Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression

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dc.contributor.authorLowe, David Men_ZA
dc.contributor.authorRangaka, Molebogeng Xen_ZA
dc.contributor.authorGordon, Fabianaen_ZA
dc.contributor.authorJames, Chris Den_ZA
dc.contributor.authorMiller, Robert Fen_ZA
dc.date.accessioned2015-12-28T06:47:50Z
dc.date.available2015-12-28T06:47:50Z
dc.date.issued2013en_ZA
dc.description.abstractObjective: Pneumocystis jirovecii pneumonia (PCP), the commonest opportunistic infection in HIV-infected patients in the developed world, is less commonly described in tropical and low and middle income countries (LMIC). We sought to investigate predictors of PCP in these settings. Design Systematic review and meta-regression. METHODS: Meta-regression of predictors of PCP diagnosis (33 studies). Qualitative and quantitative assessment of recorded CD4 counts, receipt of prophylaxis and antiretrovirals, sensitivity and specificity of clinical signs and symptoms for PCP, co-infection with other pathogens, and case fatality (117 studies). RESULTS: The most significant predictor of PCP was per capita Gross Domestic Product, which showed strong linear association with odds of PCP diagnosis (p<0.0001). This was not explained by study design or diagnostic quality. Geographical area, population age, study setting and year of study also contributed to risk of PCP. Co-infection was common (444 episodes/1425 PCP cases), frequently with virulent organisms. The predictive value of symptoms, signs or simple tests in LMIC settings for diagnosis of PCP was poor. Case fatality was >30%; treatment was largely appropriate. Prophylaxis appeared to reduce the risk for development of PCP, however 24% of children with PCP were receiving prophylaxis. CD4 counts at presentation with PCP were usually <200×10 3/ ml. CONCLUSIONS: There is a positive relationship between GDP and risk of PCP diagnosis. Although failure to diagnose infection in poorer countries may contribute to this, we also hypothesise that poverty exposes at-risk patients to a wide range of infections and that the relatively non-pathogenic P. jirovecii is therefore under-represented. As LMIC develop economically they eliminate the conditions underlying transmission of virulent infection: P. jirovecii , ubiquitous in all settings, then becomes a greater relative threat.en_ZA
dc.identifier.apacitationLowe, D. M., Rangaka, M. X., Gordon, F., James, C. D., & Miller, R. F. (2013). Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression. <i>PLoS One</i>, http://hdl.handle.net/11427/16056en_ZA
dc.identifier.chicagocitationLowe, David M, Molebogeng X Rangaka, Fabiana Gordon, Chris D James, and Robert F Miller "Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression." <i>PLoS One</i> (2013) http://hdl.handle.net/11427/16056en_ZA
dc.identifier.citationLowe, D. M., Rangaka, M. X., Gordon, F., James, C. D., & Miller, R. F. (2013). Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression. PloS one, 8(8), e69969. doi:10.1371/journal.pone.0069969en_ZA
dc.identifier.ris TY - Journal Article AU - Lowe, David M AU - Rangaka, Molebogeng X AU - Gordon, Fabiana AU - James, Chris D AU - Miller, Robert F AB - Objective: Pneumocystis jirovecii pneumonia (PCP), the commonest opportunistic infection in HIV-infected patients in the developed world, is less commonly described in tropical and low and middle income countries (LMIC). We sought to investigate predictors of PCP in these settings. Design Systematic review and meta-regression. METHODS: Meta-regression of predictors of PCP diagnosis (33 studies). Qualitative and quantitative assessment of recorded CD4 counts, receipt of prophylaxis and antiretrovirals, sensitivity and specificity of clinical signs and symptoms for PCP, co-infection with other pathogens, and case fatality (117 studies). RESULTS: The most significant predictor of PCP was per capita Gross Domestic Product, which showed strong linear association with odds of PCP diagnosis (p<0.0001). This was not explained by study design or diagnostic quality. Geographical area, population age, study setting and year of study also contributed to risk of PCP. Co-infection was common (444 episodes/1425 PCP cases), frequently with virulent organisms. The predictive value of symptoms, signs or simple tests in LMIC settings for diagnosis of PCP was poor. Case fatality was >30%; treatment was largely appropriate. Prophylaxis appeared to reduce the risk for development of PCP, however 24% of children with PCP were receiving prophylaxis. CD4 counts at presentation with PCP were usually <200×10 3/ ml. CONCLUSIONS: There is a positive relationship between GDP and risk of PCP diagnosis. Although failure to diagnose infection in poorer countries may contribute to this, we also hypothesise that poverty exposes at-risk patients to a wide range of infections and that the relatively non-pathogenic P. jirovecii is therefore under-represented. As LMIC develop economically they eliminate the conditions underlying transmission of virulent infection: P. jirovecii , ubiquitous in all settings, then becomes a greater relative threat. DA - 2013 DB - OpenUCT DO - 10.1371/journal.pone.0069969 DP - University of Cape Town J1 - PLoS One LK - https://open.uct.ac.za PB - University of Cape Town PY - 2013 T1 - Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression TI - Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression UR - http://hdl.handle.net/11427/16056 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/16056
dc.identifier.urihttp://dx.doi.org/10.1371/journal.pone.0069969
dc.identifier.vancouvercitationLowe DM, Rangaka MX, Gordon F, James CD, Miller RF. Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression. PLoS One. 2013; http://hdl.handle.net/11427/16056.en_ZA
dc.language.isoengen_ZA
dc.publisherPublic Library of Scienceen_ZA
dc.publisher.departmentInstitute of Infectious Disease and Molecular Medicineen_ZA
dc.publisher.facultyFaculty of Health Sciencesen_ZA
dc.publisher.institutionUniversity of Cape Town
dc.rightsThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.en_ZA
dc.rights.holder© 2013 Lowe et alen_ZA
dc.rights.urihttp://creativecommons.org/licenses/by/4.0en_ZA
dc.sourcePLoS Oneen_ZA
dc.source.urihttp://journals.plos.org/plosoneen_ZA
dc.subject.otherPneumocystisen_ZA
dc.subject.otherAdultsen_ZA
dc.subject.otherPediatricsen_ZA
dc.subject.otherEconomic analysisen_ZA
dc.subject.otherProphylaxisen_ZA
dc.subject.otherRespiratory infectionsen_ZA
dc.subject.otherPneumoniaen_ZA
dc.subject.otherOpportunistic infectionsen_ZA
dc.titlePneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regressionen_ZA
dc.typeJournal Articleen_ZA
uct.type.filetypeText
uct.type.filetypeImage
uct.type.publicationResearchen_ZA
uct.type.resourceArticleen_ZA
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