Surgical issues in HIV infection
- Howard Libman, MD
Howard Libman, MD
- Professor of Medicine
- Harvard Medical School
Potent antiretroviral therapy (ART) has significantly increased longevity among HIV-infected patients. As this patient population grows older, an increased need for surgical interventions, such as coronary revascularization, will likely rise. (See "HIV infection in older adults".)
This topic review will address issues surrounding HIV infection in the patient who needs surgery, including morbidity and mortality, the pre-operative evaluation, and post-surgical management. This topic will also address concerns regarding HIV transmission during surgical procedures. Discussions of postexposure prophylaxis after potential HIV exposures are discussed elsewhere. (See "Management of healthcare personnel exposed to HIV".)
HIV INFECTION AND SURGICAL MORBIDITY AND MORTALITY
With widespread use of antiretroviral therapy (ART), good surgical outcomes are reported among HIV-infected populations. Some, but not all, studies have suggested a slightly greater morbidity and mortality compared with uninfected populations [1-13]:
●In a retrospective study of United States veterans who underwent inpatient surgery, 30 day postoperative mortality was higher among 1641 HIV-infected patients compared with 3282 procedure-matched, uninfected controls (3.4 versus 1.6 percent) . Although lower CD4 cell counts were associated with higher mortality, the mortality difference between HIV-infected and uninfected patients persisted at all CD4 cell count strata. Hypoalbuminemia and older age were also independently associated with mortality.
●In another retrospective study of surgical outcomes, HIV-infected patients were matched 1:1 by type of surgery, year of intervention, gender, and age with HIV-uninfected patients . Clinical outcomes, length of stay, and number of postoperative visits were similar among the 332 matched patient pairs. Various complications were no more frequent among HIV-infected patients, except for pneumonia.
- Filsoufi F, Salzberg SP, Harbou KT, et al. Excellent outcomes of cardiac surgery in patients infected with HIV in the current era. Clin Infect Dis 2006; 43:532.
- Horberg MA, Hurley LB, Klein DB, et al. Surgical outcomes in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy. Arch Surg 2006; 141:1238.
- Miller FC. Ten goals for the American College of Obstetricians and Gynecologists for the first decade of the next millennium. Obstet Gynecol 2000; 95:1.
- Grubert TA, Reindell D, Kästner R, et al. Complications after caesarean section in HIV-1-infected women not taking antiretroviral treatment. Lancet 1999; 354:1612.
- Semprini AE, Castagna C, Ravizza M, et al. The incidence of complications after caesarean section in 156 HIV-positive women. AIDS 1995; 9:913.
- Louis J, Landon MB, Gersnoviez RJ, et al. Perioperative morbidity and mortality among human immunodeficiency virus infected women undergoing cesarean delivery. Obstet Gynecol 2007; 110:385.
- European Mode of Delivery Collaboration. Elective caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial. Lancet 1999; 353:1035.
- Watts DH, Lambert JS, Stiehm ER, et al. Complications according to mode of delivery among human immunodeficiency virus-infected women with CD4 lymphocyte counts of < or = 500/microL. Am J Obstet Gynecol 2000; 183:100.
- Guth AA, Hofstetter SR, Pachter HL. Human immunodeficiency virus and the trauma patient: factors influencing postoperative infectious complications. J Trauma 1996; 41:251.
- Albaran RG, Webber J, Steffes CP. CD4 cell counts as a prognostic factor of major abdominal surgery in patients infected with the human immunodeficiency virus. Arch Surg 1998; 133:626.
- Emparan C, Iturburu IM, Ortiz J, Mendez JJ. Infective complications after abdominal surgery in patients infected with human immunodeficiency virus: role of CD4+ lymphocytes in prognosis. World J Surg 1998; 22:778.
- Hooker CM, Meguid RA, Hulbert A, et al. Human immunodeficiency virus infection as a prognostic factor in surgical patients with non-small cell lung cancer. Ann Thorac Surg 2012; 93:405.
- King JT Jr, Perkal MF, Rosenthal RA, et al. Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators. JAMA Surg 2015; 150:343.
- Fichtenbaum CJ. Inflammatory Markers Associated with Coronary Heart Disease in Persons with HIV Infection. Curr Infect Dis Rep 2011; 13:94.
- Stanley TL, Grinspoon SK. Body composition and metabolic changes in HIV-infected patients. J Infect Dis 2012; 205 Suppl 3:S383.
- Mdodo R, Frazier EL, Dube SR, et al. Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: cross-sectional surveys. Ann Intern Med 2015; 162:335.
- Deneve JL, Shantha JG, Page AJ, et al. CD4 count is predictive of outcome in HIV-positive patients undergoing abdominal operations. Am J Surg 2010; 200:694.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on September 21, 2016).
- Chen M, Rhodes PH, Hall IH, et al. Prevalence of undiagnosed HIV infection among persons aged ≥13 years--National HIV Surveillance System, United States, 2005-2008. MMWR Suppl 2012; 61:57.
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- Freitas P, Carvalho D, Santos AC, et al. Prevalence of obesity and its relationship to clinical lipodystrophy in HIV-infected adults on anti-retroviral therapy. J Endocrinol Invest 2012; 35:964.
