Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study
Abstract Background Pneumocystis jirovecii pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lav...
| Main Authors: | , , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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SpringerOpen
2019-11-01
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| Series: | Annals of Intensive Care |
| Subjects: | |
| Online Access: | http://link.springer.com/article/10.1186/s13613-019-0604-x |
| _version_ | 1818066725137022976 |
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| author | Benjamin Jean Gaborit Benoit Tessoulin Rose-Anne Lavergne Florent Morio Christine Sagan Emmanuel Canet Raphael Lecomte Paul Leturnier Colin Deschanvres Lydie Khatchatourian Nathalie Asseray Charlotte Garret Michael Vourch Delphine Marest François Raffi David Boutoille Jean Reignier |
| author_facet | Benjamin Jean Gaborit Benoit Tessoulin Rose-Anne Lavergne Florent Morio Christine Sagan Emmanuel Canet Raphael Lecomte Paul Leturnier Colin Deschanvres Lydie Khatchatourian Nathalie Asseray Charlotte Garret Michael Vourch Delphine Marest François Raffi David Boutoille Jean Reignier |
| author_sort | Benjamin Jean Gaborit |
| collection | DOAJ |
| description | Abstract Background Pneumocystis jirovecii pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lavage fluid cytology profiles at diagnosis. Methods We prospectively enrolled all patients meeting pre-defined diagnostic criteria for PJP admitted at Nantes university hospital, France, from January 2012 to January 2017. Diagnostic criteria for PJP were typical clinical features with microbiological confirmation of P. jirovecii cysts by direct examination or a positive specific quantitative real-time polymerase chain reaction (PCR) assay. Severe PJP was defined as hypoxemic acute respiratory failure requiring high-flow nasal oxygen with at least 50% FiO2, non-invasive ventilation, or MV. Results Of 2446 respiratory samples investigated during the study period, 514 from 430 patients were positive for P. jirovecii. Of these 430 patients, 107 met criteria for PJP and were included in the study, 53 (49.5%) patients had severe PJP, including 30 who required MV. All patients were immunocompromised with haematological malignancy ranking first (n = 37, 35%), followed by solid organ transplantation (n = 27, 25%), HIV-infection (n = 21, 20%), systemic diseases (n = 13, 12%), solid tumors (n = 12, 11%) and primary immunodeficiency (n = 6, 8%). By multivariate analysis, factors independently associated with severity were older age (OR, 3.36; 95% CI 1.4–8.5; p < 0.05), a P. jirovecii microscopy-positive result from bronchoalveolar lavage (BAL) (OR, 1.3; 95% CI 1.54–9.3; p < 0.05); and absence of a BAL fluid alveolitis profile (OR, 3.2; 95% CI 1.27–8.8; p < 0.04). The 90-day mortality rate was 27%, increasing to 50% in the severe PJP group. Factors independently associated with 90-day mortality were worse SOFA score on day 1 (OR, 1.05; 95% CI 1.02–1.09; p < 0.001) whereas alveolitis at BAL was protective (OR, 0.79; 95% CI 0.65–0.96; p < 0.05). In the subgroup of HIV-negative patients, similar findings were obtained, then viral co-infection were independently associated with higher 90-day mortality (OR, 1.25; 95% CI 1.02–1.55; p < 0.05). Conclusions Older age and P. jirovecii oocysts at microscopic examination of BAL were independently associated with severe PJP. Both initial PJP severity as evaluated by the SOFA score and viral co-infection predicted 90-day mortality. Alveolitis at BAL examination was associated with less severe PJP. The pathophysiological mechanism underlying this observation deserves further investigation. |
| first_indexed | 2024-12-10T15:12:21Z |
| format | Article |
| id | doaj.art-6d8125e3407442e78821ef562407e6d8 |
| institution | Directory Open Access Journal |
| issn | 2110-5820 |
| language | English |
| last_indexed | 2024-12-10T15:12:21Z |
| publishDate | 2019-11-01 |
| publisher | SpringerOpen |
| record_format | Article |
| series | Annals of Intensive Care |
