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(Chest. 2000;118:138-145.)
© 2000 American College of Chest Physicians

Clinical Course, Prognostic Factors, and Outcome Prediction for HIV Patients in the ICU*

The PIP (Pulmonary Complications, ICU Support, and Prognostic Factors in Hospitalized Patients With HIV) Study

Bekele Afessa, MD, FCCP and Bethany Green, DO

* From the Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida Health Science Center, Jacksonville, FL.

Correspondence to: Bekele Afessa, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: Afessa.bekele{at}Mayo.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objective: To describe the clinical course and prognostic factors in patients with HIV admitted to the ICU.

Design: Prospective, observational.

Setting: A university-affiliated medical center.

Methods: We included 169 consecutive ICU admissions, from April 1995 through March 1999, of 141 adults with HIV. Data collected included APACHE (acute physiology and chronic health evaluation) II score, CD4+ lymphocyte count, serum albumin level, in-hospital mortality, and the development of organ failure, systemic inflammatory response syndrome (SIRS), and ARDS.

Results: The ICU admission rate of hospitalized patients with HIV infection was 12%. The most common reason for ICU admission was respiratory failure, occurring in 65 patient admissions. Mechanical ventilation was required in 91 admissions (54%), ARDS developed in 37 admissions (22%), Pneumocystis carinii pneumonia was diagnosed in 24 admissions (14%), and SIRS developed in 126 admissions (75%). One or more organ failures developed in 131 admissions (78%). The actual and predicted mortality rates were 29.6% and 45.2%, respectively, with a standardized mortality ratio of 0.65. The most frequent immediate cause of death was bacterial infection. The CD4+ lymphocyte count (median, 27.5 cells/µL vs 59 cells/µL; p = 0.0310) and serum albumin level (median 2.2 g/dL vs 2.6 g/dL; p = 0.0355) of nonsurvivors were lower and the APACHE II score (median, 30 vs 21; p < 0.0001) was higher, compared to those of survivors. A higher APACHE II score (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.05 to 1.16) and a transfer from another hospital ward (OR, 3.03; 95% CI, 1.20 to 7.68) were independently associated with increased mortality. The median number of organ failures that developed in survivors was one, compared to four in nonsurvivors (p < 0.0001).

Conclusions: The outcome of HIV-infected patients admitted to the ICU has improved over the years. The CD4 count does not correlate with in-hospital mortality. Higher APACHE II scores and a transfer from another hospital ward are associated with a poor outcome.

Key Words: AIDS • APACHE • ARDS • HIV • ICU admission • organ failure • outcome • Pneumocystis carinii pneumonia • respiratory failure • systemic inflammatory response syndrome


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Patients with HIV infection are admitted to the ICU for life-sustaining support or closer observation. Hospital characteristics and geographic location, independent of severity of illness and socioeconomic status, influence ICU utilization for patients with HIV infection.1 Approximately 4 to 5% of hospitalized patients with HIV infection are admitted to the ICU.2 3 The ICU admission rate is 11 to 22% for those with Pneumocystis carinii pneumonia (PCP).4 5 The ICU care of HIV-infected patients has passed through different phases.6 7 In the early 1980s, the ICU survival rate of patients with AIDS was low, and the cost per year of life saved was > $300,000.7 Based on the belief that ICU care of patients with AIDS was futile, clinical, ethical, and economic issues were raised regarding the benefits and burdens of the critical care of these patients.8 However, studies have shown improvement in survival rate and cost per life saved of HIV-infected patients admitted to the ICU.7 9 10

Because the majority of HIV-infected patients admitted to the ICU had PCP, early studies addressing the role of ICU support in HIV-infected patients focused on patients with PCP and respiratory failure.1 5 7 11 12 With the use of prophylaxis and antiretroviral therapy, the incidence of PCP has decreased.13 Although PCP is still common in HIV-infected patients admitted to the ICU, it is seen in the minority of these patients.3 9 10 The use of PCP prophylaxis, antiretroviral therapy, and corticosteroids for PCP has changed not only the reasons for ICU admission, but also the outcomes of patients with HIV infection admitted to the ICU.14 We undertook this study to describe the reasons for ICU admission, clinical course, and outcome of patients with HIV infection and to determine the prognostic factors.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
This prospective, observational study included 169 consecutive ICU admissions of 141 adults with HIV infection treated at the University Medical Center, Jacksonville, FL, during a 4-year period, April 1995 through March 1999. The total number of hospital admissions of patients with HIV infection was noted for only the first 3 years: 12% (148 of 1,225) of the patient-admissions during the first 3 years of the study were treated in the ICU. The University Medical Center is a 528-bed, inner-city teaching hospital affiliated with the University of Florida. The Institutional Review Board of the hospital waived the need for informed consent. We collected data on age, sex, race, exposure category for HIV infection, origin of admission, CD4+ lymphocyte count within 90 days prior to admission, serum albumin level, APACHE (acute physiology and chronic health evaluation) II score, length of hospital and ICU stay, and in-hospital mortality.

