Effect of Antiretroviral Therapy on the Incidence of Bacterial Pneumonia in Patients with Advanced HIV Infection

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Abstract
To determine the relationship of combination antiretroviral ther- apy and bacterial pneumonia, we assessed incidence of and risk factors for bacterial pneumonia in 1,898 human immunodeficiency virus (HIV)-infected patients with CD4 cell counts , 200/mm 3 fol- lowed in the Johns Hopkins HIV clinic between 1993 and 1998. A total of 352 episodes of bacterial pneumonia occurred during 2,310 patient-years of follow-up. Incidence of bacterial pneumonia decreased from 22.7 episodes/100 person-years (py) in the first half of 1993 to 12.3 episodes/100 py in the first half of 1996, reaching a nadir of 9.1 episodes/100 py in the second half of 1997 (p , 0.05). The use of protease inhibitor-containing regimens was associated with a decreased risk of bacterial pneumonia (risk ratio (RR) 0.55, 95% CI 0.31 to 0.94). Lower CD4 cell counts (RR 2.22, 95% CI 1.54 to 3.18), injection drug use as HIV transmission cate- gory (RR2.0, 95% CI 1.43 to 2.76), and prior Pneumocystis carinii pneumonia (RR 3.88, 95% CI 1.65 to 9.16) were also significantly associated with bacterial pneumonia. Trimethoprim-sulfamethox- azole and macrolide use were not significantly associated with risk of bacterial pneumonia. There has been a dramatic decline in the incidence of bacterial pneumonia resulting from the use of combi- nation antiretroviral therapy containing protease inhibitors. Bacterial pneumonia is a frequent cause of morbidity in hu- man immunodeficiency virus (HIV)-infected individuals (1- 3). The rate of bacterial pneumonia is 5.0 to 9.3 episodes/100 person-years (py) in HIV-seropositive patients compared with 1.5 to 2.1 episodes/100 (py) in the general adult population (3- 6). HIV-infected intravenous drug users (IDUs) are at an even greater risk of developing bacterial pneumonia compared with the general population, with an incidence of 6.7 to 12.3 epi- sodes per 100 py (7). Advancing immunosuppression is a known risk factor for bacterial pneumonia in HIV-infected pa-

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