| spelling | doaj.art-6d8125e3407442e78821ef562407e6d82022-12-22T01:43:54ZengSpringerOpenAnnals of Intensive Care2110-58202019-11-019111010.1186/s13613-019-0604-xOutcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational studyBenjamin Jean Gaborit0Benoit Tessoulin1Rose-Anne Lavergne2Florent Morio3Christine Sagan4Emmanuel Canet5Raphael Lecomte6Paul Leturnier7Colin Deschanvres8Lydie Khatchatourian9Nathalie Asseray10Charlotte Garret11Michael Vourch12Delphine Marest13François Raffi14David Boutoille15Jean Reignier16Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERMService d’Hématologie, University Hospital, INSERM, U1232, Université de NantesLaboratoire de Parasitologie-Mycologie, Institut de Biologie, University HospitalLaboratoire de Parasitologie-Mycologie, Institut de Biologie, University HospitalINSERM, UMR1087, l’institut du thoraxMedical Intensive Care, University HospitalDepartment of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERMDepartment of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERMDepartment of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERMDepartment of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERMDepartment of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERMMedical Intensive Care, University HospitalMedical Intensive Care, University HospitalMedical Intensive Care, University HospitalDepartment of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERMDepartment of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERMMedical Intensive Care, University HospitalAbstract Background Pneumocystis jirovecii pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lavage fluid cytology profiles at diagnosis. Methods We prospectively enrolled all patients meeting pre-defined diagnostic criteria for PJP admitted at Nantes university hospital, France, from January 2012 to January 2017. Diagnostic criteria for PJP were typical clinical features with microbiological confirmation of P. jirovecii cysts by direct examination or a positive specific quantitative real-time polymerase chain reaction (PCR) assay. Severe PJP was defined as hypoxemic acute respiratory failure requiring high-flow nasal oxygen with at least 50% FiO2, non-invasive ventilation, or MV. Results Of 2446 respiratory samples investigated during the study period, 514 from 430 patients were positive for P. jirovecii. Of these 430 patients, 107 met criteria for PJP and were included in the study, 53 (49.5%) patients had severe PJP, including 30 who required MV. All patients were immunocompromised with haematological malignancy ranking first (n = 37, 35%), followed by solid organ transplantation (n = 27, 25%), HIV-infection (n = 21, 20%), systemic diseases (n = 13, 12%), solid tumors (n = 12, 11%) and primary immunodeficiency (n = 6, 8%). By multivariate analysis, factors independently associated with severity were older age (OR, 3.36; 95% CI 1.4–8.5; p < 0.05), a P. jirovecii microscopy-positive result from bronchoalveolar lavage (BAL) (OR, 1.3; 95% CI 1.54–9.3; p < 0.05); and absence of a BAL fluid alveolitis profile (OR, 3.2; 95% CI 1.27–8.8; p < 0.04). The 90-day mortality rate was 27%, increasing to 50% in the severe PJP group. Factors independently associated with 90-day mortality were worse SOFA score on day 1 (OR, 1.05; 95% CI 1.02–1.09; p < 0.001) whereas alveolitis at BAL was protective (OR, 0.79; 95% CI 0.65–0.96; p < 0.05). In the subgroup of HIV-negative patients, similar findings were obtained, then viral co-infection were independently associated with higher 90-day mortality (OR, 1.25; 95% CI 1.02–1.55; p < 0.05). Conclusions Older age and P. jirovecii oocysts at microscopic examination of BAL were independently associated with severe PJP. Both initial PJP severity as evaluated by the SOFA score and viral co-infection predicted 90-day mortality. Alveolitis at BAL examination was associated with less severe PJP. The pathophysiological mechanism underlying this observation deserves further investigation.http://link.springer.com/article/10.1186/s13613-019-0604-xPneumocystis jirovecii pneumoniaEarly prognostic scoreHigh flow oxygenHaematological malignanciesAlveolitis |
| spellingShingle | Benjamin Jean Gaborit Benoit Tessoulin Rose-Anne Lavergne Florent Morio Christine Sagan Emmanuel Canet Raphael Lecomte Paul Leturnier Colin Deschanvres Lydie Khatchatourian Nathalie Asseray Charlotte Garret Michael Vourch Delphine Marest François Raffi David Boutoille Jean Reignier Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study Annals of Intensive Care Pneumocystis jirovecii pneumonia Early prognostic score High flow oxygen Haematological malignancies Alveolitis |
| title | Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study |
| title_full | Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study |
| title_fullStr | Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study |
| title_full_unstemmed | Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study |
| title_short | Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study |
| title_sort | outcome and prognostic factors of pneumocystis jirovecii pneumonia in immunocompromised adults a prospective observational study |
| topic | Pneumocystis jirovecii pneumonia Early prognostic score High flow oxygen Haematological malignancies Alveolitis |
| url | http://link.springer.com/article/10.1186/s13613-019-0604-x |
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