The development of organ failure, systemic inflammatory response syndrome (SIRS), and ARDS were noted. Liver failure was defined as a serum bilirubin level > 6 mg/dL and a prolongation of the prothrombin time at least 4 s greater than the control. GI failure was defined as GI bleeding or obstruction or pancreatitis preventing enteral feeding for at least 24 h or until death. Cardiovascular, pulmonary, renal, hematologic, and CNS organ failures were defined as per Knaus et al.15 SIRS, sepsis, severe sepsis, and septic shock were defined according to the American College of Chest Physicians and the Society of Critical Care Medicine Consensus Conference.16 ARDS was defined according to the American-European Consensus Conference.17 The cardiac index, systemic vascular resistance, and pulmonary artery occlusion pressure were noted in patients who had pulmonary artery catheters.

For the purpose of this study, multiple hospital admissions of the same patient were analyzed independently of each other. The APACHE II-predicted mortality was calculated. The standardized mortality ratio was defined as the ratio of the observed to the predicted mortality rate. The area under the receiver operating characteristic curve (AUC) was calculated. StatView 5.0 computer software (SAS Institute; Cary, NC) was used for statistical analysis. All means were expressed with their standard deviations. Odds ratios (ORs) were expressed with their 95% confidence intervals (CIs). Comparisons between groups were made using Student’s t test, Mann-Whitney U test, {chi}2, Fisher’s Exact Test, and multiple logistic regression analysis test. Continuity-corrected p values were used for {chi}2 analysis. The p values < 0.05 were considered significant.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Based on the data from the first 3 years of our study, 12% of hospitalized patient admissions with HIV infection were treated in the ICU. Thirty-eight of the 169 admissions (22%) were transferred from the medical or surgical ward of the same hospital or from other hospitals, and 131 of admissions (78%) were admitted from the emergency department. Their demographic characteristics, exposure categories, serum albumin level, CD4+ lymphocyte count, APACHE II scores, and predicted mortality are listed in Table 1 .


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  		Table 1.. The Demographic Characteristics, Exposure Categories, CD4+ Lymphocyte Count, Serum Albumin, APACHE II Scores, and Predicted Mortality of 169 HIV-Infected Patient Admissions Treated in the ICU*

 
The length of hospital stay was 11.5 ± 10.4 days (median, 8 days), and the length of ICU stay was 5.6 ± 7.2 days (median, 3 days). The in-hospital mortality rate was 29.6% (50 of 169 admissions). The immediate causes of death were bacterial infections in 22 patients, nonbacterial infections in 13 patients, pancreatitis in 3 patients, encephalitis of undetermined etiology in 3 patients, intracranial hemorrhage in 2 patients, and renal failure, hyperkalemia, liver failure, Kaposi’s sarcoma, ischemic bowel, perforated bowel, and pulmonary embolism each in 1 patient.

A "do not resuscitate" order was written for 18 of the 119 survivors (15%), compared to 31 of the 50 nonsurvivors (62%; p < 0.0001). The standardized mortality ratio was 0.65. For patient admissions whose CD4+ lymphocyte count was >= 200 cells/µL, the predicted and observed mortality rates were 42.4% and 22.2%, respectively, and the standardized mortality ratio was 0.52. For patient admissions whose CD4 count was < 200 cells/µL, the predicted and observed mortality rates were 47.4% and 32.8%, respectively, and the standardized mortality ratio was 0.69. Thirty-two of the 131 patient admissions (24%) admitted directly to the ICU died, compared to 18 of the 38 patient admissions (47%) who were transferred (p = 0.0115). There were no significant differences in age, sex, race, or risk category between survivors and nonsurvivors.

