Chest Email Content Delivery
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (24)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Feldman, C.
Right arrow Articles by Klugman, K. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Feldman, C.
Right arrow Articles by Klugman, K. P.
(Chest. 1999;116:107-114.)
© 1999 American College of Chest Physicians

Bacteremic Pneumococcal Pneumonia in HIV-Seropositive and HIV-Seronegative Adults*

Charles Feldman, PhD, FCCP; Michael Glatthaar, MB BCh; Rajen Morar, M MED (Int Med), FCCP; Akhter Goolam Mahomed, MB BCh, FCCP; Suleiman Kaka, MB, ChB; Marlene Cassel, Dip Tech, Micro and Keith P. Klugman, PhD

* From the Department of Medicine (Drs. Feldman, Morar, and Mahomed), Hillbrow Hospital, University of the Witwatersrand, Johannesburg; and the Wits/MRC Pneumococcal Diseases Research Unit (Drs. Glatthaar, Kaka, Klugman, and Ms. Cassel), University of the Witwatersrand, Johannesburg, South Africa.

Correspondence to: Charles Feldman PhD, FCCP, Department of Medicine, University of the Witwatersrand, Medical School, 7 York Road, Parktown, 2193, Johannesburg, South Africa; e-mail: 014charl{at}chiron.wits.ac.za


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Study objectives: To compare the demographic, clinical, laboratory, and microbiological data, and the hospital course and outcome of HIV-seropositive and HIV-seronegative adults with bacteremic pneumococcal pneumonia.

Design: Retrospective observation study conducted over a 2-year period.

Setting: Academic teaching hospital attached to the University of the Witwatersrand, Johannesburg, South Africa.

Patients: Consecutive patients with bacteremic pneumococcal pneumonia were identified on the basis of positive blood culture results.

Interventions: All available demographic, clinical, routine laboratory, radiographic, and microbiological data were recorded retrospectively for each of the patients, and the combined data for the HIV-seropositive patients were compared with those of the HIV-seronegative patients.

Measurement and results: A total of 112 patients (31 HIV-seropositive and 81 HIV-seronegative patients) were entered into the study. The HIV-seropositive patients were significantly younger than the HIV-seronegative patients (32.8 vs 39.6 years old) and had lower admission hemoglobin (11.8 vs 13.4 g/dL), WBC count (10.3 vs 14.3 x 109/L), serum albumin (31 vs 36 g/L), sodium (129 vs 132 mmol/L), and potassium (3.0 vs 3.5 mmol/L), respectively. Although the HIV-seropositive patients appeared to have more multilobar pulmonary consolidation on the chest radiograph than the HIV-seronegative patients (60% vs 34%), this did not quite reach statistical significance. In addition, the HIV-seropositive patients had significantly more infections (48.4% vs 20.8%) with pneumococcal serogroups/serotypes (serogroups 6, 19, 23, and serotype 14) that are found more commonly in children, and they also had more penicillin-resistant isolates (13% vs 2.5%) than the HIV-seronegative patients, respectively. Similarly, it was noted that when these data were analyzed according to gender (irrespective of HIV status), women had significantly more infections than men (47% vs 21%) with serogroups/serotypes that are usually found in children, more penicillin-resistant isolates (15% vs 1%), and more co-trimoxazole-resistant isolates (21% vs 5%), respectively. There were no differences noted in any of the other parameters, including initial APACHE (acute physiology and chronic health evaluation) II score, PaO2/fraction of inspired oxygen ratio, duration of temperature, duration of IV therapy, duration of hospitalization, complications, and outcome, when comparing HIV-seropositive and HIV-seronegative patients. Two patients in each group died.

Conclusions: The clinical features of bacteremic pneumococcal pneumonia are similar in HIV-seropositive and HIV-seronegative patients. Although differences are noted in various laboratory and microbiological parameters, they do not appear to have an impact on outcome.

