Management of HIV-infected patients in the intensive care unit

Abstract

The widespread use of combination antiretroviral therapies (cART) has converted the prognosis of HIV infection from a rapidly progressive and ultimately fatal disease to a chronic condition with limited impact on life expectancy. Yet, HIV-infected patients remain at high risk for critical illness due to the occurrence of severe opportunistic infections in those with advanced immunosuppression (i.e., inaugural admissions or limited access to cART), a pronounced susceptibility to bacterial sepsis and tuberculosis at every stage of HIV infection, and a rising prevalence of underlying comorbidities such as chronic obstructive pulmonary diseases, atherosclerosis or non-AIDS-defining neoplasms in cART-treated patients aging with controlled viral replication. Several patterns of intensive care have markedly evolved in this patient population over the late cART era, including a steady decline in AIDS-related admissions, an opposite trend in admissions for exacerbated comorbidities, the emergence of additional drivers of immunosuppression (e.g., anti-neoplastic chemotherapy or solid organ transplantation), the management of cART in the acute phase of critical illness, and a dramatic progress in short-term survival that mainly results from general advances in intensive care practices. Besides, there is a lack of data regarding other features of ICU and post-ICU care in these patients, especially on the impact of sociological factors on clinical presentation and prognosis, the optimal timing of cART introduction in AIDS-related admissions, determinants of end-of-life decisions, long-term survival, and functional outcomes. In this narrative review, we sought to depict the current evidence regarding the management of HIV-infected patients admitted to the intensive care unit.

Keywords: Acquired immunodeficiency syndrome; Antiretroviral therapy; Bacterial sepsis; Intensive care unit; Mechanical ventilation; Outcome; Pneumocystis jirovecii pneumonia.

Fig. 1

Etiological spectrum of critical illnesses in HIV-infected patients. ARF acute respiratory failure, OI opportunistic infection, PCP Pneumocystis jirovecii pneumonia, KS Kaposi sarcoma, MAC Mycobacterium avium complex, cART combination antiretroviral therapy, CNS central nervous system, PML progressive multifocal encephalopathy (JC virus encephalitis), NHL non-Hodgkin lymphoma, IRIS immune reconstitution inflammatory syndrome, COPD chronic obstructive pulmonary diseases. (1) Pulmonary tuberculosis is also a major cause of IRIS that may lead to ARF; (2) interstitial pneumonitis, drug toxicity, asthma, pulmonary embolism, others; (3) sepsis, endocarditis, anoxia, metabolic disorders, drug toxicity or overdose, malignancies, thrombotic microangiopathy, others

Fig. 2

Selected imaging examples of AIDS-related opportunistic infections in the ICU. aPneumocystis jirovecii pneumonia (chest CT scan showing diffuse ground-glass opacities with focal alveolar consolidations, thickened septal lines, relative sparing of the subpleural regions, and absence of pleural effusion); b pulmonary tuberculosis (chest CT scan showing typical apical excavated lesions with pleural effusion in a patient with CD4 cell count > 250/µL); c cerebral toxoplasmosis (T1-weighted cerebral magnetic resonance imaging showing gadolinium-enhanced lesions of the hemispheric grain matter with peripheral edema and mass effect); d multicentric Castleman disease (positron emission tomography showing enlarged liver, spleen and axillary/cervical lymph nodes with hypermetabolic patterns)

Fig. 3

Proposed algorithm for use of combination antiretroviral therapy in the ICU. Authors’ proposal based on the guidelines of the Centers for Disease Control and Prevention, the National Institutes of Health, and the Infectious Diseases Society of America for the use of antiretroviral agents in adults and adolescents with HIV [98]. Note that no academic guidelines exist for the management of antiretroviral drugs in the specific context of critical illnesses. Close collaboration with an infectious disease physician is mandatory in every case. ICU intensive care unit, cART combination antiretroviral therapy, PML progressive multifocal encephalopathy, CNS central nervous system, OI opportunistic infection, PCP Pneumocystis jirovecii pneumonia. (1) Delayed cART initiation due to the substantial risk of severe immune reconstitution inflammatory syndrome (e.g., up to 10 weeks in cryptococcal meningoencephalitis with elevated intra-cranial pressure and delayed clinical improvement or CSF culture sterilization); (2) cART initiation may be differed for up to 8 weeks in patients with pulmonary tuberculosis and CD4 cells > 50/µL