Abstract and Introduction
Abstract
Objectives: Despite better access to antiretroviral therapy (ART) over recent years, HIV remains a major global cause of mortality. The present study aimed to identify predictors of in-hospital mortality among HIV-positive patients presenting to an emergency department (ED).
Methods: In this cross-sectional study, HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED between 07 July 2017 and 18 October 2018 were prospectively enrolled. Data were compared between participants who survived to hospital discharge and those who died. The data were further subjected to univariate and multivariate logistic regression analyses to determine variables that were associated with in-hospital mortality.
Results: Of a total of 1224 participants, the in-hospital mortality was 13.6% (n = 166). On multivariate analysis, respiratory rate > 20 breaths/min [odds ratio (OR) = 1.90, P = 0.012], creatinine > 120 μmol/L (OR = 1.97, P = 0.006), oxygen saturation < 90% (OR = 2.09, P = 0.011), white cell count < 4.0 × 109/L (OR = 2.09, P = 0.008), ART non-adherence or not yet on ART (OR = 2.39, P = 0.012), Glasgow Coma Scale < 15 (OR = 2.53, P = 0.000), albumin < 35 g/L (OR = 2.61, P = 0.002), lactate > 2 mmol/L (OR = 4.83, P = 0.000) and cryptococcal meningitis (OR = 6.78, P = 0.000) were significantly associated with in-hospital mortality.
Conclusions: Routine clinical and laboratory parameters are useful predictors of in-hospital mortality in HIV-positive patients presenting to the ED with an acute illness. These parameters may be of value in guiding clinical decision-making, directing the appropriate use of resources and influencing patient disposition, and may also be useful in developing an outcome prediction tool.
Introduction
Globally, there are approximately 38 million people living with HIV (PLWH).[1] From 2003 to 2009, HIV was the leading cause of death worldwide, with the annual mortality peaking at just under 1.4 million deaths in 2007.[2] Better availability and improved access to antiretroviral therapy (ART) over the past 15 years has resulted in a significant reduction in HIV mortality (690 000 deaths in 2019), such that HIV now ranks as the third highest cause of global deaths after cardiovascular disease and cancer.[1,2]
South Africa has approximately one-fifth of the world’s HIV cases, with an overall HIV prevalence of 20.4%.[3] In 2017, HIV was reported to be the fifth highest cause of mortality in South Africa.[4] South Africa currently boasts the world’s largest HIV programme, the success of which is evident from an increase in life expectancy of 56 years in 2010 to 63 years in 2018.[5] Although there has been a 47% reduction in new HIV infections and a 40% reduction in HIV-related deaths from 2010 to 2019, the burden of HIV is still substantial, with c.200 000 new HIV infections and 72 000 HIV-related deaths reported in South Africa in 2019.[1] The high mortality associated with HIV has had far-reaching socioeconomic consequences, including a reduction in labour supply, agricultural productivity, human capital and national development as well as an upsurge in widow-and-orphan-headed households.[6,7]
Previous studies conducted in both outpatient and inpatient non-emergency department (ED) settings have indicated that various clinical and laboratory parameters such as the presenting diagnosis, requiring admission to the intensive care unit (ICU), a low CD4 cell count, an elevated HIV viral load (VL), anaemia, renal dysfunction, albuminaemia, hyperlactataemia etc. have been associated with a higher likelihood of mortality in HIV-positive patients.[8–13] However, there is a lack of data emanating from the ED setting. In addition to guiding timely management such as the early initiation of empirical antimicrobial therapy, judicious haemodynamic resuscitation, fast-tracking of special investigations and early ICU admission, the prompt identification of factors associated with poor outcomes at ED presentation may also assist clinicians with the appropriate channelling of resources, particularly in environments where these are limited. Hence, the aim of this study was to determine variables that may be associated with a higher likelihood of in-hospital mortality in HIV-positive patients presenting to the ED with an acute illness. Identifying such variables may also potentially be useful for developing a predictive tool to identify HIV-positive patients with higher risk of mortality.