Key Words: bacteremia • HIV • outcome • penicillin-resistant isolates • serogroups/serotypes • Streptococcus pneumoniae


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Infections with Streptococcus pneumoniae continue to be associated with significant morbidity and mortality in patients worldwide.1 In the United States, for example, pneumococcus is associated with > 500,000 cases of pneumonia, > 50,000 cases of bacteremia, and > 3,000 cases of meningitis annually, and these infections result in approximately 40,000 deaths.2 The burden of disease is greatest in certain categories of patients, and so these infections occur most frequently in the young and the elderly.2

Pneumococcus is also the leading cause of community-acquired bacterial pneumonia and associated bacteremia in HIV-seropositive individuals.3 4 Pneumococcal infections occur in HIV-seropositive individuals at all levels of CD4 count, but they are particularly common at levels < 200 x 109/L.3 This has major implications for the prevalence of invasive pneumococcal disease in countries such as South Africa, where the rates of HIV infection and AIDS are increasing exponentially.5 6 This prevalence of HIV infection is coupled to the additional problem of penicillin-resistant isolates that have been increasing in frequency in South Africa since the 1970s, especially among pediatric patients.7

Numerous studies8 9 10 11 12 13 14 15 16 17 18 19 20 21 of pneumococcal bacteremia (some including data on HIV-seropositive individuals) have been published over the past several years. While some of the more recent studies16 have focused on the comparative clinical features of bacteremic infections in HIV-seropositive and HIV-seronegative individuals, others18 have compared the microbiological findings in the two population groups more specifically. Having previously published data22 on bacteremic pneumococcal infections in the pre-HIV era, we undertook the current investigation of HIV-seropositive and HIV-seronegative patients with bacteremic pneumococcal pneumonia. We wished to compare and contrast the demographic, clinical, routine laboratory, radiographic, and microbiological data of these two groups of patients to determine whether there were any differences in clinical course, occurrence of complications, and outcome, particularly as they may relate to differences in microbiology. We also wished to compare the data on the different serogroups/serotypes isolated in the current study with data from the study conducted previously.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
In this study, consecutive adult patients with bacteremic pneumococcal pneumonia admitted over a 2-year period to the Hillbrow Hospital in Johannesburg were recruited prospectively. Permission to conduct the study was obtained from the Committee for Research on Human Subjects of the University of the Witwatersrand, with the requirement of verbal informed consent from each patient. All patients received pretest and posttest counseling for HIV infection as was appropriate. The patients who were noted to be HIV seropositive were subsequently referred to the Infectious Diseases/HIV Clinic for follow-up. The microorganisms that were isolated were sent immediately for typing and antibiotic susceptibility testing as described below. Subsequently, patient data were collected retrospectively via a record review.

Clinical and Routine Laboratory Data
Clinical data were recorded retrospectively, where available, for each patient, and included the following: age, gender, HIV status, possible predisposing factors to the infection, APACHE (acute physiology and chronic health evaluation) II score, PaO2/fraction of inspired oxygen (FIO2) ratio, admission systolic and diastolic BP, temperature (oC), pulse rate, and respiratory rate. As an indication of the clinical course of the infection, we recorded the following: duration of pyrexia, duration of need for IV therapy, duration of hospital stay, need for ICU admission and/or mechanical ventilation, complications, and outcome.

Routine laboratory data that was recorded included the following: initial hemoglobin, WBC count, platelet count, CD4 count, CD4/CD8 ratio, PaO2, serum sodium, potassium, urea, creatinine, and albumin. It was noted whether the area of consolidation on chest radiograph was unilobar or multilobar.

Microbiological Data
HIV testing was performed using a third-generation recombinant enzyme immunoassay (HIV-1/-2 Test; Abbott Diagnostic Products; Wiesbaden, Germany). Blood cultures were processed using a radiometric method (Bactec analyzer; Becton Dickinson; Cockeysville, MD). Pneumococci were identified using standard microbiological methods, including optochin sensitivity and capsular typing with specific pneumococcal antiserum. Initial antibiotic susceptibility testing for penicillin was performed with the disk diffusion method on 5% blood agar plates using a 1-µg disk of oxacillin. Oxacillin zone sizes >= 20 mm were interpreted as indicating penicillin susceptibility, and zone sizes <= 19 mm were interpreted as indicating resistance. Susceptibility to trimethoprim-sulfamethoxazole was tested using 1.25-µg and 23.75-µg discs on Mueller-Hinton agar with laked blood.