- Ryu T, Ikeda M, Okazaki Y, et al. Myelodysplasia associated with acquired immunodeficiency syndrome. Intern Med 2001; 40:795.
- Ray PE. HIV-associated nephropathy: a diagnosis in evolution. Nephrol Dial Transplant 2012; 27:3969.
- Ando M, Tsuchiya K, Nitta K. How to manage HIV-infected patients with chronic kidney disease in the HAART era. Clin Exp Nephrol 2012; 16:363.
- Rose DK, Byrick RJ, Cohen MM, Caskennette GM. Planned and unplanned postoperative admissions to critical care for mechanical ventilation. Can J Anaesth 1996; 43:333.
- Witt DJ, Craven DE, McCabe WR. Bacterial infections in adult patients with the acquired immune deficiency syndrome (AIDS) and AIDS-related complex. Am J Med 1987; 82:900.
- Shepp DH, Tang IT, Ramundo MB, Kaplan MK. Serious Pseudomonas aeruginosa infection in AIDS. J Acquir Immune Defic Syndr 1994; 7:823.
- Tumbarello M, Tacconelli E, de Gaetano K, et al. Bacterial pneumonia in HIV-infected patients: analysis of risk factors and prognostic indicators. J Acquir Immune Defic Syndr Hum Retrovirol 1998; 18:39.
- Stock PG, Barin B, Murphy B, et al. Outcomes of kidney transplantation in HIV-infected recipients. N Engl J Med 2010; 363:2004.
- Subramanian A, Sulkowski M, Barin B, et al. MELD score is an important predictor of pretransplantation mortality in HIV-infected liver transplant candidates. Gastroenterology 2010; 138:159.
- Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med 2002; 347:284.
- Muller E, Barday Z, Mendelson M, Kahn D. HIV-positive-to-HIV-positive kidney transplantation--results at 3 to 5 years. N Engl J Med 2015; 372:613.
- Gerberding JL, Littell C, Tarkington A, et al. Risk of exposure of surgical personnel to patients' blood during surgery at San Francisco General Hospital. N Engl J Med 1990; 322:1788.
- Lawrence VA, Gafni A, Kroenke K. Preoperative HIV testing: is it less expensive than universal precautions? J Clin Epidemiol 1993; 46:1219.
- Joyce MP, Kuhar D, Brooks JT. Notes from the field: occupationally acquired HIV infection among health care workers - United States, 1985-2013. MMWR Morb Mortal Wkly Rep 2015; 63:1245.
- Lot F, Séguier JC, Fégueux S, et al. Probable transmission of HIV from an orthopedic surgeon to a patient in France. Ann Intern Med 1999; 130:1.
- Bosch X. Second case of doctor-to-patient HIV transmission. Lancet Infect Dis 2003; 3:261.
- Centers for Disease Control (CDC). Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR Morb Mortal Wkly Rep 1990; 39:489.
- Centers for Disease Control (CDC). Update: transmission of HIV infection during invasive dental procedures--Florida. MMWR Morb Mortal Wkly Rep 1991; 40:377.
- Ciesielski C, Marianos D, Ou CY, et al. Transmission of human immunodeficiency virus in a dental practice. Ann Intern Med 1992; 116:798.
- Danila RN, MacDonald KL, Rhame FS, et al. A look-back investigation of patients of an HIV-infected physician. Public health implications. N Engl J Med 1991; 325:1406.
- Centers for Disease Control (CDC). Update: investigations of patients who have been treated by HIV-infected health-care workers. MMWR Morb Mortal Wkly Rep 1992; 41:344.
- Robert LM, Chamberland ME, Cleveland JL, et al. Investigations of patients of health care workers infected with HIV. The Centers for Disease Control and Prevention database. Ann Intern Med 1995; 122:653.
- Centers for Disease Control and Prevention (CDC). Investigation of patients treated by an HIV-infected cardiothoracic surgeon--Israel, 2007. MMWR Morb Mortal Wkly Rep 2009; 57:1413.
- Henderson DK, Dembry L, Fishman NO, et al. SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Infect Control Hosp Epidemiol 2010; 31:203.
- United Kingdom Department of Health. HIV infected health care workers: guidance on management and patient notification. July, 2005.
- HIV INFECTION AND SURGICAL MORBIDITY AND MORTALITY
- PREOPERATIVE ASSESSMENT
- General health status
- HIV disease status
- Medication history
- Past medical history
- Nutritional status
- Laboratory assessment
- Advance directives
- PERIOPERATIVE MANAGEMENT
- POSTOPERATIVE MANAGEMENT
- Postoperative fever
- - Common causes
- - Opportunistic infections
- - Pneumonia
- ORGAN TRANSPLANTATION IN HIV-INFECTED PATIENTS
- SURGERY AND HIV TRANSMISSION
- Risk of HIV transmission from patient to healthcare worker
- Risk of HIV transmission from infected healthcare workers to patients
- - Large-scale look-back investigations
- - Management of the HIV-infected healthcare worker
- SUMMARY AND RECOMMENDATIONS