© 2002 American Thoracic Society
Acquired Immunodeficiency Syndrome in the Intensive Care UnitWill Human Immunodeficiency Virus–related Admissions Continue to Decline?Critical Care Medicine Department National Institutes of Health Bethesda, Maryland In 1986, Wachter and colleagues reported their experience with 86 acquired immunodeficiency syndrome (AIDS) patients admitted to the intensive care unit (ICU) at San Francisco General Hospital during the prior five years (1). During that period at the very beginning of the AIDS epidemic, 82 patients were admitted to the ICU over four and a half years. Pneumocystis carinii pneumonia (PCP) was responsible for 84% of those admissions. A distressing 69% of all ICU admissions died, including 87% of those admitted for mechanical ventilation related to PCP. While total admissions to San Francisco General Hospital for AIDS were escalating rapidly, from 12 admissions during the fourth quarter of 1982 to 158 admissions during the fourth quarter of 1985, the ICU admissions fell from a peak of 17 per quarter in 1984 to five per quarter in 1985. Patients and health care providers appeared to have been concerned that critical care of AIDS patients was futile, especially for the 63% of ICU admissions who were admitted for PCP. Nickas and Wachter at the same institution reviewed their experience with 443 admissions from 1992 to 1995 (2). Compared with the earlier era, this period was characterized by the availability of antiretroviral drugs with modest activity and by major improvements in Pneumocystis prevention and treatment strategies. During this period, the reasons for admission to the ICU had broadened: only 20% of admissions were related to PCP. In-hospital mortality had declined to 37% for the cohort as a whole, although 59% of patients with a primary diagnosis of PCP died before discharge. The authors were encouraged that a substantial minority of patients achieved long-term survival. In this issue of AJRCCM, Morris and colleagues (3) (pp. 262–267) report on trends in ICU admission at San Francisco General Hospital during 1996 to 1999, the period in which highly active antiretroviral therapy (HAART) became widely used. During this period, the number of ICU admissions, 79–86 patients per year, was not substantially different from the 1992 to 1995 period. In-hospital mortality declined from 69% during the earliest period, and 37% immediately before HAART, to 29%. PCP accounted for only 10% of ICU admissions, compared with 63% in the earliest period and 20% for the period immediately before the introduction of HAART. This remarkable series of articles documents many striking changes that have occurred in the AIDS epidemic. The demographics of the patients being admitted have changed: in the earliest period, San Francisco General Hospital's clientele was largely male, white, and homosexual. More recently, mirroring national trends, San Francisco General Hospital is serving a clientele that is largely African American, substance abusing, and often female. Many patients in San Francisco have taken advantage of HAART regimens, as demonstrated by the increasing number of patients who were taking HAART when they were admitted to the ICU. More and more patients were admitted to the ICU for problems unrelated to their AIDS (e.g., drug overdose, trauma, gastrointestinal bleed) (63%). These latter patients had an especially high likelihood of surviving their hospitalization. Morris and colleagues categorize patients into those who were receiving HAART at the time of their ICU admission and those who were not. This is an important distinction. A great tragedy in the United States is the large number of patients not under medical supervision who present to emergency rooms with acute opportunistic infections. For many of these patients, this acute opportunistic infection is their first clue that they have human immunodeficiency virus (HIV) infection. A recent survey of over 20,000 patients by the Adult Spectrum of Disease Study reported that 45% of all cases of PCP at their survey hospitals were occurring in patients who were not under regular medical supervision (4). This country can and should be able to perform far better in terms of educating its at-risk population and providing them with the care they need before they develop an acute opportunistic infection. Patients who were receiving HAART had better survival than patients not receiving HAART. However, patients receiving HAART could probably be divided further than the analysis of Morris and coworkers into those who had achieved a sustained response to HAART (i.e., a plasma viral load less than 50 copies/ml after 48 weeks of therapy, plus a substantial rise in CD4+ T lymphocyte counts) and those who did not. Admittedly, such data are not easy to collect. These two groups of patients, however, are likely to present very different ICU problems. Any patient receiving HAART may develop drug toxicities, some of which can be life threatening, such as abacavir hypersensitivity response (5), nucleoside induced lactic acidosis (6), nonnucleoside reverse transcriptase inhibitor-related Stevens–Johnson syndrome (7), or various drug interactions (8). For those patients who have had a "good" response, admission to the ICU is much more likely to be related to a non–HIV-related event or, perhaps HIV-related accelerated atherosclerosis. Patients who have had a "poor" response to HAART are more likely to be admitted to the ICU for a HIV-related opportunistic infection. Clinicians should be aware of the fact that we are likely, unfortunately, to be seeing more and more of these patients. In most clinical trials evaluating regimens that are recommended in current guidelines, only 50 to 60% of patients have a sustained response to HAART. This suggests that more patients will develop resistance to all currently available antiretroviral agents and will suffer progressive immunologic decline. As this occurs, ICUs are likely to see an upsurge in acute opportunistic infections. If in fact drug resistant pathogens, such as sulfonamide-resistant Pneumocystis (9) or ganciclovir-resistant cytomegalo virus (CMV) (10), become more prevalent, ICU activity and mortality may have an additional reason to rise. The first two decades of AIDS epidemic have seen remarkable changes and heartening progress in medical management. However, lack of access to care and rising rates of retroviral resistance to available drugs should alert intensivists that admission patterns may change in undesirable directions and that knowledge about a wide range of HIV-related complications, and not just opportunistic infections, remains an essential part of critical care medicine. REFERENCES
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