Minimum inhibitory concentrations (MICs) were determined for strains with reduced zones of inhibition by using the broth microdilution method with cation-adjusted Mueller-Hinton broth. Penicillin MICs <= 0.06 µg/mL were regarded as indicating susceptibility, penicillin MICs between 0.12 and 1 µg/mL were regarded as indicating intermediate susceptibility, and penicillin MICs > 1 µg/mL were regarded as indicating resistance.

The isolates were serogrouped or serotyped on the basis of the quellung reaction using specific pneumococcal antisera (Statens Seruminstitut; Copenhagen, Denmark).

Statistical Analysis
All available data were compared in HIV-seropositive and HIV-seronegative patients using the Mann-Whitney U Test (2-tail) for continuous variables and Fisher's Exact Test (2-tail) for categorical variables.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
A total of 112 patients were enrolled in the study: 81 were HIV seronegative and 31 were HIV seropositive. None of the patients in this study had received prior immunization with the pneumococcal vaccine, and none were known to be HIV seropositive prior to this episode of pneumococcal bacteremia. Eleven HIV-seronegative patients and 1 HIV-seropositive patient had underlying disorders other than HIV infection that may have predisposed them to pneumococcal bacteremia. In the HIV-seronegative group, these disorders included the following: diabetes mellitus in three patients, and one case each of COPD, asthma, metastatic carcinoma of the prostate, rheumatic heart disease, IV drug abuse, chronic pancreatitis, cardiomyopathy, and hypertensive heart disease. In the HIV-seropositive group, there was one case of old pulmonary tuberculosis with reactivation.

Comparative clinical data are shown in Table 1 . The mean age of the HIV-seropositive group was significantly lower and the ratio of women to men was significantly greater than the HIV-seronegative group. As shown in Table 1 , there were marked similarities in clinical presentation, hospital course, complications, and outcome between the two groups of patients. In addition, both indexes of severity of illness (the APACHE II score and the PaO2/FIO2 ratio) were identical. Although multilobar consolidation was more common among HIV-seropositive patients, this did not quite reach statistical significance (p = 0.06478).


View this table:
[in this window]
[in a new window]

  		Table 1. Comparative Clinical Data for Patients With Pneumococcal Bacteremia Comparing HIV-Positive and HIV-Negative Individuals*

 
Table 2 shows comparative data of the routine laboratory and microbiological investigations in the two groups of patients. As shown in Table 2 , there were significantly lower levels of hemoglobin, WBC count, CD4 count, serum sodium, potassium, and albumin in HIV-seropositive patients.


View this table:
[in this window]
[in a new window]

  		Table 2. Comparative Routine Laboratory Data of HIV–Positive and HIV–Negative Patients With Bacteremic Pneumococcal Pneumonia*

 
A number of differences were noted when comparing the microbiological data of the two groups, as shown in Figure 1 and Table 3 . Figure 1 shows the numbers of patients in each of the groups with the different serogroups/serotypes isolated. The HIV-seropositive patients (15 of 31 patients; 48.4%) had more infections with serogroups/serotypes (serogroups 6, 19, 23, and serotype 14) that are more usually found in children than did the HIV-seronegative patients (16 of 77 patients; 20.8%; p = 0.00552). The HIV-seropositive patients (4 of 31 patients; 13%) also had more infections with penicillin-resistant isolates than the HIV-seronegative patients (2 of 80 patients; 2.5%; p = 0.05024; Table 3 ). When these data were analyzed according to gender, irrespective of HIV status, it was noted that women (15 of 32 patients; 47%) had significantly more infections with serogroups/serotypes that are more commonly seen in children than did men (16 of 76 patients; 21%; p = 0.01012). Women also had more penicillin-resistant isolates (5 of 33 patients; 15%) than did men (1 of 78 patients; 1%; p = 0.00867), and women had more co-trimoxazole-resistant isolates (7 of 33 patients; 21%) than did men (4 of 77 patients; 5%; p = 0.01622; Table 4 ). Two patients were noted to be infected simultaneously with two serotypes: one patient was HIV-seronegative (with serotypes 5 and 15), and the other patient was HIV-seropositive (with serotypes 1 and 15).



