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Pneumococcal Bacteremia in the Era of Potent Combination Antiretroviral Therapy

Potent combination antiretroviral therapy and pneumococcal vaccination have reduced the incidence of invasive pneumococcal disease among HIV-infected patients, but mortality has increased, primarily among those with liver cirrhosis.

Streptococcus pneumoniae can be considered an opportunistic pathogen among HIV-infected people. The incidence of invasive pneumococcal disease may be 35 to 100 times greater than in the general population (ACC Jul 13 2005), recurrences are common, and pneumococcal vaccination is thought to offer limited protection once advanced immunosuppression occurs. Potent combination antiretroviral therapy has led to a decline in the incidence of many HIV-related opportunistic infections. Could invasive pneumococcal disease be one of them? To evaluate this possibility, investigators assessed the incidence of pneumococcal bacteremia among 3143 HIV-infected adults in Barcelona before and after the introduction of potent combination antiretroviral therapy (1986–1996 vs. 1997–2002).

From January 1986 to December 2002, 142 episodes of pneumococcal bacteremia occurred in the cohort; most (83%) were secondary to pneumococcal pneumonia. The annual incidence of pneumococcal bacteremia was significantly lower after the introduction of potent antiretroviral therapy than before it (8.2 vs. 24.1 episodes per 1000 patient-years). Patients who had pneumococcal bacteremia in the era of potent therapy had more associated comorbidities (such as cirrhosis) and were significantly older (mean age, 37.2 vs. 31.6) than those who had bacteremia before potent therapy was available. Mortality from pneumococcal bacteremia was significantly higher after the introduction of potent therapy than before (26% vs. 8%), mainly because of the presence of cirrhosis.

In the era of potent therapy, use of the 23-valent pneumococcal vaccine increased, and recurrent pneumococcal bacteremia decreased. The most frequent serotypes of S. pneumoniae isolated from patients were 19 (14%) and 9 (12%). Serotypes included in the 23-valent vaccine accounted for 86% of strains, both before and after the introduction of potent therapy. Compared with pneumococcal isolates from non-HIV–infected patients, isolates from infected patients had a higher proportion of strains that were not susceptible to penicillin (40% vs. 29%), trimethoprim-sulfamethoxazole (51% vs. 42%), or tetracycline (34% vs. 26%).

Comment: These data suggest that the use of potent combination antiretroviral therapy and the 23-valent pneumococcal vaccine can lower risk for pneumococcal bacteremia in HIV-infected patients. However, those with liver cirrhosis are at substantial risk for both morbidity and mortality from S. pneumoniae.

— Carlos del Rio, MD

Published in Journal Watch HIV/AIDS Clinical Care July 27, 2005

Citation(s):

Grau I et al. Epidemiologic changes in bacteremic pneumococcal disease in patients with human immunodeficiency virus in the era of highly active antiretroviral therapy. Arch Intern Med 2005 Jul 11; 165:1533-40.

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