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Critical Care

, 23:356 | Cite as

Extracorporeal membrane oxygenation in Pneumocystis jirovecii pneumonia: outcome in HIV and non-HIV patients

  • Jonathan RilingerEmail author
  • Dawid L. Staudacher
  • Siegbert Rieg
  • Daniel Duerschmied
  • Christoph Bode
  • Tobias Wengenmayer
Open Access
Research Letter

Keywords

Extracorporeal membrane oxygenation Pneumocystis jirovecii Acute respiratory distress syndrome Outcome 

Abbreviations

APACHE II

Acute Physiology and Chronic Health Evaluation

ARDS

Acute respiratory distress syndrome

HIV

Human immunodeficiency virus

ICU

Intensive care unit

MV

Mechanical ventilation

PJP

Pneumocystis jirovecii pneumonia

RESP

Respiratory Extracorporeal Membrane Oxygenation Survival Prediction

SOFA

Sequential Organ Failure Assessment

VV-ECMO

Veno-venous extracorporeal membrane oxygenation

Main text

Pneumocystis jirovecii pneumonia (PJP) is a severe complication of immunosuppression that is associated with high mortality, depending on the underlying type of immunosuppression [1]. Consequently, the incidence of PJP is higher in non-HIV patients than in HIV patients, because of the increased use of immunosuppressive therapies for widespread indications [2]. So far, there is little evidence for veno-venous extracorporeal membrane oxygenation (ECMO) treatment in cases of PJP-induced severe acute respiratory distress syndrome (ARDS). Particularly, there is no study reporting and comparing the outcome of PJP requiring ECMO therapy in HIV and non-HIV patients.

Therefore, we report retrospective data of a single-centre registry of patients with severe respiratory failure, requiring ECMO support at our centre between January 2009 and April 2019. ECMO support was initiated when lung-protective mechanical ventilation was not able to prevent hypoxemia or hypercapnia, based on the treating medical team’s judgement.

A total of 337 ECMO patients were screened, and 18 patients with PJP were identified (Table 1). Diagnosis of PJP was verified via positive immunofluorescence microscopy in 13 patients (72%). Five patients (28%) displayed high PCR levels (median 67.000 [5.200–250.000] copies/ml) with conclusive symptoms and radiological findings but negative immunofluorescence microscopy. Microbiological testing was performed in bronchoalveolar lavage. In 14 patients (78%), PJP was diagnosed before the initiation of ECMO therapy.
Table 1

Baseline characteristics and outcome

 

All (n = 18)

HIV (n = 6)

non-HIV (n = 12)

p value

Age (years)

49.7 ± 18.4

36.8 ± 9.7

56.2 ± 18.6

0.032

Sex (male)

11 (61.1%)

4 (66.7%)

7 (58.3%)

1.0

BMI (kg/m2)

24.6 ± 3.4

23.0 ± 4.2

25.5 0 ± 2.6

0.149

Underlying pulmonary disease*

2 (11.1%)

0 (0%)

2 (16.7%)

0.407

Comorbidities

 Hypertension

5 (27.8%)

0 (0%)

5 (41.27%)

0.114

 Renal insufficiency

2 (11.1%)

0 (0%)

2 (16.7%)

0.529

 Chronic haemodialysis

1 (5.6%)

0 (0%)

1 (8.3%)

1.0

MV pre-ECMO

 PEEP (mbar)

14.9 ± 3.1

13.8 ± 2.9

15.3 ± 3.2

0.489

 Plateau pressure (mbar)

28.5 ± 4.6

29.3 ± 4.0

28.2 ± 4.9

0.571

 Driving pressure (mbar)

13.6 ± 4.2

15.5 ± 4.5

12.9 ± 4.1

0.412

 Tidal volume (ml)

390.7 ± 107.9

362.5 ± 104.4

400.9 ± 112.3

0.571

 Minute volume (l/min)

9.9 ± 3.6

10.6 ± 4.3

9.6 ± 3.5

0.571

 Compliance (ml/mbar)

32.7 ± 15.8

23.3 ± 10.4

35.5 ± 17.0

0.226

 FiO2 (%)

83.8 ± 19.4

87.5 ± 19.4

81.8 ± 19.4

0.660

 Horowitz index (mmHg)

87.6 ± 37.6

90.8 ± 40.8

85.8 ± 37.6

1.0

 D(A-a)O2 (mmHg)

466.4 ± 133.4

481.7 ± 132.9

458.1 ± 139.4

0.884

MV duration before ECMO (days)