View larger version (21K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1. The pneumococcal serogroups/serotypes isolated in 112 patients with bacteremic pneumococcal pneumonia, with comparative data for HIV-seropositive and HIV-seronegative patients. HIV - ve = HIV negative; HIV + ve = HIV positive.

 

View this table:
[in this window]
[in a new window]

  		Table 3. Comparative Microbiological Data of HIV-Positive and HIV-Negative Patients With Bacteremic Pneumococcal Pneumonia*

 

View this table:
[in this window]
[in a new window]

  		Table 4. Comparative Microbiological Data of Female and Male Patients With Bacteremic Pneumococcal Pneumonia, Irrespective of HIV Status*

 
Further data on the patients infected with penicillin-resistant isolates are shown in Table 5 . The initial antibiotic therapy was recorded in four of these cases: one patient received parenteral penicillin G, 2 MU q6h, followed by oral penicillin VK, 500 mg qid; another patient received parenteral penicillin G, 2 MU q6h, together with gentamicin, followed by oral cephalexin, 500 mg qid; a third patient received IV cefuroxime, 750 mg bid, together with amikacin and metronidazole, followed by oral penicillin VK, 500 mg qid; and the fourth patient received IV cephazolin and IV amikacin, followed by ceftriaxone and clindamycin given empirically once the presence of the antibiotic resistance became known. All of these patients survived.


View this table:
[in this window]
[in a new window]

  		Table 5. Demographic Clinical and Laboratory Data of Patients With Bacteremic Pneumococcal Pneumonia due to Penicillin-Resistant Isolates

 
Complications of the infection were noted in 12 of the HIV-seronegative patients (15%), including pleural effusions in 5 patients, respiratory failure in 5 patients, complicating meningitis in 1 patient, data not recorded in 1 patient. Complications of the infection were noted in three of the HIV-seropositive patients (13%), including respiratory failure in one patient and data not recorded in two patients. Five HIV-seronegative patients and one HIV-seropositive patient were mechanically ventilated. Two patients in each group were known to have died; all were < 40 years old. Of the two HIV-seronegative patients who died, both were men: one patient was mechanically ventilated and the other patient was not. Both patients were infected with penicillin-sensitive type 1 pneumococci. The former had an APACHE II score of 16 and unilobar pulmonary consolidation. The latter had an admission WBC count of 2.2 x 109/L, an APACHE II score of 19, multilobar pulmonary consolidation, and renal failure. Both of the two HIV-seropositive patients who died (one male and one female) had renal failure. The male patient required mechanical ventilation and had multilobar consolidation, an admission WBC count of 6.1 x 109/L, and an APACHE II score of 26. This patient was infected with a penicillin-sensitive type 14 pneumococcus. The female patient had an admission WBC count of 2.2 x 109/L, an APACHE II score of 17, and was infected with a penicillin-sensitive serotype 1 pneumococcus.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
In this comparative study of HIV-seronegative and HIV-seropositive patients with bacteremic pneumococcal pneumonia, we noted few differences in the clinical presentation of the patients. A number of significant differences were noted in routine laboratory data, as well as in the microbiological parameters. With regard to the microbiology, more infections were noted with serogroups/serotypes that are more commonly noted in children (serogroups 6, 19, 23, and serotype 14), and significantly more infections with penicillin-resistant isolates were recorded in the HIV-seropositive group. Despite these differences, there were no differences noted in the hospital course, complications, or outcome.