The reasons for ICU admission and the associated mortality are listed in Table 2 . The most common reason for admission to the ICU was respiratory failure (Table 2) . The in-hospital mortality rate was 26% for patient admissions admitted for respiratory failure, compared to 32% for patient admissions admitted for nonrespiratory reasons (p = 0.5481). The causes of the respiratory failure were pneumonia in 49 patient admissions, status asthmaticus in 7 admissions, pulmonary edema due to kidney or heart failure in 5 admissions, cocaine abuse in 2 admissions, sepsis in 1 admission, and pulmonary embolism in 1 admission. P carinii was the most common organism causing pneumonia. The ICU admission rate for patients with PCP was 24%. Twenty-four of the 169 patient admissions (14%) treated in the ICU had PCP. Nine of the 24 patient admissions (38%) with PCP died, compared to 41 of the 145 patient admissions (28%) without PCP (p = 0.4984). Seven of the 15 patient admissions (47%) with PCP who required positive pressure ventilation died, compared to 2 of the 9 patient admissions (22%) with PCP who did not require positive pressure ventilation (p = 0.3891).


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  		Table 2.. Reasons for ICU Admission and Associated Mortality of Patients With HIV Infection

 
ARDS developed in 37 of the 169 patient admissions (22%). Twenty of the 37 patient admissions (54%) with ARDS died, compared to 30 of the 132 patient admissions (23%) without ARDS (p = 0.0005). Mechanical ventilation was required in 91 of the 169 patient admissions (54%): invasive positive pressure ventilation in 85 admissions, and noninvasive positive pressure ventilation in 6 admissions. Invasive mechanical ventilation was required for a mean of 7.6 ± 8.5 days (median, 5 days) for the 85 patient admissions. The in-hospital mortality rate of patient admissions requiring invasive mechanical ventilation was 48%. Twenty-two of the 49 patient admissions (45%) who underwent mechanical ventilation for pulmonary disorders died, compared to 20 of 42 patient admissions (48%) who required mechanical ventilation for nonpulmonary disorders (p = 0.9593). Seven of the 15 patient admissions (47%) who required mechanical ventilation for PCP died, compared to 15 of 34 patient admissions (44%) who required mechanical ventilation for other pulmonary disorders (p > 0.9999).

A pulmonary artery catheter was used in 16 patient admissions. The initial hemodynamic findings from the pulmonary artery catheters showed elevated cardiac index and decreased systemic vascular resistance in all 16 patient admissions, normal pulmonary artery occlusion pressure in 14 patient admissions, and elevated pulmonary artery occlusion pressure in 2 patient admissions. Eleven of the 16 patient admissions who required pulmonary artery catheters (69%) died, compared to 39 of the 153 patient admissions (25%) who did not require pulmonary artery catheters (p = 0.0009). Multiple logistic regression analysis showed that the APACHE II-predicted mortality rate (OR, 1.04; 95% CI, 1.02 to 1.06), but not pulmonary artery catheter use (OR, 2.97; 95% CI, 0.89 to 10.06), was independently associated with mortality.

SIRS developed in 126 of the 169 patient admissions (75%). In 46 of the 126 patient admissions with SIRS (37%), the patient died, compared to 4 of the 43 patient admissions (9%) without SIRS (p = 0.0005). The most common cause of SIRS was sepsis (Table 3 ). The severity of sepsis was mild in 13 patient admissions (12%), severe in 70 admissions (67%), and shock in 22 admissions (21%). The lungs were the most common source of infection, causing sepsis in 62 of the 105 patient admissions (59%). Among the 126 patient admissions with SIRS, the patient died in 39 of the 105 admissions with sepsis (37%), compared with 7 of 21 admissions without sepsis (33%; p = 0.9340). The in-hospital mortality rate was 0 for patient admissions with mild sepsis, compared to 30% for admissions with severe sepsis and 82% for admissions with septic shock (p < 0.0001). Among the 105 patient admissions with sepsis, 34% of the admissions with pneumonia resulted in death, compared to 42% of the admissions with nonpulmonary sources of infection (p = 0.5288).


