Characteristics, risk factors and outcomes of pneumocystis jirovecii pneumonia in HIV infected patients in three hospitals in South Africa

Abstract

Background Despite advances in chemoprophylaxis and universal coverage of antiretroviral therapy (ART), Pneumocystis Jirovecii Pneumonia (PJP) remains an important opportunistic infection in HIV- infection. We describe clinical characteristics, treatment outcomes of PJP and determinants of mortality among HIV-infected patients in South Africa. Methods A retrospective review of demographic and clinical characteristics of adult (≥18 years) patients enrolled in a multicentre surveillance study measuring the burden of physician- diagnosed Community Acquired Pneumonia (CAP) incidence and a prospective cohort study measuring the prospective incidence of Chest X-ray (CXR) confirmed, hospitalized CAP and recurrent CAP from three tertiary hospitals in South Africa. Records of all HIV-infected patients with a diagnosis of PJP between January 2019 and December 2021 were included. Clinical data, admission records (laboratory parameters, radiological assessments, symptoms), and demographic information (age, gender, area of residence) were analysed. Results A total of 160 HIV-infected patients were included in the study. The median age of patients was 39 (interquartile range: 32-45) years and 95 (59.4%) were female. A total of 152 (95.0%) were known HIV patients and 64 (40.0%) were on ART. The median log10 viral load (VL) was 5.4 (4.2-5.8) and the median absolute CD4 cell count was 26 (9-76) cells/mm3 at admission. A total of 74(46.3%) patients reported being on cotrimoxazole prophylaxis and 63(39.4%) were not, whereas cotrimoxazole use in the remaining 23(14.4%) was unknown. Most patients presented with severe symptoms at admission, 75% had hypoxia, 65% had respiratory failure, and 61% had extensive pulmonary involvement on imaging. Lower respiratory tract infections were documented in 66 (41.3%) patients, active pulmonary tuberculosis among 25 (15.6%), SARS-CoV-2 among 14 (8.75%) and pneumonia among 12 (7.5%) patients. Overall, 64 (40.0%) patients died (median time of 23 days (5-100) from admission, while 36 (22.5%) died in the hospital (median of 6 days (4-18). In adjusted analyses, age group ≥50 years, patients newly diagnosed with HIV and having SARS-CoV-2 at admission were significantly associated with higher risk of death in the study. iv Conclusion Regular monitoring of viremia, CD4 count, and adherence to antiretroviral therapy (ART) is imperative in preventing Pneumocystis jirovecii pneumonia (PJP) in individuals infected with HIV, particularly in the context of universal ART coverage. This proactive monitoring approach is essential for optimizing health outcomes in this population. HIV monitoring efforts should target high risk groups such as patients ≥50 years, people with concurrent infections and patients newly diagnosed with HIV.