We calculated the possible burden of pneumococcal bacteremia in the population of HIV-infected patients served by the hospital in the current study for the age group of 15 to 40 years old. There were 54 patients in our study in this age group. The approximate prevalence of HIV infection in this community at the time of the study was 5.6%.5 If there was no association between invasive pneumococcal disease and HIV infection, the percentage of HIV-seropositivity in the study group would be expected to be 5.6%. As such, the prevalence of HIV-seropositivity in our study was actually 19 of 54 patients (35.2%). Thus, there was roughly a 6.2 times increased risk of invasive pneumococcal disease in the population of HIV-positive individuals served by our hospital. This figure is similar to the figure of 8.5 times found in another study of adult patients (age group range, 20 to 39 years old) from South Africa (Nicola Jones; personal communication; August 1998).

None of the patients in this study had been previously immunized with the pneumococcal vaccine, reflecting our current policy not to vaccinate HIV-seropositive patients routinely. Although routine vaccination of HIV-seropositive patients is recommended by some,2 caution may need to be exercised with this recommendation, based on preliminary data from a recent study23 in Uganda. Neither were patients with pneumococcal bacteremia routinely screened for HIV infection at our hospital at the time of the study, as others have recommended,21 and hence the need for informed consent from our patients for the study. In this regard, none of the patients in our study were known to be HIV seropositive prior to their episode of pneumococcal bacteremia; therefore, a policy of routine screening for HIV infection in patients with pneumococcal bacteremia may well uncover a large number of undiagnosed HIV infections.

The clinical features of invasive pneumococcal pneumonia were very similar in the HIV-seronegative and HIV-seropositive patients (Table 1) . The only differences noted were the younger age group in the HIV-seropositive patients (32.8 vs 39.6 years old) and the higher ratio of female patients in this group (42% vs 20%). Other investigators16 have also noted the younger age of HIV-seropositive patients presenting with invasive pneumococcal disease. There appeared to be more multilobar consolidation among our HIV-seropositive patients, but this difference did not quite reach statistical significance. While some investigators16 have noted a difference in the radiologic appearance of AIDS patients with bacteremic pneumococcal pneumonia compared with HIV-seropositive patients without AIDS and HIV-seronegative individuals (such patients being more likely to have bilateral infiltrates), other investigators9 16 24 have found no differences when comparing the radiologic findings in HIV-seropositive and HIV-seronegative patients alone.

A number of differences were noted in the routine laboratory data when comparing HIV-seropositive and HIV-seronegative patients (Table 2) . In particular, there were lower levels of initial WBC count and serum albumin in the HIV-seropositive patients. Although these two parameters have previously been noted by some investigators16 17 19 22 24 25 to be important negative prognostic factors in pneumococcal bacteremia (being present more commonly in patients who require ICU admission or in patients who died), their presence in the HIV-seropositive patients in our study was not associated with a worse outcome. This may simply reflect a statistical analysis that was performed with a small number of patients; however, it is important to note that although the overall WBC count in our HIV-seropositive group was lower than that of the HIV-seronegative group, only three patients actually had leukopenia, one of whom died. Leukopenia, per se, may be the more important prognostic factor, as shown in a recent study,19 rather than simply a lower WBC count.

The overall mortality for invasive pneumococcal disease varies significantly in the studies12 quoted in the literature. Several investigators8 9 16 20 have noted a low mortality among patients with pneumococcal bacteremia without concomitant HIV infection, even among patients who are HIV infected but do not have AIDS. In the study by Gilks et al15 of invasive pneumococcal disease among predominantly HIV-seropositive female sex workers, there was a zero mortality rate. The overall mortality for our study group, as well as for both subgroups, was very low: 2.8% in the HIV-seronegative patients and 8.7% in the HIV-seropositive patients (not significant). This similarity in outcome of the two subgroups correlates well with the fact that they were noted to have a similar severity of illness based on two different scoring indexes, the APACHE II score and the PaO2/FIO2 ratio. Two recent studies17 26 of invasive pneumococcal pneumonia, one noting a low mortality of 8% and the other noting an overall fatality rate of 24.1%, have both confirmed that the APACHE II score is an important predictor of death in this disease. In the latter study,26 it was noted that an APACHE II score > 15 was associated with a higher fatality rate. This fits in well with our findings of APACHE II scores of 16, 17, 19, and 26, respectively, in the four patients who died, and the fact that only four of our patients who survived were noted to have scores > 15.

