Sepsis in AIDS patients: clinical, etiological and inflammatory characteristics

Abstract

Introduction: Intensive care mortality of HIV-positive patients has progressively decreased. However, critically ill HIV-positive patients with sepsis present a worse prognosis. To better understand this condition, we propose a study comparing clinical, etiological and inflammatory data, and the hospital course of HIV-positive and HIV-negative patients with severe sepsis or septic shock.

Methods: A prospective observational study enrolling patients with severe sepsis or septic shock associated or not with HIV infection, and admitted to intensive care unit (ICU). Clinical, microbiological and inflammatory parameters were assessed, including C-reactive protein (CRP), procalcitonin (PCT), interleukin-6, interleukin-10 and TNF-α. Outcome measures were in-hospital and six-month mortality.

Results: The study included 58 patients with severe sepsis/septic shock admitted to ICU, 36 HIV-positive and 22 HIV-negative. All HIV-positive patients met the criteria for AIDS (CDC/2008). The main foci of infection in HIV-positive patients were pulmonary and abdominal (p=0.001). Fungi and mycobacteria were identified in 44.4% and 16.7% of HIV-positive patients, respectively. In contrast, the main etiologies for sepsis in HIV-negative patients were Gram-negative bacilli (36.4%) and Gram-positive cocci (36.4%) (p=0.001). CRP and PCT admission concentrations were lower in HIV-positive patients (130 vs. 168 mg/dL p=0.005, and 1.19 vs. 4.06 ng/mL p=0.04, respectively), with a progressive decrease in surviving patients. Initial IL-10 concentrations were higher in HIV-positive patients (4.4 pg/mL vs. 1.0 pg/mL, p=0.005), with moderate accuracy for predicting death (area under receiver-operating characteristic curve =0.74). In-hospital and six-month mortality were higher in HIV-positive patients (55.6 vs. 27.3% p=0.03, and 58.3 vs. 27.3% p=0.02, respectively).

Conclusions: The course of sepsis was more severe in HIV-positive patients, with distinct clinical, etiological and inflammatory characteristics.

Keywords: AIDS; HIV; etiology; inflammatory markers; mortality; sepsis.

Figure 1

Initial concentrations of C-reactive protein and procalcitonin in HIV-positive and HIV-negative septic patients. Box plot definitions: horizontal bars represent medians; boxes represent interquartile range (IQR); vertical bars represent values between upper and lower outlier limits; upper outlier limit=upper quartile +1.5×IQR; lower outlier limit=lower quartile −1.5×IQR; circles represent outliers. *Wilcoxon–Mann–Whitney test.

Figure 2

Initial interleukin-10 concentrations and interleukin-6/interleukin-10 ratio in HIV-positive and HIV-negative septic patients. Box plot definitions: horizontal bars represent medians; boxes represent interquartile range (IQR); vertical bars represent values between upper and lower outlier limit; upper outlier limit=upper quartile+1.5×IQR; lower outlier limit=lower quartile−1.5×IQR; circles represent outliers; plus signs represent extreme outliers. ±Wilcoxon–Mann–Whitney test.

Figure 3

Receiver operating characteristic curves of biomarkers for prediction of hospital mortality in HIV-positive and HIV-negative septic patients. Definition of abbreviations: CRP, C-reactive protein; PCT, procalcitonin; IL6, interleukin-6; IL10, interleukin-10.

Figure 4

C-reactive protein and procalcitonin concentrations in HIV-positive septic patients according to survival and time of measurement. D1, admission; D3, third day; D7, seventh day; ±Wilcoxon–Mann–Whitney test comparing survivor and non-survivor patients; † Friedman test for D1, D3 and D7 comparisons between survivor and non-survivor patients.