Bacterial community-acquired pneumonia in HIV-infected patients

In this review, we focus on the clinical features, diagnosis, outcome and management of bacterial community-acquired pneumonia (BCAP) in HIV-infected patients, with particular attention to the most recent findings in this area.

Clinical features of BCAP are often atypical in HIV-infected individuals, especially when liver cirrhosis is also present. Streptococcus pneumoniae is the most common causative agent and is frequently associated with bacteriemic disease even in low-risk patients according to pneumonia severity index. An etiologic diagnosis is obtained in an average 35% of cases with standard culture methods. In such conditions, urinary antigen test for S. pneumoniae identification may help in reaching a rapid and etiologic diagnosis. CD4 cell count should be carefully considered in HIV patients with BCAP. In consideration of their high mortality risk, patients with a CD4 cell count of less than 200 cells/mul should be hospitalized, whereas those with a CD4 cell count of at least 200 cells/mul could be managed according to pneumonia severity index score. Empiric antibiotic therapy should include a combination of a beta-lactam and a macrolide or a respiratory fluoroquinolone alone. Finally, prevention strategies should include lifestyle modification, highly active antiretroviral therapy access and adherence programs and the implementation of pneumococcal vaccination.

A correct diagnosis and management together with a comprehensive approach to preventive measures, including lifestyle modification, highly active antiretroviral therapy access and adherence programs and the implementation of pneumococcal vaccination, are key factors to reduce BCAP incidence and mortality in HIV-infected patients.