Prognosis

In all patients with Pneumocystis pneumonia (PCP), overall survival has improved. In a large US death certificate database, the mortality rate declined from 0.470 deaths per 100,000 persons in 1999 to 0.154 per 100,000 persons in 2014.[113] More directly, in the Adult and Adolescent Spectrum HIV disease project, the 12-month survival increased from 40% in 1992/1993 to 63% in 1996/1998.[114] Factors associated with poor survival were a history of previous PCP, low CD4 cell count (<50 cells/microliter), CD4 cell percentage <15% and age >60 years. In HIV-positive patients admitted with PCP to three major academic centers between 1995 and 1997, the overall inpatient mortality was 11.3%.[115] Factors that were associated with an increased mortality were:

  • Elevated A-a gradient

  • Hypoalbuminemia

  • Illicit drug use

  • Increased respiratory rate

  • Prior Mycobacterium avium intracellulare infection prophylaxis

  • Prior AIDS diagnosis

  • Elevated WBC count

  • Elevated serum creatinine

  • Neurologic symptoms.

One 2008 study showed mortality from PCP between 1996 and 2006 was 9.7% and early predictors of mortality were:[116]

  • Increasing patient age

  • Subsequent episodes of PCP

  • Low hemoglobin level at hospital admission

  • Low partial pressure of oxygen breathing room air at hospital admission

  • Presence of medical comorbidity

  • Pulmonary Kaposi sarcoma.

Another study of 136 episodes of PCP between 2000 and 2013 found that mortality was 11%, and 5-year survival was 73% overall (88% in those compliant with combination antiretroviral therapy [ART], and 34% in those not adherent to ART).[16]

At San Francisco General Hospital, there has been a series of studies of outcomes and epidemiology of PCP in the intensive care unit (ICU) that span the entire HIV/AIDS epidemic at that institution.[117][118][119][120][121][122] Further studies in this series show survival in critically ill HIV-positive patients continued to improve in the era of ART and the incidence of PCP diagnosis for admission to the ICU continued to decrease.[117][119][123] In critically ill HIV-positive patients admitted to the ICU, PCP was the most common cause of respiratory failure and was associated with decreased survival, although the incidence of PCP in patients on ART was much lower than in those not taking ART (3% versus 19%, P < 0.001).[119] In patients admitted to the ICU with PCP, the use of ART was an independent predictor of improved survival and the need for mechanical ventilation and/or development of a pneumothorax. Delayed ICU admission was associated with increased mortality.[123]

In HIV-negative patients with PCP, morbidity and mortality is higher than in those who are HIV-positive.[25][27][28][124][125] In one case series of HIV-negative patients who developed PCP, 97% required hospital admission, 69% were admitted to the ICU, 66% required mechanical ventilation, and mortality was 39%.[124] In another series, mortality was 69% and factors associated with mortality (i.e., Acute Physiology and Chronic Health Evaluation II score, acute lung injury/acute respiratory distress syndrome, late diagnosis, nosocomial infections) were high.[126]

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