The ART of caring for patients with HIV infection in the ICU

Excerpt

William Osler once wrote, “The practice of medicine is an art, based on science.” Never is this statement truer than in the care of patients with HIV infection in the intensive care unit (ICU) in the current era of combination antiretroviral therapy (ART). In this issue of Intensive Care Medicine, Barbier and colleagues describe the etiologies and outcomes of acute respiratory failure in patients with HIV infection over the first decade of ART (1996–2000) [1]. Remarkably, the etiology of respiratory failure was identified in >98% of the 145 patients in the retrospective study. Bacterial pneumonia was the most common cause, followed by Pneumocystis pneumonia (PCP). Notably, non-invasive ventilation averted the need for endotracheal intubation and mechanical ventilation in 19 of 22 patients. To differentiate between patients taking ART and patients only reporting receipt of ART, the authors considered patients with evidence of poor adherence (i.e., patients for whom medical chart review indicated non-adherence with prescription of ART, patients with stationary viral loads and no evidence of viral resistance, or patients who had not received therapy for >6 months) in the non-treatment group. Almost one-third of patients were considered in the ART treatment group at the time of ICU admission. Although not a statistically significant difference, patients receiving ART actually had higher mortality (30%) compared to those not receiving ART (15%) (p = 0.07), despite having higher CD4 lymphocyte counts, lower HIV viral loads, and fewer opportunistic infections. Overall hospital survival was 80%, was stable across the study period, and was not statistically different across different etiologic groups. …