A number of significant differences were noted in the microbiological data in the current study (Table 3) . HIV-seropositive patients were more commonly infected with penicillin-resistant isolates. All of these isolates had an MIC level in the intermediate range of resistance. Penicillin resistance did not appear to impact negatively on the outcome of these patients, all of whom survived, despite the fact that some of the patients had been treated solely with penicillin. In the Kenyan study,15 a good response to penicillin therapy in HIV-infected women with penicillin-resistant pneumococcal bacteremia was also noted. There was no difference in the prevalence of co-trimoxazole-resistant isolates in the two groups of patients in the current investigation. HIV-seropositive patients in our study were more commonly infected with serogroups/serotypes that are more usually found in children (serogroups 6, 14, 19, and serotype 23), as has been noted in other studies18 of pneumococcal bacteremia. The exact reason for the increased incidence of serogroups/serotypes that are more commonly found in children is uncertain and needs to be studied further. One explanation may be the loss of immunity to these serogroups/serotypes as a consequence of the immune defects that occur in HIV-seropositive patients.27 A second possibility may be that these serogroups/serotypes are the ones that are most commonly associated with penicillin resistance,7 occurring more commonly in HIV-seropositive patients who have been exposed to previous courses of antibiotics, a well-known risk factor for such infections.

Similar differences in microbiological data were also noted and, in fact, were even more striking when comparing the female and male patients in the study group, irrespective of their HIV status (Table 4) . Women were much more likely to be infected with childhood serogroups/serotypes (p = 0.01012), with penicillin-resistant isolates (p = 0.00867), and with co-trimoxazole-resistant isolates (p = 0.01622). These observations are similar to the findings of other studies18 28 of pneumococcal bacteremia that have suggested that invasive disease in adults with childhood serogroups/serotypes and/or demonstrating penicillin resistance occurs most commonly in mothers who are in close contact with their children; the infections that the children are exposed to in hospital or in day care centers are then commonly expressed in their closest adult contacts, particularly if these adults are immunocompromised, such as by way of HIV infection.

The spectrum of serogroups/serotypes isolated was similar to that noted in our previous study of pneumococcal bacteremia conducted at the same hospital, as well to that of other studies18 22 from South Africa (Fig 1) . The differences noted between the current study and our previous study were that serogroups/serotypes 10, 11, 15, 18, and 23 (as noted in the current study) were not noted among patients in the previous study,22 and that serogroups/serotypes 12, 13, 17, 20, and 25 (as noted in the previous study) were not noted among the current patients. Serotype 1 was the most commonly noted isolate in the current study in both HIV-seropositive and HIV-seronegative patients. This was also noted in the previous study22 from Hillbrow Hospital, as well as in the recent publication18 from Chris Hani Baragwanath Hospital in South Africa. We also noted that serotype 5 was relatively uncommon in both the current study and the previous study,22 as described in the Chris Hani Baragwanath Hospital study.18 Penicillin-resistant strains in both HIV-seropositive and HIV-seronegative patients were all among the serogroups/serotypes more commonly found in children (ie, 6, 19, and 23). Two patients in the current study were noted to be concomitantly infected with two serotypes: one patient was HIV seronegative (serotypes 5 and 15), and the other patient was HIV seropositive (serotypes 1 and 15). All of the serogroups/serotypes isolated in both HIV-seropositive and HIV-seronegative patients are present in the 23 valent pneumococcal vaccines currently available for use in adults; therefore, the use of pneumococcal vaccine should be expected to reduce the incidence of invasive pneumococcal infection in the community served by our hospital.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
In conclusion, we have noted that bacteremic pneumococcal pneumonia remains an important disease among both HIV-seronegative and HIV-seropositive patients. While the clinical picture in these two groups of patients is very similar, a number of significant differences are noted in the routine laboratory and microbiological data. These differences do not seem to impact on the outcome of the cases, which is very similar, and even infections with organisms of intermediate susceptibility to penicillin appear to respond adequately to routine antibiotic therapy.


