背景:吉罗韦西肺孢子虫肺炎(PcP)仍然与高死亡率和免疫功能低下的潜在疾病对临床表现的影响有关,PcP的严重程度和死亡率尚未得到充分评估.
目的:导致吉氏肺孢子虫肺炎(PcP)的基础疾病和免疫抑制是否影响该疾病的预后和临床表现?
方法:在这项多中心回顾性观察研究中,从2011年1月至2021年12月,纳入所有根据欧洲癌症研究和治疗组织(EORTC)共识定义确诊或可能诊断为PcP的连续患者,以评估基础免疫抑制疾病对总体和90日死亡率的流行病学和影响.
结果:总体而言,481名患者被纳入研究,180(37.4%)被定义为已证实的PcP,301(62.6%)被定义为可能的PcP。免疫介导的炎性疾病(IMID)或实体瘤患者在D90时的预后比其他PcP患者差。在多变量分析中,在艾滋病毒阴性人群中,实体瘤基础疾病(OR5.47,2.16-14.1;p<0.001),IMID(OR2.19,1.05-4.60;p=0.037),长期皮质类固醇暴露(OR2.07,1.03-4.31;p=0.045),痰/BAL涂片中的囊肿(OR1.92,1.02-3.62;p=0.043),入院时SOFA评分(OR1.58,1.39-1.82;p<0.001)与90天死亡率独立相关。先前的皮质治疗是与90天死亡率相关的唯一免疫抑制剂(OR1.67,1.03-2.71;p=0.035),尤其是泼尼松日剂量≥10mg(OR1.80,1.14-2.85;p=0.010)。
结论:在HIV阴性患者中,PcP诊断前的长期皮质类固醇与90天死亡率增加独立相关,特别是IMID患者。这些结果突出了IMID患者对PcP预防的需求以及IMID患者重症肺炎中早期考虑PcP治愈性治疗的需求。
BACKGROUND: Pneumocystis jirovecii pneumonia (PcP) remains associated with high rates of mortality, and the impact of immunocompromising underlying disease on the clinical presentation, severity, and mortality of PcP has not been adequately evaluated.
OBJECTIVE: Does the underlying disease and immunosuppression causing PcP impact the outcome and clinical presentation of the disease?
METHODS: In this multicenter retrospective observational
study, conducted from January 2011 to December 2021, all consecutive patients admitted with a proven or probable diagnosis of PcP according to the European Organisation for Research and Treatment of Cancer consensus definitions were included to assess the epidemiology and impact of underlying immunosuppressive diseases on overall and 90-day mortality.
RESULTS: Overall, 481 patients were included in the
study; 180 (37.4%) were defined as proven PcP and 301 (62.6%) were defined as probable PcP. Patients with immune-mediated inflammatory diseases (IMIDs) or solid tumors had a statistically poorer prognosis than other patients with PcP at day 90. In multivariate analysis, among the HIV-negative population, solid tumor underlying disease (OR, 5.47; 95% CI, 2.16-14.1; P < .001), IMIDs (OR, 2.19; 95% CI, 1.05-4.60; P = .037), long-term corticosteroid exposure (OR, 2.07; 95% CI, 1.03-4.31; P = .045), cysts in sputum/BAL smears (OR, 1.92; 95% CI, 1.02-3.62; P = .043), and SOFA score at admission (OR, 1.58; 95% CI, 1.39-1.82; P < .001) were independently associated with 90-day mortality. Prior corticotherapy was the only immunosuppressant associated with 90-day mortality (OR, 1.67; 95% CI, 1.03-2.71; P = .035), especially for a prednisone daily dose ≥ 10 mg (OR, 1.80; 95% CI, 1.14-2.85; P = .010).
CONCLUSIONS: Among patients who were HIV-negative, long-term corticosteroid prior to PcP diagnosis was independently associated with increased 90-day mortality, specifically in patients with IMIDs. These results highlight both the needs for PcP prophylaxis in patients with IMIDs and to early consider PcP curative treatment in severe pneumonia among patients with IMIDs.