Research Article: Should highly active antiretroviral therapy be prescribed in critically ill HIV-infected patients during the ICU stay? A retrospective cohort study

Date Published: September 28, 2012

Publisher: BioMed Central

Author(s): Agnes Meybeck, Lydie Lecomte, Michel Valette, Nicolas Van Grunderbeeck, Nicolas Boussekey, Arnaud Chiche, Hugues Georges, Yazdan Yazdanpanah, Olivier Leroy.

http://doi.org/10.1186/1742-6405-9-27

Abstract

The impact of highly active antiretroviral therapy (HAART) in HIV-infected patients admitted to the intensive care unit (ICU) remains controversial. We evaluate impact of HAART prescription in HIV-infected patients admitted to the ICU of Tourcoing Hospital from January 2000 to December 2009.

There were 91 admissions concerning 85 HIV-infected patients. Reasons for ICU admission were an AIDS-related diagnosis in 46 cases (51%). Fifty two patients (57%) were on HAART at the time of ICU admission, leading to 21 immunovirologic successes (23%). During the ICU stay, HAART was continued in 29 patients (32%), and started in 3 patients (3%). Only one patient experienced an adverse event related to HAART. Mortality rate in ICU and 6 months after ICU admission were respectively 19% and 27%. Kaplan-Meier estimates of the cumulative unajusted survival probability over 6 months were higher in patients treated with HAART during the ICU stay (Log rank: p = 0.04). No benefit of HAART in ICU was seen in the adjusted survival proportion at 6 months or during ICU stay. Prescription of HAART during ICU was associated with a trend to lower incidence of new AIDS-related events at 6 months (respectively 17% and 34% with and without HAART, p = 0.07), and with higher incidence of antiretroviral resistance after ICU stay (respectively 25% and 7% with and without HAART, p = 0.02).

Our results suggest a lower death rate over 6 months in critically ill HIV-infected patients taking HAART during ICU stay. The optimal time to prescribe HAART in critically ill patients needs to be better defined.

Partial Text

Highly active antiretroviral therapy (HAART) has increased the life expectancy of patients who are infected with the human immunodeficiency virus (HIV) and has reduced the incidence of illnesses associated with the acquired immunodeficiency syndrome (AIDS). HIV-infected adults with CD4 cell count greater than 500 cells/mm3 on long-term combination antiretroviral therapy reach same mortality rates as the general population
[1]. Survival of HIV-infected patients admitted to the intensive care unit (ICU) has been evaluated in a number of studies
[2-6]. Most of these studies have shown improved survival since the late 1990s for HIV infected patients, associated with the advent of HAART. But whether or not the improved survival is dependent of the use of HAART remains controversial
[5-7]. Changing practices of ICU care and decrease of AIDS-related admissions may explain survival improvement
[2,8].

In our cohort of HIV-infected patients admitted to the ICU, the only independent predictor of ICU outcome was severity of acute illness assessed by SAPS II score at ICU admission. Two factors were independent predictors of decreased 6-month survival: SAPS II score and AIDS-associated diagnosis at ICU admission. Use of HAART during ICU stay improved unadjusted survival at 6 months. But no benefit was seen specifically in the adjusted survival proportion at 6 months or during ICU stay. Use of HAART during ICU stay tended to reduce AIDS progression. Tolerance of HAART in ICU was good. IRIS was rare. Prescription of HAART during ICU stay was associated with higher incidence of antiretroviral resistance after ICU stay.

In our cohort of critically ill HIV-infected patients, benefit of HAART administration during ICU stay was limited. The reticence of intensivists to use HAART and the early prescription of HAART after ICU discharge may have reduced the impact of HAART use in ICU. Our results support the need for prospective randomized clinical trials to address the optimal timing to prescribe HAART in critically ill patients. Future trials should provide antiretroviral drug monitoring and data on compliance to HAART after ICU discharge.

AIDS: Acquired immunodeficiency syndrome; CI: Confidence interval; HAART: Highly active antiretroviral therapy; HIV: Human immunodeficiency virus; ICU: Intensive care unit; IRIS: Immune reconstitution and inflammatory syndrome; NRTI: Nucleoside/Nucleotide reverse transcriptase inhibitor; PI: Protease inhibitor; OR: Odds ratio; SAPS: Simplified acute physiology score.

The authors declare that they have no competing interests.

AM, LL have contributed to study design, analysis and interpretation of data. MV has performed statistical analysis. NV has contributed to interpretation of data and has revised critically the manuscript. NB, AC, HG drafted the manuscript. YY, OL have participated in data interpretation and manuscript drafting. All authors read and approved the final manuscript.

 

Source:

http://doi.org/10.1186/1742-6405-9-27

 

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