Correspondence

Bacterial Pneumonia in HIV

N Engl J Med 1996; 334:195January 18, 1996

Article

To the Editor:

Hirschtick et al. (Sept. 28 issue)1 report an increased frequency of bacterial pneumonia among persons positive for the human immunodeficiency virus (HIV) as compared with seronegative controls, even among patients with CD4 counts of more than 500 per cubic millimeter. Although the authors suggest smoking cessation and prophylaxis with trimethoprim–sulfamethoxazole as strategies to use for persons at risk, they do not comment on vaccination to prevent pneumonia. The two pathogens cultured most frequently from the sputum in their series were Streptococcus pneumoniae and Haemophilus influenzae. Pneumococcal vaccine is recommended and H. influenzae type b vaccine should be considered for HIV-infected patients.2,3 In this era of increasing use of prophylactic antibiotics in patients with AIDS, it is important not to forget vaccination, especially early in the course of disease, when a more effective immune response may be more likely to induce protection.

Jeffrey I. Cohen, M.D.
National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892

3 References

1. 1

   Hirschtick RE, Glassroth J, Jordan MC, et al. Bacterial pneumonia in persons infected with the human immunodeficiency virus. N Engl J Med 1995;333:845-851
   Full Text | Web of Science | Medline

2. 2

   Update on adult immunization: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep 1991;40:1-94
   Medline

3. 3

   Task Force on Adult Immunization, Infectious Diseases Society of America. Guide for adult immunization. 2nd ed. Philadelphia: American College of Physicians, 1990.
   

Author/Editor Response

The authors reply:

To the Editor: We appreciate Dr. Cohen's comments on the vaccination of HIV-infected persons against S. pneumoniae. This intervention is routinely practiced at each of the institutions participating in our study. We attempted to analyze the effect of pneumococcal vaccination on the subsequent development of pneumococcal pneumonia within our cohort. No protective effect could be demonstrated with regard to the overall occurrence of pneumococcal pneumonia.

Because the study was not designed to evaluate this intervention specifically, many confounding factors were present. For example, the timing of vaccine administration with regard to the CD4 lymphocyte count was not uniform. This is important in that the magnitude of the antibody response has been shown to be reduced in patients with more advanced HIV disease.1,2 Attempts to correct for these confounding factors proved unsatisfactory. An evaluation of the possible effects of vaccination on complications of S. pneumoniae pneumonia, such as bacteremia, was not possible because of the infrequent occurrence of such complications.

Despite the difficulties that we and other investigators have had in definitively proving its value, we support the administration of pneumococcal vaccine to HIV-infected persons regardless of the CD4 lymphocyte count. This is an inexpensive and low-risk intervention that may be beneficial in at least some persons infected with HIV. It is logical to administer the vaccine early in the course of HIV infection, when the antibody response is more robust. Antibody responses are greater in zidovudine-treated patients, and it has been suggested that vaccination be delayed at least four weeks after the initiation of antiretroviral therapy.2

The development of a polysaccharide-conjugated vaccine, which in the case of H. influenzae is associated with an enhanced antibody response,3 may prove beneficial in the prevention of pneumococcal disease in HIV-infected persons.4 With regard to H. influenzae, currently available vaccines are directed against type b strains, which occur relatively infrequently in adults, including those with HIV.5 Thus, vaccination against H. influenzae would be expected to be less beneficial than vaccination against S. pneumoniae in HIV-infected adults.

Robert E. Hirschtick, M.D.
Northwestern University Medical School, Chicago, IL 60611

Jeffrey Glassroth, M.D.
Medical College of Pennsylvania and Hahnemann University, Philadelphia, PA 19129

Matthew C. Jordan, M.S.
Research Triangle Institute, Research Triangle Park, NC 27709

5 References

1. 1

   Janoff EN, Douglas JM Jr, Gabriel M, et al. Class-specific antibody response to pneumococcal capsular polysaccharides in men infected with human immunodeficiency virus type 1. J Infect Dis 1988;158:983-990
   CrossRef | Web of Science | Medline

2. 2

   Glaser JB, Volpe S, Aguirre A, Simpkins H, Schiffman G. Zidovudine improves response to pneumococcal vaccine among persons with AIDS and AIDS-related complex. J Infect Dis 1991;164:761-764
   CrossRef | Web of Science | Medline

3. 3

   Steinhoff MC, Auerbach BS, Nelson KE, et al. Antibody responses to Haemophilus influenzae type B vaccines in men with human immunodeficiency virus infection. N Engl J Med 1991;325:1837-1842
   Full Text | Web of Science | Medline

4. 4

   Janoff EN, Breiman RF, Daley CL, Hopewell PC. Pneumococcal disease during HIV infection: epidemiologic, clinical, and immunologic perspectives. Ann Intern Med 1992;117:314-324
   Web of Science | Medline

5. 5

   Steinhart R, Reingold AL, Taylor F, Anderson G, Wenger JD. Invasive Haemophilus influenzae infections in men with HIV infection. JAMA 1992;268:3350-3352
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Frank P. Kroon, Jaap T. van Dissel, Elisabeth Ravensbergen, Peter H. Nibbering, Ralph van Furth. (2000) Enhanced antibody response to pneumococcal polysaccharide vaccine after prior immunization with conjugate pneumococcal vaccine in HIV-infected adults. Vaccine 19:7-8, 886-894
   CrossRef