Community-acquired pneumonia in adult HIV-infected patients: course, treatment, and prevention

This is a review of published data on community-acquired pneumonia (CAP) in adult HIV-infected patients. Morbidity of bacterial pneumonia in HIV-infected patients is 5- to 10-fold higher than that in general population. Wide use of antiretroviral therapy (ARVT) is associated with a reduction in morbidity of CAP in HIV-infected patients, but this reduction is not as significant as for other opportunistic infections. The most important risk factors for CAP are drug abuse, tobacco smoking, HIV-associated immunosuppression, hepatic cirrhosis, not to be treated with ARVT or ARVT withdrawal. Severe, complicated and invasive course of CAP and poor outcomes are seen more often in HIV-infected patients compared to general population. Bacterial pneumonia should be differed from pneumonia caused by Pneumocystis and from tuberculosis, especially in endemic countries and in patients with insidious onset of the disease. The standard therapy of CAP is applied in all patients independently of HIV status. However, administration of fluoroquinolones is restricted in regions with high prevalence of multi-drug resistant tuberculosis in HIV-infected patients before tuberculosis is excluded. Several studies have demonstrated that, in case of false initial diagnosis, 10-day monotherapy with a fluoroquinolone could form the resistance of Mycobacteria tuberculosis against this drug; this significantly complicates further treatment of tuberculosis and increases the treatment cost. Beta-lactams are not effective against tuberculosis; in 2016, WHO excluded macrolides from the list of medications for therapy of tuberculosis due to their low activity against M. tuberculosis. Therefore, empirical therapy of CAP in HIV-infected patients should be started with combination of beta-lactam antibiotic and newer macrolide. A strong protective effect of PPV23 vaccine against CAP was confirmed in HIV-infected patients, but the highest protective efficacy was seen in patients with relatively preserved immunity compared to patients with CD4 < 200 cells × µL^-1.

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