5.4 ± 5.4

9.3 ± 6.5

3.3 ± 3.3

0.048

Acute renal failure

3 (16.7%)

0 (0%)

3 (25.0%)

0.276

LDHmax (U/l) before ECMO

734.1 ± 268.2

577.2 ± 182.1

812.5 ± 275.5

0.083

Scores

 SOFA score

9.7 ± 3.6

8.7 ± 3.4

10.3 ± 3.7

0.733

 APACHE II score

24.9 ± 8.1

25.0 ± 9.0

24.9 ± 8.1

0.961

 RESP score

− 3.3 ± 3.2

− 2.8 ± 1.9

− 3.55 ± 3.8

1.0

Successful ECMO weaning

7 (38.9%)

3 (50%)

4 (33.3%)

0.494

Survival

4 (22.2%)

3 (50%)

1 (8.3%)

0.045

ICU length of stay (days)

26.2 ± 20.5

33.8 ± 15.4

22.4 ± 22.3

0.053

ECMO duration (days)

13.2 ± 8.7

13.8 ± 11.0

12.9 ± 7.8

0.892

MV duration (days)

20.8 ± 14.8

25.2 ± 17.1

18.4 ± 13.7

0.462

Acute haemodialysis

6 (33.3%)

0 (0%)

6 (50.0%)

0.054

Prone position while ECMO

11 (61.1%)

5 (83.3%)

6 (50.0%)

0.588

ICU intensive care unit, MV mechanical ventilation

*Underlying pulmonary disease: lung fibrosis (n = 2)

ICU and hospital survival

HIV was the cause of immunosuppression in 6 patients, whereas 12 patients had other subtypes of immunosuppression (non-HIV group, Fig. 1a). In all cases, HIV was diagnosed during index hospitalisation. Patients therefore were without previous antiretroviral treatment.
Fig. 1

a Underlying subtypes of immunosuppression in ECMO patients with PJP. b Survival of PJP with severe respiratory failure and ECMO therapy in HIV vs. non-HIV patients

There were no significant differences between these two groups in relation to sex, comorbidities, ventilator settings, LDH levels or survival prediction scores (SOFA, APACHE II and RESP, Table 1). Patients with HIV were younger than non-HIV patients, and the interval between the start of mechanical ventilation and ECMO therapy was shorter in the non-HIV group.

Overall ECMO weaning rate was 39%, without a significant difference between HIV and non-HIV patients. Overall hospital survival was 22%. Withdrawal of care when further curative treatment was deemed futile was the most common cause of death (nine patients, 64.3%). Survival rate was higher in HIV than in non-HIV patients (50% vs. 8%, p = 0.045, Fig. 1b).

It has been shown previously in a non-ECMO setting that the outcome in HIV-negative PJP patients is worse than in patients with HIV [3], and our data confirm these earlier observations.

There are possible explanations for the better prognosis of HIV in this setting. On average, HIV patients are younger, and immunosuppression in HIV patients is reversible and can be resolved with the initiation of antiretroviral treatment. Moreover, the high mortality of non-HIV patients is associated with the underlying disease itself and a faster and more fulminant progression of the disease with more severe hypoxia and a higher prevalence of shock [4].

One third of our patients in the non-HIV group could be weaned successfully from ECMO support, suggesting that mortality was not only associated with ARDS, but underlying comorbidities may have been predominant. Moreover, there was a trend towards more frequent acute haemodialysis in non-HIV patients, illustrating that these patients had more complications and suffered from multi-organ failure.

In summary, a survival rate of 50% in HIV patients is similar to the average survival of ECMO patients with ARDS of any origin as shown by the CAESAR (63%) or the EOLIA trial (65%) [5, 6]. Therefore, ECMO therapy should not be withheld from patients with HIV-associated PJP.

Notes

Acknowledgements

Not applicable.

Authors’ contributions

JR and TW contributed to the conception of the study. JR and TW contributed to the data collection. JR, DLS, SR, DD, CB and TW contributed to the data analysis and interpretation. JR and TW drafted the manuscript. DLS, SR, DD and CB revised the manuscript for important intellectual content. All authors approved the final version of the manuscript.

Funding

None.

Ethics approval and consent to participate

The protocol was approved by our institution’s ethical committee (EK-Freiburg 151/14).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

References

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Copyright information

© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  1. 1.Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
  2. 2.Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
  3. 3.Division of Infectious Diseases, Department of Medicine II, Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany

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