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  		Table 3.. Causes of SIRS in 126 Patient Admissions With HIV Infection Treated in the ICU

 
One or more organ failures developed in 131 of the 169 patient admissions (78%). The types of organ failures are listed in Table 4 . The median number of organ failures in survivors was one, compared to four in nonsurvivors (p < 0.0001). The numbers of organ failures and associated mortality are listed in Table 5 . In distinguishing survivors from nonsurvivors, the AUC for the number of organ failures was 0.872.


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  		Table 4.. Types of Organ Failure That Developed in 169 HIV-Infected Patient Admissions Treated in the ICU

 

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  		Table 5.. Number of Organ Failures and Associated Mortality in 169 HIV-Infected Patient Admissions Treated in the ICU

 
Six of the 15 patient admissions (40%) requiring an ICU stay for > 2 weeks resulted in death, compared with 44 of the 154 patient admissions (29%) requiring an ICU stay for <= 2 weeks (p = 0.5279). The median CD4+ lymphocyte count of survivors was 59 cells/µL, compared to 27.5 cells/µL of nonsurvivors (p = 0.0310). The median serum albumin level of survivors was 2.6 g/dL, compared to 2.2 g/dL of nonsurvivors (p = 0.0355). The APACHE II score of survivors was 21.7 ± 8.6 (median, 21), compared to 31.2 ± 10.3 (median, 30) of nonsurvivors (p < 0.0001). The predicted mortality rate of survivors was 36%, compared to 67% of nonsurvivors (p < 0.0001). In distinguishing survivors from nonsurvivors, the AUC for CD4 count, serum albumin level, APACHE II score, and predicted mortality were 0.608, 0.606, 0.758, and 0.800, respectively.

The relationship between the observed mortality and the APACHE II-predicted mortality is listed in Table 6 . Multiple logistic regression analysis, based on a model consisting of in-hospital mortality as a dependent variable, and the origin of admission, CD4+ lymphocyte count, serum albumin level, and APACHE II score as independent variables showed that higher APACHE II score and transfer from another unit, but not the CD4+ lymphocyte count and serum albumin level, correlated independently with in-hospital mortality (Table 7 ).


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  		Table 6.. The Relationship Between the Observed and APACHE II-Predicted Mortality

 

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  		Table 7.. Logistic Regression Analysis Showing the Relationship of the Observed Mortality With Origin of Admission, Serum Albumin Level, CD4+ Lymphocyte Count, and APACHE II Score*

 
There were 79 patient admissions during the first 2-year period, and 90 patient admissions during the second 2-year period of the study. There were no significant differences in age, race, serum albumin level, CD4+ lymphocyte count, APACHE II-predicted mortality rate, and in-hospital mortality between patient admissions during the first and second 2-year periods of the study. Twenty-five of the 79 patient admissions (32%) during the first 2-year period were female, compared to 48 of the 90 patient admissions (53%) during the second 2-year period (p = 0.0072).


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
This study describes the reasons for ICU admission, prognostic factors, development of organ failure, development of SIRS and sepsis, length of hospital stay, and in-hospital mortality of 169 patient admissions with HIV infection treated in the ICU. In this study, the ICU admission rate of hospitalized patients with HIV infection was 12%; the most common reason for ICU admission was respiratory failure; the most common cause of respiratory failure was PCP.

Our ICU admission rate of hospitalized patients with HIV infection is higher than the 4 to 5% reported in the literature.2 3 Many studies have shown that respiratory failure is the most common reason for ICU admission of patients with HIV infection.2 3 9 10 The ICU and in-hospital mortality of HIV-infected patients admitted to the ICU for respiratory failure ranges from 17 to 67%.2 3 9 10 In the study by Rosen et al,3 the mortality rate of patients admitted for pulmonary disorders was 67%, compared to the 20% of patients admitted for nonpulmonary disorders (p = 0.0004). In the study by De Palo et al,2 the mortality rate of patients admitted for respiratory failure was 63%, compared to 37% of patients admitted for nonrespiratory failure (p = 0.0628). In our study, we did not find significant differences in mortality between patients admitted for respiratory failure and patients admitted for nonrespiratory reasons. Differences in patient characteristics and ICU admission criteria may account for these variations between different studies.

