, Volume 194, Issue 5, pp 755–762 | Cite as

Presence of an Alcohol Use Disorder is Associated with Greater Pneumonia Severity in Hospitalized HIV-Infected Patients

  • Sarah E. Jolley
  • Qasim Alkhafaf
  • Catherine Hough
  • David A. WelshEmail author



Pneumonia is common and more severe in human immunodeficiency virus (HIV)-infected patients. Alcohol consumption in pneumonia patients without HIV is associated with excess mortality and morbidity. However, studies are lacking on the impact of alcohol on pneumonia and HIV. Our goal was to determine if alcohol use was an independent risk factor for pneumonia severity in HIV-infected patients.


Secondary analysis of prospective cohort study data evaluating early bronchoscopy for pneumonia diagnosis in HIV patients between 2007 and 2011 was conducted. We defined AUDs using an alcohol use disorder identification test (AUDIT) score as follows: ≥8 indicates hazardous drinking and ≥14 indicates dependence. We quantified pneumonia severity using the pneumonia severity index (PSI). Multivariable linear regression was used to investigate the independent association between alcohol and pneumonia severity.


A total of 196 HIV+ individuals comprised our cohort. Most cohort subjects were middle-aged African American men. Most subjects (70 %) reported not taking antiretroviral therapy. The overall prevalence of hazardous drinking was 24 % in our cohort (48/196) with 10 % (19/196) meeting the criteria for alcohol dependence. Alcohol consumption was significantly associated with pneumonia severity (r = 0.25, p < 0.001). Hazardous drinking (β-coefficient 10.12, 95 % CI 2.95–17.29, p = 0.006) and alcohol dependence (β-coefficient 12.89, 95 % CI 2.59–23.18, p = 0.014) were independent risk factors for pneumonia severity. Reported homelessness and men who have sex with men (MSM) status remained independent risk factors for more severe pneumonia after adjustment for the effects of alcohol.


In a cohort of HIV patients with pneumonia, presence of an AUD was an independent risk factor for pneumonia severity. Homelessness and MSM status were associated with greater pneumonia severity in AUD patients.


Pneumonia severity Alcohol use disorder HIV/AIDS Respiratory illness 



Alcohol use disorder


Alcohol use disorders identification test


Highly active antiretroviral therapy


Human immunodeficiency virus


Interquartile range


Opportunistic infection


People living with HIV


Pneumonia severity index


Oxygen saturation



SJ, QA, and DW conceived of the study and generated the study design. SJ completed the data analysis. SJ, QA, DW, CH, and SJ contributed to drafting and revision of the manuscript.


This work was funded by the following National Institutes of Health Grants: P60 AA009803, R24AA19661, PO1 HL076100, and U54 GM104940 (LA CaTS Center).

Compliance with Ethical Standards

Conflicts of interest

The authors have no significant conflicts of interest to report.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Supplementary material

408_2016_9920_MOESM1_ESM.docx (17 kb)
Supplementary material 1 (DOCX 16 kb)


