Similar Outcomes of<i>Legionella</i>Pneumonia in Treated Human Immunodeficiency Virus Infection

To the Editor—We read with interest the article by Cillóniz et al [1] on the first retrospective case-control series of Legionella pneumonia among human immunodeficiency virus (HIV)-infected individuals from 3 Spanish hospitals. The report significantly adds to the literature by comparing HIV-infected to HIV-uninfected individuals in terms of Legionella pneumonia disease severity, treatment, and outcomes. Essentially, the pneumonia severity scores, antimicrobial regimens, and need for intensive care admission were not different between cases and controls. The study findings are in keeping with the report on the South Bronx Legionella outbreak, in which 24 of 138 individuals had an underlying diagnosis of HIV, suggesting overrepresentation of HIV among those who became clinically ill with Legionella [2]. The mortality of HIV-infected individuals did not differ from that of non-HIV–infected individuals. In contrast, in a 2016 publication by Wolter et al [3] who looked at Legionella-infected patients with known HIV status (n = 20) from 2 sites in South Africa, HIV-infected individuals had higher case-fatality rates than HIV-uninfected individuals (20% vs 0%) and, unlike in Cillóniz et al, only 24% of Legionella patients were administered appropriate anti-Legionella antibiotic therapy. Although we recognize that this article is a stepping-stone to better understanding Legionella infection in HIV, the series has several limitations that must be acknowledged. As Cillóniz et al stated, HIV infection was well controlled in the majority of their cases, with patients having a median CD4+ T-cell count of 335/μL (interquartile range, 215–500/μL), representing individuals with a relatively conserved immune state. Consequently, due to their intact immune status, as is stipulated by the Morbidity and Mortality Weekly Report and the Infectious Disease Society of America treatment guidelines [4, 5], cases and controls were administered a similar treatment regimen that included appropriate empirical coverage for Legionella, which may explain the low rates of intensive care unit admission and the favorable outcomes seen in these patients. The results may not be applicable to HIV-infected individuals with advanced disease and low CD4 counts. Individuals with CD4+ T-cell counts <200/μL, in whom opportunistic infections such as Pneumocystis jirovecii, Mycobacterium Tuberculosis, or avium complex are of high concern, atypical bacterial pneumonia agents such as Legionella spp. are often not targeted by empirical antimicrobial therapy [6]. Therefore, the findings by Cillóniz et al may be relevant for treated HIV-infected individuals with preserved CD4 T-cell counts but may not hold true for patients who are profoundly immunocompromised but should not be generalized to conclude that the clinical presentation and outcomes do not differ between HIV-infected and non-HIV–uninfected individuals. Potential conflicts of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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