Despite its decline as a result of prophylaxis, PCP has remained a common complication in patients with HIV infection.18 PCP is the most common cause of respiratory failure in HIV-infected patients admitted to the ICU.2 3 9 10 19 20 Because of its high frequency, most of the studies addressing ICU support of HIV-infected patients have focused on respiratory failure due to PCP.5 21 Based on clinicians’ and patients’ perception of the futility of intensive care, our approach to acute respiratory failure due to PCP in HIV-infected patients has passed through different phases.6 The ICU admission rate of hospitalized, HIV-infected patients with PCP also varies from hospital to hospital: 11% at public hospitals, 22% at Veterans Administration hospitals, and 19% at private hospitals.4 Although our hospital is a public hospital, 24% of hospitalized patients with HIV infection and PCP were admitted to the ICU in our study.

There are only a few studies on ICU support of HIV-infected patients admitted for nonpulmonary causes.2 3 9 10 19 The nonrespiratory causes for ICU admission of HIV-infected patients include GI disorders, cardiovascular disorders, CNS dysfunction, and sepsis.3 In our study, the second most common cause for ICU admission was CNS dysfunction, which was associated with in-hospital mortality of 32%. CNS dysfunction was the second most common cause of ICU admission in two other studies.9 10 The mortality rate of HIV-infected patients admitted for CNS dysfunction ranges from 20 to 50%.2 3 9 10 21 In a study of 84 HIV-infected patients admitted to the ICU for neurologic failure, the 3-month mortality rate was 68%.22

Most of our patients admitted to the ICU required life-sustaining support, and only a few of them were admitted for monitoring purposes. Mechanical ventilation, mostly invasive, was provided to the majority of patient admissions. In the early 1980s, the in-hospital mortality rate of patients with AIDS who required mechanical ventilation for respiratory failure was about 90%.19 In two more recent studies, the in-hospital mortality rate of HIV-infected patients who required mechanical ventilation was 57% and 79%, respectively.2 3 At the present time, patients with PCP who require mechanical ventilation are more likely to be admitted with recurrent episodes; to have failed prophylaxis, anti-Pneumocystis and antiretroviral therapy, and adjunctive corticosteroids; and thus to have a poor prognosis.3 7 23 24 In our study, the in-hospital mortality rate of patients requiring mechanical ventilation was < 50% in all groups of patients, including those with PCP.

Most studies of patients with HIV infection admitted to the ICU do not mention the frequency of pulmonary artery catheterization. In the study by Casalino et al,10 37% of 421 HIV-infected patients admitted to the ICU underwent right heart catheterization. Patients with severe PCP manifest a hyperdynamic, hemodynamic profile with an increased cardiac index and low systemic vascular resistance.25 In our study, 9% of the patients underwent pulmonary artery catheterization, and all of them demonstrated an elevated cardiac index and low systemic vascular resistance.

In a multicenter study of 3,708 hospitalized patients, 68% met the criteria of SIRS.26 The development of SIRS in hospitalized patients is associated with increased morbidity and mortality. In a study by Thyrault et al,27 the 28-day mortality rate of HIV-positive patients with septic shock was 93%, compared to 46% of HIV-negative patients with septic shock. In our study, SIRS developed in 75% of the patient admissions; the in-hospital mortality rate of patient admissions without SIRS was 9%, compared to 37% of patient admissions with SIRS. We did not find a significant difference in mortality between patient admissions with sepsis and patient admissions with SIRS of noninfectious etiology. Not surprisingly, the severity of sepsis correlated well with in-hospital mortality in our study.

Previous studies have identified several factors associated with poor outcome in HIV-infected patients admitted to the ICU. Age, prehospitalization functional status, number of previous opportunistic infections, HIV disease stage, time since AIDS diagnosis, weight loss, initiation and duration of mechanical ventilation, and reason for ICU admission are associated with the outcome of patients with HIV infection admitted to the ICU.2 9 10 Although we did not look at most of these factors, we could not find significant differences in age between survivors and nonsurvivors. Low serum albumin was reported as a poor prognostic indicator in the study by De Palo et al,2 but not in the study by Lazard et al.9 In our study, we did not find serum albumin to be an independent prognostic indicator. Although low CD4+ lymphocyte count correlates with poor long-term prognosis, its association with short-term outcome has not been similar among different studies. In four studies of HIV-infected patients admitted to the ICU, a low CD4+ lymphocyte count was associated with poor hospital outcome.2 7 28 29 In studies by Casalino et al10 and Lazard et al,9 a low CD4+ lymphocyte count was associated with poor long-term outcome but not short-term outcome. We found no independent association between low CD4+ lymphocyte count and increased mortality rates, results similar to those in the multicenter study by Rosen et al.3 In one study5 of patients with severe PCP, the in-hospital mortality rate of patients who stayed in the ICU for > 2 weeks was 100%. We did not find this to be the case in our patients.