  1. 1.
    Sullivan PS, Jones JS, Baral SD (2014) The global north: HIV epidemiology in high-income countries. Curr Opin HIV AIDS 9(2):199–205CrossRefPubMedGoogle Scholar
  2. 2.
    Prevention CfDCa: today’s HIV/AIDS Epidemic. In: CDC (ed) (2015)Google Scholar
  3. 3.
    Buchacz K, Baker RK, Palella FJ Jr, Chmiel JS, Lichtenstein KA, Novak RM, Wood KC, Brooks JT, Investigators H (2010) AIDS-defining opportunistic illnesses in US patients, 1994–2007: a cohort study. AIDS 24(10):1549–1559CrossRefPubMedGoogle Scholar
  4. 4.
    Benito N, Moreno A, Miro JM, Torres A (2012) Pulmonary infections in HIV-infected patients: an update in the 21st century. Eur Respir J 39(3):730–745CrossRefPubMedGoogle Scholar
  5. 5.
    Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, Pickering RP, Ruan WJ, Smith SM, Huang B et al (2015) Epidemiology of DSM-5 alcohol use disorder: results from the national epidemiologic survey on alcohol and related conditions III. JAMA Psychiatry 72(8):757–766CrossRefPubMedGoogle Scholar
  6. 6.
    Bryant KJ, Nelson S, Braithwaite RS, Roach D (2010) Integrating HIV/AIDS and alcohol research. Alcohol Res Health 33(3):167–178PubMedPubMedCentralGoogle Scholar
  7. 7.
    Justice A, Sullivan L, Fiellin D (2010) Veterans aging cohort study project T: HIV/AIDS, comorbidity, and alcohol: can we make a difference? Alcohol Res Health 33(3):258–266PubMedPubMedCentralGoogle Scholar
  8. 8.
    Pandrea I, Happel KI, Amedee AM, Bagby GJ, Nelson S (2010) Alcohol’s role in HIV transmission and disease progression. Alcohol Res Health 33(3):203–218PubMedPubMedCentralGoogle Scholar
  9. 9.
    Samokhvalov AV, Irving HM, Rehm J (2010) Alcohol consumption as a risk factor for pneumonia: a systematic review and meta-analysis. Epidemiol Infect 138(12):1789–1795CrossRefPubMedGoogle Scholar
  10. 10.
    Zhang P, Bagby GJ, Happel KI, Raasch CE, Nelson S (2008) Alcohol abuse, immunosuppression, and pulmonary infection. Curr Drug Abuse Rev 1(1):56–67CrossRefPubMedGoogle Scholar
  11. 11.
    Babor T, Higgins-Biddle JC, Saunders JB, Monteiro MG (2001) The alcohol use disorder identification test: guidelines for use in primary care. In: WHO Publication, vol 01.6a. World Health Organization, GenevaGoogle Scholar
  12. 12.
    McGinnis KA, Justice AC, Kraemer KL, Saitz R, Bryant KJ, Fiellin DA (2013) Comparing alcohol screening measures among HIV-infected and -uninfected men. Alcohol Clin Exp Res 37(3):435–442CrossRefPubMedGoogle Scholar
  13. 13.
    Johnson JA, Lee A, Vinson D, Seale JP (2013) Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: a validation study. Alcohol Clin Exp Res 37(Suppl 1):E253–E259CrossRefPubMedGoogle Scholar
  14. 14.
    Bradley KA, McDonell MB, Bush K, Kivlahan DR, Diehr P, Fihn SD (1998) The AUDIT alcohol consumption questions: reliability, validity, and responsiveness to change in older male primary care patients. Alcohol Clin Exp Res 22(8):1842–1849PubMedGoogle Scholar
  15. 15.
    Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory care quality improvement project (ACQUIP). Alcohol use disorders identification test. Arch Intern Med 158(16):1789–1795CrossRefPubMedGoogle Scholar
  16. 16.
    Tuunanen M, Aalto M, Seppa K (2007) Binge drinking and its detection among middle-aged men using AUDIT, AUDIT-C and AUDIT-3. Drug Alcohol Rev 26(3):295–299CrossRefPubMedGoogle Scholar
  17. 17.
    Chew KW, Yen IH, Li JZ, Winston LG (2011) Predictors of pneumonia severity in HIV-infected adults admitted to an Urban public hospital. AIDS Patient Care STDS 25(5):273–277CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Curran A, Falco V, Crespo M, Martinez X, Ribera E, Villar del Saz S, Imaz A, Coma E, Ferrer A, Pahissa A (2008) Bacterial pneumonia in HIV-infected patients: use of the pneumonia severity index and impact of current management on incidence, aetiology and outcome. HIV Med 9(8):609–615CrossRefPubMedGoogle Scholar
  19. 19.
    Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN (1997) A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 336(4):243–250CrossRefPubMedGoogle Scholar
  20. 20.
    Pereira JM, Paiva JA, Rello J (2012) Assessing severity of patients with community-acquired pneumonia. Semin Respir Crit Care Med 33(3):272–283CrossRefPubMedGoogle Scholar
  21. 21.
    Sanders KM, Marras TK, Chan CK (2006) Pneumonia severity index in the immunocompromised. Can Respir J 13(2):89–93CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Shah BA, Ahmed W, Dhobi GN, Shah NN, Khursheed SQ, Haq I (2010) Validity of pneumonia severity index and CURB-65 severity scoring systems in community acquired pneumonia in an Indian setting. Indian J Chest Dis Allied Sci 52(1):9–17PubMedGoogle Scholar
