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Empiric Outpatient Management of HIV-Related Pneumonia: Economical or Unwise?
- Henry Masur, MD; and
- James Shelhamer, MD
- National Institutes of Health, Bethesda, MD 20892. Requests for Reprints: Henry Masur, MD, National Institutes of Health, Building 10, Room 4D43, 10 Center Drive, MSC 1662, Bethesda, MD 20892-1662. Current Author Addresses: Drs. Masur and Shelhamer: National Institutes of Health, Building 10, Room 4D43, 10 Center Drive, MSC 1662, Bethesda, MD 20892-1662.
When immunologically normal patients present with pneumonia that is not severe enough to require immediate hospitalization, most health care providers initiate empiric oral therapy with a macrolide or tetracycline after a radiologic and laboratory evaluation that rarely extends further than a chest radiograph, leukocyte count determination, and perhaps a Gram stain of sputum [1]. Empiric therapy is directed against the common, treatable, community-acquired pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species.
For immunosuppressed patients, health care providers have hesitated to use such an empiric management approach because the range of potential pathogens is so broad that a comprehensive empiric regimen is difficult to administer, especially on an outpatient basis. Moreover, in many immunosuppressed patient populations, patients may deteriorate precipitously, making outpatient management unwise. This potential for rapid deterioration also encourages prompt diagnostic intervention at a time when patients' oxygenation and blood pressure allow them to tolerate sputum induction or bronchoscopy. Finally, early initiation of specific and appropriate therapy maximizes the likelihood of a favorable outcome and minimizes toxicity in patient populations that often have compromised organ function because of underlying disease or various drug therapies.
Many patients with human immunodeficiency virus (HIV) infection are now being followed by primary care practitioners in outpatients settings at which facilities for bronchoscopy and the examination of induced sputum are not conveniently available. There is also severe pressure to minimize the number of costly procedures that do not definitively alter outcome. In the United States, an estimated 1 million persons have HIV infection, and 25% of these persons (250 000) have CD4 counts less than 200 cells/mm3[2]. A decade ago, empiric management of pneumonia in patients with low CD4 counts was anathema to many specialists. In the interim, empiric management …
