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Empirically treated Pneumocystis carinii pneumonia in London, 1983-1989
E J Beck1, P D French, M H Helbert
1Academic Department of Public Health, St Mary's Hospital and Medical School, London, UK.
Abstract:
For 227 episodes of Pneumocystis carinii pneumonia (PCP) treated at St Mary's between 1983 and 1989, factors predictive of fatal outcome were age, haemoglobin levels, peripheral lymphocyte count and alveolar-arterial oxygen gradient. Case fatality for the 47 empirically-treated episodes was significantly higher compared with the 180 cytologically proven episodes (55% vs 18%, chi 2 = 25.7, P less than 0.0001). Case fatality for episodes which could not be bronchoscoped was significantly higher compared with bronchoscopy negative cases (66% vs 25%, chi 2 = 4.5, P less than 0.05). Predictive factors for fatal outcome differed significantly for cases which could not be bronchoscoped and cytologically proven cases: haemoglobin level (10.7 g/dl vs 12.0 g/dl, P less than 0.001), lymphocyte count (0.64 x 10(9)/l vs 0.87 x 10(9)/l, P = 0.05) and oxygen gradient (77.7 mmHg vs 58.9 mmHg, P less than 0.02). Such differences were not observed between bronchoscopy negative and cytologically proven cases. Case fatality decreased significantly over time (b = -0.39, SE = 0.14, P less than 0.05). Total and non-fatal first time episodes displayed an inverse relationship between oxygen gradient and time (r = -0.22, P less than 0.006 and r = -0.24, P less than 0.01, respectively). Mean oxygen gradient of fatal episodes for sequential years increased significantly from 73 mmHg in 1983 to 102 mmHg in 1989 (r = 0.92, P less than 0.01). This suggests that medical intervention as well as presentation with less severe disease both contributed to improved case fatality over time.
Insights
Pneumocystis pneumonia (PCP) outcomes improved over time due to medical advances and less severe initial presentations. Key predictors of fatal PCP outcomes included age, hemoglobin, lymphocyte count, and oxygen gradient.
Area of Science:
- Infectious Diseases
- Pulmonology
- Critical Care Medicine
Background:
- Pneumocystis pneumonia (PCP) is a significant opportunistic infection, particularly in immunocompromised individuals.
- Early identification and management of PCP are crucial for improving patient outcomes.
- Understanding prognostic factors in PCP is essential for risk stratification and targeted treatment.
Purpose of the Study:
- To identify factors predictive of fatal outcomes in Pneumocystis pneumonia (PCP).
- To compare case fatality rates between empirically treated and cytologically proven PCP episodes.
- To investigate the influence of diagnostic methods (bronchoscopy) and time on PCP outcomes.
Main Methods:
- Retrospective analysis of 227 episodes of Pneumocystis pneumonia (PCP) treated between 1983 and 1989.
- Statistical comparison of case fatality rates based on treatment approach (empirical vs. cytological) and diagnostic procedures (bronchoscopy).
- Analysis of predictive factors for fatal outcomes, including age, hemoglobin, lymphocyte count, and alveolar-arterial oxygen gradient, over time.
Main Results:
- Factors predicting fatal PCP outcomes included age, low hemoglobin, low peripheral lymphocyte count, and increased alveolar-arterial oxygen gradient.
- Empirically treated PCP episodes had significantly higher case fatality (55%) compared to cytologically proven episodes (18%).
- Case fatality was higher in episodes where bronchoscopy could not be performed (66% vs. 25%). Predictive factors differed between non-bronchoscoped and cytologically proven cases.
- Case fatality significantly decreased over time, with an inverse relationship observed between oxygen gradient and time for non-fatal episodes.
Conclusions:
- Medical intervention and less severe initial disease presentation contributed to improved PCP case fatality over the study period.
- Diagnostic approach (empirical vs. confirmed) and feasibility of bronchoscopy significantly impacted PCP outcomes.
- Prognostic factors like oxygenation status and hematological parameters are critical in managing PCP patients.