   Footnotes
 
Abbreviations: APACHE = acute physiology and chronic health evaluation; FIO2 = fraction of inspired oxygen; MIC = minimum inhibitory concentration

Received for publication September 17, 1998. Accepted for publication February 1, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

  1. Musher, DM (1995) Streptococcus pneumoniae. Mandell, GL Bennet, JE Dolin, R eds. Principles and practices of infectious diseases 4th ed. ,1811-1826 Churchill Livingstone New York, NY.
  2. Centers for Disease Control, and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR (Morb Mortal Wkly Rep) 1997; 46:1–24
  3. Janoff, EN, Breiman, RF, Daley, CL, et al (1992) Pneumococcal disease during HIV infection. Ann Intern Med 117,314-324
  4. Hirschtick, RE, Glassroth, J, Jordan, MC, et al (1995) Bacterial pneumonia in persons infected with the human immunodeficiency virus. N Engl J Med 333,845-851[Abstract/Free Full Text]
  5. Department of National Health. Fourth national HIV survey of women attending antenatal clinics, South Africa, October/November, 1993. Epidemiol Comments 1994; 21:68–75
  6. Department of National Health. Fifth national HIV survey in women attending antenatal clinics of the public health services in South Africa, October/November 1994. Epidemiol Comments 1995; 22:90–100
  7. Koornhof, HJ, Wasas, A, Klugman, K (1992) Antimicrobial resistance in Streptococcus pneumoniae: a South African perspective. Clin Infect Dis 15,84-94[ISI][Medline]
  8. Redd, SC, Rutherford, GW, Sande, MA, et al (1990) The role of human immunodeficiency virus infection in pneumococcal bacteremia in San Francisco residents. J Infect Dis 162,1012-1017[ISI][Medline]
  9. Pesola, GR, Charles, A (1992) Pneumococcal bacteremia with pneumonia: mortality in acquired immunodeficiency syndrome. Chest 101,150-155[Abstract/Free Full Text]
  10. Lippmann, ML, Goldberg, SK, Walkenstein, MD, et al (1995) Bacteremic pneumococcal pneumonia: a community hospital experience. Chest 108,1608-1613[Abstract/Free Full Text]
  11. Watanakunakorn, C, Greifenstein, A, Stroh, K, et al (1993) Pneumococcal bacteremia in three community teaching hospitals from 1980 to 1989. Chest 103,1152-1156[Abstract/Free Full Text]
  12. Mirzanejad, Y, Roman, S, Talbot, J, et al (1996) Pneumococcal bacteremia in two tertiary care hospitals in Winnipeg, Canada. Chest 109,173-178[Abstract/Free Full Text]
  13. Mao, C, Harper, M, McIntosh, K, et al (1996) Invasive pneumococcal infections in human immunodeficiency virus-infected children. J Infect Dis 173,870-876[ISI][Medline]
  14. Plouffe, JF, Breiman, RF, Facklam, RR (1996) Bacteremia with Streptococcus pneumoniae. JAMA 275,194-198[Abstract]
  15. Gilks, CF, Ojoo, SA, Ojoo, JC, et al (1996) Invasive pneumococcal disease in a cohort of predominantly HIV-1 infected female sex-workers in Nairobi, Kenya. Lancet 347,718-723[CrossRef][ISI][Medline]
  16. Afessa, B, Greaves, WL, Frederick, WR (1997) Pneumococcal bacteremia in adults: differences between patients with and without human immunodeficiency virus infection. Int J Infect Dis 2,21-25
  17. Watanakunakorn, C, Bailey, TA (1997) Adult bacteremic pneumococcal pneumonia in a community teaching hospital, 1992–1996. Arch Intern Med 157,1965-1971[Abstract]
