Published ahead of print on July 10, 2008, doi:10.1164/rccm.200804-617OC Am. J. Respir. Crit. Care Med., Volume 178, Number 6, September 2008, 630-636 A more recent version of this article appeared on September 15, 2008
Submitted on April 25, 2008 Pneumonia in HIV-Infected Persons: Increased Risk with Cigarette Smoking and Treatment InterruptionFred M Gordin1*,1 Veterans Affairs Medical Center, Washington, DC, USA; George Washington University, Washington, DC, USA, 2 Division of Biostatistics, School of Public Health, University of Minneapolis, Minneapolis, MN, USA, 3 Service des Maladies Infectieuses et Tropicales -- Hopital Saint-Antoine, Paris, France; Universite Pierre et Marie Curie, Paris, France; Institut Medecine et d'Epidemiologie Appliquee, Paris, France, 4 Centre for Viral Diseases@KMA, Rigshospitalet, Copenhagen, Denmark; Copenhagen HIV Programme, University of Copenhagen, Copenhagen, Denmark, 5 Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain, 6 University Hospitals of Leicester, London, United Kingdom; Medical Research Council, London, United Kingdom, 7 Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Baylor College of Medicine, Houston, TX, USA, 8 University of Chile School of Medicine, Santiago, Chile; Arriaran Foundation, Santiago, Chile, 9 Department of HIV/GUM, Kings College, London, United Kingdom, 10 University of New South Wales, Sydney, Australia, 11 University of Oklahoma College of Medicine, Oklahoma City, OK, USA; Veterans Affairs Medical Center, Oklahoma City, OK, USA * To whom correspondence should be addressed. E-mail: fred.gordin{at}med.va.gov.
Rationale and Objectives: Bacterial pneumonia is a major cause of morbidity for HIV-infected persons and contributes to excess mortality in this population. We evaluated the frequency and risk factors for occurrence of bacterial pneumonia in the present era of potent antiretroviral therapy. Methods: We evaluated data from a randomized trial of episodic antiretroviral therapy. The study--Strategies for Management of Antiretroviral Therapy (SMART)--enrolled 5,472 participants at 318 sites in 33 countries. Study patients had >350 CD4 cells at baseline. Diagnosis of bacterial pneumonia was confirmed by a blinded clinical-events committee. Measurements and Main Results: During a mean follow-up of 16 months, 116 participants (2.2%) developed at least one episode of bacterial pneumonia. Patients randomized to receive episodic antiretroviral therapy were significantly more likely to develop pneumonia than patients randomized to receive continuous antiretroviral therapy, with a hazard ratio (HR) of 1.55 (95% CI, 1.07 to 2.25; P=0.02). Cigarette smoking was a major risk factor, current-smokers had more than an 80% higher risk of pneumonia compared to never-smokers with a HR of 1.82 (95% CI, 1.09 to 3.04; P=0.02). Participants who were on continuous HIV-treatment, and were current smokers, were 3-fold more likely to develop bacterial pneumonia than non-smokers. Current smoking status was significant but a past history of smoking history was not. Conclusions: Bacterial pneumonia is a major source of morbidity, even for persons on potent antiretroviral therapy, including those with high CD4 cells. Efforts to reduce this illness should stress: (1) the importance of uninterrupted antiretroviral therapy, (2) attainment and/or maintenance of non-smoking status. Clinical Trials Registration: NCT00027352 at www.clinicaltrials.gov Key words: Pneumonia, Smoking, HIV, Bacterial Infections
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