Infectious Disease Physician Fails to Prevent Pneumonia in HIV Patient

This case involved a thirty-five-year-old, HIV positive male who died of pneumocystis pneumonia as a result of failed medical prophylaxis. This man was diagnosed with HIV prior to his death, and had been properly managed with anti-retroviral therapy. The patient would see his infectious disease physician every couple of months for disease monitoring. In between visits, he began to develop a cough, shortness of breath, and fever which prompted him to schedule an appointment with his infectious disease doctor. The patient’s CD4 count was investigated showing a level of 190 cells/mm^3. The doctor’s physician assistant collected sputum from the patient but did not initiate therapy. He stated that he wanted to see which organism is the cause of his symptoms. Three days later, the patient had severe difficulties breathing, which required admission at the local hospital. His health rapidly declined requiring intubation. His CD4 count in the hospital was measured to be 80 cells/mm^3. Two days later, he was unable to mount a response to the infection and died in the intensive care unit. Later on, it was discovered that the patient’s sputum grew the organism pneumocystis jirovecii.

Question(s) For Expert Witness

1. Did the infectious disease physician follow the standard of care in this situation, and what should he have done to prevent this from happening?

Expert Witness Response

In this case, the physician did not follow the proper standard of care for this man. Medical prophylaxis against pneumocystis should be initiated in HIV patients when their CD4 count falls below 200 cells/mm^3. Trimethoprim Sulfamethoxazole combination (TMP-SMX) is usually the recommended prophylactic agent used. The proper dosage of this combination is 320 mg of TMP and 1600 mg of SMX. Other agents include TMP Dapsone combination, Clindamycin Primquine combination, Atovaquone, Pentamidine, and Trimetrexate. In addition to prophylaxis, the physician should have inquired about the patient’s medication compliance. Anti-retroviral therapy is very precise, requiring numerous agents and dosages throughout the day. Any deviation from the regimen can result in altered HIV virus activity and subsequent infections.