and adolescents who have a CD4+ count of greater than 200 cells/uL should be administered a single dose of 23-valent polysaccharide pneumococcal vaccine (PPV23) unless they have received this vaccine during the previous 5 years" [3].
Researchers at Saint-Louis Hospital in Paris conducted this analysis of all HIV-positive people cared for at the hospital and diagnosed with invasive pneumococcal disease from January 2000 through March 2011. For every HIV-positive person with such a diagnosis, the researchers randomly selected 2 HIV-positive controls without a history of invasive pneumococcal disease or pneumonia and matched to cases by date of HIV diagnosis.
Of the 42 HIV-positive adults with invasive pneumococcal disease, 33 (79%) were men, 16 (38%) were from Europe, 18 (43%) were from sub-Saharan Africa, and the others were from North Africa (12%), South America (5%), and Asia (2%). Their median age was 42 years and ranged from 23 to 62. When invasive pneumococcal disease was diagnosed, 21 people (50%) had a CD4 count below 200, and 32 (76%) had a viral load above 400. Only 2 people (5%) had the PPV23 pneumococcal vaccine. Follow-up lasted for a median of 48 months (range 2 to 126).
Higher proportions of invasive pneumococcal disease occurred in winter (34%) or spring (30%) than in summer (20%) or fall (16%). Study participants were treated for a median of 10 days (range 5 to 90), and the median hospital stay was 14 days (range 2 to 106).
The Charlson Comorbidity Index estimates 10-year survival according to age and number of comorbidities (such as AIDS, cerebrovascular disease, chronic pulmonary disease, and myocardial infarction) [4]. Twenty-seven people (64%) with invasive pneumococcal disease had a least one comorbidity. Median Charlson Comorbidity Index was 2 in HIV-positive people with invasive pneumococcal disease and 0 in the group without invasive pneumococcal disease (P = 0.0001).
Multivariate analysis identified four independent predictors of invasive pneumococcal disease in HIV-positive people, at the following odds ratios (OR) and 95% confidence intervals (CI):
-- Charlson Comorbidity Index at or above 2: OR 7.07, 95% CI 1.99 to 25.1, P = 0.003
-- CD4 count below 200: OR 6.93, 95% CI 1.80 to 26.7, P = 0.005
-- Viral load above 400 copies: OR 5.56, 95% CI 1.58 to 19.5, P = 0.007
-- Non-European origin: OR 4.26, 95% CI 1.02 to 17.9, P = 0.047
The researchers concluded that invasive pneumococcal disease "remains a major burden in the HIV-infected adult population despite the availability of antiretroviral therapy." They stressed that only 5% of these patients with invasive pneumococcal disease had received the PPV23 vaccine, despite recommendations. The high impact of comorbidities on invasive pneumococcal disease underlines the importance of multidisciplinary care for HIV-positive people, the Paris team advised.
Because a low CD4 count proved a major risk factor for invasive pneumococcal disease, they called for efforts to offer HIV testing to "the largest population and to initiate antiretroviral therapy once the CD4 cell count reaches 500 cells/uL in accordance with the French treatment guidelines to ensure a good immunological status."
References
1. Munier A, de Lastours V, Porcher R, et al. Risk factors of invasive pneumococcal disease in HIV-infected patients in France from 2000-2011. 52nd Interscience Conference on Antimicrobials and Chemotherapy (ICAAC). September 9-12, 2012. San Francisco. Abstract H-219.
2. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1997;46(No. RR-8):1-19. http://www.cdc.gov/mmwr/pdf/rr/rr4608.pdf.
3. Centers for Disease Control and Prevention. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR. 2009;58(No. RR-4):1-216.
4. Institute of Algorithmic Medicine. Comorbidity Index and Score of Charlson et al. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php.
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