Systematic review on the etiology and antibiotic treatment of pneumonia in human immunodeficiency virus-infected children

Abstract

Background: Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality in human immunodeficiency virus (HIV)-infected children.

Objectives and methods: A systematic review of studies that were published between January 1990 and February 2009 on the etiology and antimicrobial or adjunctive systemic management of CAP in HIV-infected children.

Results: Pneumocystis jirovecii had the strongest association with HIV infection, with a summary odds ratio of 10.1 (95% confidence interval [CI], 17.7-62.1) and 9.1 (95% CI, 2.5-33.1) in antemortem and postmortem studies, respectively. Cytomegalovirus was strongly associated with HIV positivity among fatal cases of pneumonia (summary odds ratio = 14.4 [95% CI, 6.7-30.8]). There was a trend toward a greater prevalence of Staphylococcus aureus (odds ratio, 2.5; 95% CI, 0.95-6.4) in HIV-infected children. Major limitations identified included substantial methodological heterogeneity across studies, limited sensitivity of assays for diagnosing bacterial pneumonia, and studies primarily being undertaken in the absence of antiretroviral treatment or cotrimoxazole prophylaxis. No a priori-planned randomized controlled trials on antimicrobial management of CAP in HIV-infected children were identified.

Conclusions: A World Health Organization panel used this review as well as analysis of risks and benefits to revise recommendations for antimicrobial treatment of CAP. Ampicillin plus gentamicin or ceftriaxone is now recommended as first-line empiric regimens for treating severe and very severe CAP in HIV-infected children. In addition, treatment with cloxacillin or vancomycin is recommended in settings with a high incidence of methicillin-resistant S. aureus, and particularly if clinical or microbiological evidence of S. aureus pneumonia exist. Further studies in HIV-infected children on CAP etiology and antibiotic treatment are required in the era of antiretroviral treatment.