  18. Crewe-Brown, HH, Karstaedt, AS, Saunders, GL, et al (1997) Streptococcus pneumoniae blood culture isolates from patients with and without human immunodeficiency virus infection: alterations in penicillin susceptibilities and in serogroups or serotypes. Clin Infect Dis 25,1165-1172[ISI][Medline]
  19. Torres, JM, Cardenas, O, Vasquez, A, et al (1998) Streptococcus pneumoniae bacteremia in a community hospital. Chest 113,387-390[Abstract/Free Full Text]
  20. Totapally, BR, Walsh, WT (1998) Pneumococcal bacteremia in childhood. Chest 113,1207-1214[Abstract/Free Full Text]
  21. Hibbs, JR, Douglas, JM, Jr, Judson, FN, et al (1997) Prevalence of human immunodeficiency virus infection, mortality rate, and serogroup distribution among patients with pneumococcal bacteremia at Denver General Hospital, 1984–1994. Clin Infect Dis 25,195-199[ISI][Medline]
  22. Feldman, C, Sacho, H, Levy, H, et al (1988) Pneumococcal bacteraemia in adults in a low socio-economic urban population. Q J Med 69,961-971[Abstract/Free Full Text]
  23. Gilks CF, French N, Nakiyingi J, et al. Lack of efficacy of 23-valent pneumococcal polysaccharide vaccine in HIV-1-infected Ugandan adults [abstract]. Pneumococcal Vac-cines for the World Congress; October 12–14, 1998; Washington, DC
  24. Garcia-Leoni, ME, Moreno, S, Rodeno, P, et al (1992) Pneumococcal pneumonia in adult hospitalized patients infected with the human immunodeficiency virus. Arch Intern Med 152,1808-1812[Abstract]
  25. Afessa, B, Greaves, WL, Frederick, WR (1995) Pneumococcal bacteremia in adults: a 14-year experience in an inner-city university hospital. Clin Infect Dis 21,345-351[ISI][Medline]
  26. Ortqvist A. Clinical aspects on invasive pneumococcal disease [abstract]. International Symposium on Pneumococci and Pneumococcal Diseases, Copenhagen; June 13–17, 1998; Copenhagen, Sweden; Abstract book:29
  27. Janoff, EN, Rubins, JB (1997) Invasive pneumococcal disease in the immunocompromised host. Microb Drug Resist 3,215-232[ISI][Medline]
  28. Kronenberger, CB, Hoffman, RE, Lezotte, DC, et al (1996) Invasive penicillin-resistant pneumococcal infections: a prevalence and historical cohort study. Emerg Infect Dis 2,121-124[ISI][Medline]



This article has been cited by other articles:


Home page
 Eur Respir JHome page
C. Spindler and A. Ortqvist
Prognostic score systems and community-acquired bacteraemic pneumococcal pneumonia
Eur. Respir. J., October 1, 2006; 28(4): 816 - 823.
[Abstract] [Full Text] [PDF]

Home page
 Arch Intern MedHome page
I. Grau, R. Pallares, F. Tubau, M. H. Schulze, F. Llopis, D. Podzamczer, J. Linares, F. Gudiol, and for the Spanish Pneumococcal Infection Study Netwo
Epidemiologic Changes in Bacteremic Pneumococcal Disease in Patients With Human Immunodeficiency Virus in the Era of Highly Active Antiretroviral Therapy
Arch Intern Med, July 11, 2005; 165(13): 1533 - 1540.
[Abstract] [Full Text] [PDF]

Home page
 Eur Respir JHome page
A. Ortqvist
Pneumococcal vaccination: current and future issues
Eur. Respir. J., July 1, 2001; 18(1): 184 - 195.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (24)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Feldman, C.
Right arrow Articles by Klugman, K. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Feldman, C.
Right arrow Articles by Klugman, K. P.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS