Pneumocystis jirovecii pneumonia in intensive care units: a multicenter study by ESGCIP and EFISG

Giacobbe, D. R.; Dettori, S.; Di Pilato, V.; Asperges, E.; Ball, L.; Berti, E.; Blennow, O.; Bruzzone, B.; Calvet, L.; Capra Marzani, F.; Casabella, A.; Choudaly, S.; Dartevel, A.; De Pascale, G.; Di Meco, G.; Fallon, M.; Galerneau, L. -M.; Gallego, M.; Giacomini, M.; Gonzalez Saez, A.; Hansel, L.; Icardi, G.; Koehler, P.; Lagrou, K.; Lahmer, T.; Lewis White, P.; Magnasco, L.; Marchese, A.; Marelli, C.; Marin-Arriaza, M.; Martin-Loeches, I.; Mekontso-Dessap, A.; Mikulska, M.; Mularoni, A.; Nordlander, A.; Poissy, J.; Russelli, G.; Signori, A.; Tascini, C.; Vaconsin, L. -M.; Vargas, J.; Vena, A.; Wauters, J.; Pelosi, P.; Timsit, J. -F.; Bassetti, M.; Cerchiaro, M.; Zaccarelli, M.; Robba, C.; Battaglini, D.; Brunetti, I.; Del Puente, F.; Mora, S.; de la Villa, S.; Valerio, M.; Munoz, P.; Lombardi, G.; Cesarano, M.; Gennenzi, V.; Meersseman, P.; Hermans, G.; Wilmer, A.; Razazi, K.; Carteaux, G.; de Prost, N.; Cornely, O. A.; Seidel, D.; Alastruey-Izquierdo, A.; Garcia Borrega, J.; Bonnal, C.; de Montmollin, E.; Dessajan, J.; Ceresini, M.; Mojoli, F.; Vola, A.; Garnaud, C.; Diaz, E.; Gasch, O.; Prina, E.; Rasch, S.; Dibos, M.; Haschka, S.

doi:10.1186/s13054-023-04608-1

Background: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic, life-threatening disease commonly affecting immunocompromised patients. The distribution of predisposing diseases or conditions in critically ill patients admitted to intensive care unit (ICU) and subjected to diagnostic work-up for PJP has seldom been explored. Materials and methods: The primary objective of the study was to describe the characteristics of ICU patients subjected to diagnostic workup for PJP. The secondary objectives were: (i) to assess demographic and clinical variables associated with PJP; (ii) to assess the performance of Pneumocystis PCR on respiratory specimens and serum BDG for the diagnosis of PJP; (iii) to describe 30-day and 90-day mortality in the study population. Results: Overall, 600 patients were included in the study, of whom 115 had presumptive/proven PJP (19.2%). Only 8.8% of ICU patients subjected to diagnostic workup for PJP had HIV infection, whereas hematological malignancy, solid tumor, inflammatory diseases, and solid organ transplants were present in 23.2%, 16.2%, 15.5%, and 10.0% of tested patients, respectively. In multivariable analysis, AIDS (odds ratio [OR] 3.31; 95% confidence interval [CI] 1.13–9.64, p = 0.029), non-Hodgkin lymphoma (OR 3.71; 95% CI 1.23–11.18, p = 0.020), vasculitis (OR 5.95; 95% CI 1.07–33.22, p = 0.042), metastatic solid tumor (OR 4.31; 95% CI 1.76–10.53, p = 0.001), and bilateral ground glass on CT scan (OR 2.19; 95% CI 1.01–4.78, p = 0.048) were associated with PJP, whereas an inverse association was observed for increasing lymphocyte cell count (OR 0.64; 95% CI 0.42–1.00, p = 0.049). For the diagnosis of PJP, higher positive predictive value (PPV) was observed when both respiratory Pneumocystis PCR and serum BDG were positive compared to individual assay positivity (72% for the combination vs. 63% for PCR and 39% for BDG). Cumulative 30-day mortality and 90-day mortality in patients with presumptive/proven PJP were 52% and 67%, respectively. Conclusion: PJP in critically ill patients admitted to ICU is nowadays most encountered in non-HIV patients. Serum BDG when used in combination with respiratory Pneumocystis PCR could help improve the certainty of PJP diagnosis.