  23. 23.
    Lifson AR, Lando HA (2012) Smoking and HIV: prevalence, health risks, and cessation strategies. Curr HIV/AIDS Rep 9(3):223–230CrossRefPubMedGoogle Scholar
  24. 24.
    Galvan FH, Bing EG, Fleishman JA, London AS, Caetano R, Burnam MA, Longshore D, Morton SC, Orlando M, Shapiro M (2002) The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV Cost and Services Utilization Study. J Stud Alcohol 63(2):179–186CrossRefPubMedGoogle Scholar
  25. 25.
    Lefevre F, O’Leary B, Moran M, Mossar M, Yarnold PR, Martin GJ, Glassroth J (1995) Alcohol consumption among HIV-infected patients. J Gen Intern Med 10(8):458–460CrossRefPubMedGoogle Scholar
  26. 26.
    Surah S, Kieran J, O’Dea S, Shiel C, Raffee S, Mulcahy F, Keenan E, Lyons F (2013) Use of the alcohol use disorders identification test (AUDIT) to determine the prevalence of alcohol misuse among HIV-infected individuals. Int J STD AIDS 24(7):517–521CrossRefPubMedGoogle Scholar
  27. 27.
    Mdodo R, Frazier EL, Dube SR, Mattson CL, Sutton MY, Brooks JT, Skarbinski J (2015) Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: cross-sectional surveys. Ann Intern Med 162(5):335–344CrossRefPubMedGoogle Scholar
  28. 28.
    de Wit M, Zilberberg MD, Boehmler JM, Bearman GM, Edmond MB (2011) Outcomes of patients with alcohol use disorders experiencing healthcare-associated infections. Alcohol Clin Exp Res 35(7):1368–1373CrossRefPubMedGoogle Scholar
  29. 29.
    Palepu A, Khan NA, Norena M, Wong H, Chittock DR, Dodek PM (2008) The role of HIV infection and drug and alcohol dependence in hospital mortality among critically ill patients. J Crit Care 23(3):275–280CrossRefPubMedGoogle Scholar
  30. 30.
    D’Souza NB, Bagby GJ, Nelson S, Lang CH, Spitzer JJ (1989) Acute alcohol infusion suppresses endotoxin-induced serum tumor necrosis factor. Alcohol Clin Exp Res 13(2):295–298CrossRefPubMedGoogle Scholar
  31. 31.
    Mandrekar P, Dolganiuc A, Bellerose G, Kodys K, Romics L, Nizamani R, Szabo G (2002) Acute alcohol inhibits the induction of nuclear regulatory factor kappa B activation through CD14/toll-like receptor 4, interleukin-1, and tumor necrosis factor receptors: a common mechanism independent of inhibitory kappa B alpha degradation? Alcohol Clin Exp Res 26(11):1609–1614PubMedGoogle Scholar
  32. 32.
    Nelson S, Bagby G, Summer WR (1989) Alcohol suppresses lipopolysaccharide-induced tumor necrosis factor activity in serum and lung. Life Sci 44(10):673–676CrossRefPubMedGoogle Scholar
  33. 33.
    Zhang P, Bagby GJ, Boe DM, Zhong Q, Schwarzenberger P, Kolls JK, Summer WR, Nelson S (2002) Acute alcohol intoxication suppresses the CXC chemokine response during endotoxemia. Alcohol Clin Exp Res 26(1):65–73CrossRefPubMedGoogle Scholar
  34. 34.
    Tamura DY, Moore EE, Partrick DA, Johnson JL, Offner PJ, Harbeck RJ, Silliman CC (1998) Clinically relevant concentrations of ethanol attenuate primed neutrophil bactericidal activity. J Trauma 44(2):320–324CrossRefPubMedGoogle Scholar
  35. 35.
    Zhang P, Bagby GJ, Stoltz DA, Summer WR, Nelson S (1999) Granulocyte colony-stimulating factor modulates the pulmonary host response to endotoxin in the absence and presence of acute ethanol intoxication. J Infect Dis 179(6):1441–1448CrossRefPubMedGoogle Scholar
  36. 36.
    Boe DM, Richens TR, Horstmann SA, Burnham EL, Janssen WJ, Henson PM, Moss M, Vandivier RW (2010) Acute and chronic alcohol exposure impair the phagocytosis of apoptotic cells and enhance the pulmonary inflammatory response. Alcohol Clin Exp Res 34(10):1723–1732CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Burnham EL, Kovacs EJ, Davis CS (2013) Pulmonary cytokine composition differs in the setting of alcohol use disorders and cigarette smoking. Am J Physiol Lung Cell Mol Physiol 304(12):L873–L882CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Goss CH, Rubenfeld GD, Park DR, Sherbin VL, Goodman MS, Root RK (2003) Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital. Chest 124(6):2148–2155CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Sarah E. Jolley
    • 1
  • Qasim Alkhafaf
    • 1
  • Catherine Hough
    • 2
  • David A. Welsh
    • 1
    Email author
  1. 1.Section of Pulmonary/Critical Care Medicine and Allergy/ImmunologyLouisiana State University Health Sciences CenterNew OrleansUSA
  2. 2.Division of Pulmonary and Critical Care MedicineUniversity of WashingtonSeattleUSA

Personalised recommendations