The development of multiple organ failure in ICU patients is associated with increased mortality. The mortality rate of patients with three or more organ-system failures persisting > 3 days is 98%.15 Underscoring the importance of multiple organ failure in determining the outcome of critically ill patients, various organ failure assessment models have been developed recently. In patients admitted to the ICU for AIDS-related PCP and respiratory failure, a previously developed multisystem organ failure scoring was validated to be an effective predictor of in-hospital mortality.30 31 In our study, the number of organ failures had a high correlation with in-hospital mortality.

Objective and accurate estimation of outcome is important in high-risk and high-cost environments, such as the ICU. The APACHE III,32 simplified acute physiology score (SAPS) II,33 and mortality probability models II34 are current, updated scoring systems designed to estimate the probability of in-hospital mortality for adult ICU patients. SAPS I9 10 and APACHE II2 28 35 36 prognostic systems were used to predict mortality in some of the published studies dealing with HIV-infected ICU patients. However, both SAPS I and APACHE II are unlikely to have accurate prediction, because they were developed at a time when ICUs had few patients with HIV infection. Studies addressing the role of SAPS I and APACHE II in HIV-infected patients had mixed results. In the study by Lazard et al,9 there were significant differences in the SAPS I score between survivors and nonsurvivors; in the study by Casalino et al,10 multivariate analysis did not demonstrate significant correlation between the SAPS I score and in-hospital mortality. In the study by De Palo et al,2 survivors had a significantly higher APACHE II score than did nonsurvivors; in the study by Smith et al,36 there was no significant difference in the APACHE II score between survivors and nonsurvivors. However, our study showed significant differences in the APACHE II score and predicted mortality rate between survivors and nonsurvivors. Unlike two previous studies28 36 that showed that the APACHE II-predicted mortality rate was lower than the observed mortality rate for patients with HIV infection, the observed mortality rate was lower than the predicted mortality rate in our study. Differences in patient mix and recent improvements in the care of HIV-infected patients may explain the lower mortality in our study.

In the United States, the 1996 inpatient cost of HIV-infected individuals was estimated to be $2.1 billion.37 Regardless of the financial burden, the decision whether to admit a patient to an ICU should depend on the patient’s wishes and the likelihood of benefit from the admission.38 Identifying outcome predictors in the ICU will help patients and health-care providers in making decisions about when to pursue aggressive therapy and when to withhold or withdraw such therapy. In our study, we evaluated the role of many prognostic variables. We showed the observed mortality rate of HIV-infected patients admitted to ICU was far < 100%, even when the predicted mortality was > 90% and when they developed three or more organ failures. We demonstrated that HIV-infected patients could survive to hospital discharge even if they spent > 2 weeks in the ICU. Our study was limited to one center, and we did not address long-term outcome and quality of life following each patient’s discharge from the hospital. Early in the AIDS epidemic, the outcome of AIDS patients admitted to the ICU was dismal. With antiretroviral therapy, PCP prophylaxis, and adjunctive corticosteroid use in PCP, outcome has improved. The ICU care of HIV-infected patients is no longer futile. Future developments are likely to modify the clinical manifestations, treatments, and prognostic factors of critical illness in patients with HIV infection. In order to make appropriate medical decisions based on current, objective data, we need to continue gathering data and keep up with the changes.


   Acknowledgements
 
We thank Dr. David Armbruster for reviewing the manuscript.


   Footnotes
 
Abbreviations: APACHE = acute physiology and chronic health evaluation; AUC = area under the receiver operating characteristic curve; CI = confidence interval; OR = odds ratio; PCP = Pneumocystis carinii pneumonia; SAPS = simplified acute physiology score; SIRS = systemic inflammatory response syndrome

Received for publication September 8, 1999. Accepted for publication January 19, 2000.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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