INTRODUCTION — Highly active antiretroviral therapy (HAART) has significantly increased longevity among HIV-infected patients. As this patient population matures, an increased need for surgical interventions, such as coronary revascularization, will likely rise. Surgical intervention may also be necessitated by complications of HIV infection itself, especially among patients with advanced immune dysfunction. (See "HIV and the older patient".)
This topic review will address issues surrounding HIV infection in the patient who needs surgery, including transmission, morbidity and mortality, screening, and post-surgical management.
SURGERY AND THE RISK OF HIV TRANSMISSION
HIV-infected health care worker to patient — Although the public remains concerned about the possibility of HIV transmission from healthcare workers (HCWs) during invasive procedures, only three cases resulting in eight infections have been documented globally. In a widely publicized incident in 1990, a Florida dentist was identified by DNA sequencing as the source of HIV infection in six of his patients . Despite intensive epidemiologic investigation, the mechanism of transmission was never established. Subsequently only three additional cases have been reported of probable transmission from a health care worker to a patient .
Large-scale look-back investigations — Following the incident involving the dentist, the Centers for Disease Control and Prevention (CDC) initiated 66 "look-back" investigations involving 22,759 patients who had invasive procedures performed by HIV-infected HCWs . Only 113 (0.5 percent) were found to have HIV infection, most of whom were aware of their condition prior to the time of the procedure. In the other cases, none of the viral strains were found to be identical to those of the HCWs based on DNA sequencing. In reviewing the available data, the CDC has estimated that the risk of HIV transmission from a HCW to a patient during a surgical procedure is between one in 2.4 million to 24 million.
Management of the HIV-infected health care worker — In 1991, the CDC published recommendations for HIV-infected HCWs . They advocated HIV antibody testing or work restrictions if the HCW performed "exposure-prone invasive procedures", defined as "digital palpation of a needle tip in a body cavity or the simultaneous presence of the HCW's fingers and a needle or other sharp instrument or object in a poorly visualized or confined anatomic site" . In this setting, options include either review of the safety of planned procedure(s) by an expert panel or notification of the patient of the HCW's HIV serostatus as part of the informed consent process.
These CDC guidelines have been controversial in the medical community since their inception, but they have not been updated in recent years. The American Medical Association argued that they were not strong enough, but several others contended that they were unnecessarily restrictive . A cost-effectiveness analysis concluded that screening all surgeons for HIV infection would result in expenditures of approximately $1.1 million per year of life saved, which greatly exceeds the cost of most accepted health interventions .
The impetus to reexamine these guidelines has been further supported by data that have emerged from an investigation of an Israeli cardiothoracic surgeon who was found to be HIV-infected in 2007 when he presented with unexplained fevers . The surgeon had advanced HIV disease with a CD4 cell count of 49/mm(3) and an HIV RNA level of >100,000 copies/mL. A look-back investigation was performed of all patients on whom he had operated during the previous 10 years. Of the 1,669 patients identified, 545 (33 percent) underwent serologic testing; all were HIV-seronegative.
One limitation of the study was that not all patients came to the Ministry of Health for testing and may have been diagnosed with HIV infection elsewhere. However, more than one year after the investigation, none of the patients' names appeared in the national registry of known HIV-seropositive persons.
After receipt of these results, the expert panel recommended allowing the surgeon to return to work with no restrictions on the types of procedures he performed, provided that the following criteria were met:
Completion of instruction by infection control personnel regarding standard precautions
Adherence to routine HIV RNA monitoring to confirm ongoing viral suppression on antiretroviral therapy
On the basis of the investigation and the published literature, the panel did not require notification of prospective patients of the surgeon's HIV status because of the extremely low likelihood of transmission if these conditions were met.
This report adds to the existing body of data, which argue for a very low risk of provider-to-patient HIV transmission in the present era. Revised CDC guidelines are expected. Guidelines from the United Kingdom recommend that patient notification should be decided on a case-by-case basis depending upon the perceived risk of transmission.
HIV-infected patient to healthcare worker — Measuring the true incidence of occupational exposure to infectious agents is difficult because an estimated 50 percent of events are unreported. Surgeons have approximately one dozen percutaneous blood exposures per person-year, which is the highest among HCWs, while inpatient nurses average one exposure per year. However, because nurses represent such a large proportion of the HCW population, more than one-half of all exposures occur in this group. Most reported percutaneous exposures are related to phlebotomy or manipulation of an intravenous catheter; the majority of mucocutaneous exposures involve the eyes.
Between 1981 and 2006, there were 57 documented and 140 possible cases of occupationally acquired HIV infection in the United States (table 1). It is significant that no new documented cases have been reported since 2000, although several remain under investigation (graph 1). Preventing needlestick injuries and other parenteral exposures is the key to risk reduction in HCWs. The incidence of needlestick injuries has been reduced by advances in education, use of universal precautions, needle disposal, engineering changes (eg, needleless devices, safety needles) and worker protection. In the event of any exposure, prompt post-exposure prophylaxis is critically important. These issues are discussed in detail elsewhere. (See "General principles of infection control" and "Management of healthcare workers exposed to HIV".)
PREOPERATIVE SCREENING FOR HIV INFECTION IN THE PATIENT WITH UNKNOWN HIV STATUS — Routine preoperative screening for HIV infection in surgical patients is neither cost-effective nor a reasonable alternative to universal precautions [17]. There is no evidence that identifying the HIV status of patients prior to procedures reduces the chance of accidental blood exposures .
With respect to patient care, the CDC advocates routine voluntary HIV testing of all patients aged 13 to 64 years. (See "Diagnostic assays for HIV infection".)
HIV INFECTION AND SURGICAL MORBIDITY AND MORTALITY — Most of the data regarding surgical morbidity and mortality in the HIV-infected patient predated the availability of effective antiretroviral therapy . In the modern treatment era, generally excellent outcomes have been reported:
In a retrospective study of 4952 patients who underwent cardiac surgery at a tertiary care center, 25 HIV-infected patients were identified; a low operative mortality (four percent) was reported among this subgroup . Post-operative complications occurred in 20 percent. These outcomes were similar to a matched HIV-seronegative control population undergoing cardiac procedures within the same time period (1998 to 2004). Interestingly, in more than one-quarter of the HIV-infected patients, the indication for cardiac surgery was coronary artery disease.
In another retrospective study in a large health care organization, HIV-infected patients were matched 1:1 with HIV-seronegative patients undergoing surgical procedures by type, location, and year of surgery as well as age and gender . 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. Among the HIV-infected group of patients, a viral load of 30,000 copies/mL or greater was associated with a threefold increased risk of complications; a CD4 cell count <200/mm(3) was not associated with any increased risk.
Elective Cesarean section has been recommended in HIV-infected women with viral loads greater than 1000 copies/mL based upon evidence that it reduces the risk of neonatal transmission . Some case-control studies have reported a higher risk of postoperative complications after Cesarean section, including wound infection, endometritis, and pneumonia, in HIV-infected women, especially in those with low CD4 cell counts . However, other cohort studies have not found any increased risk associated with elective Cesarean section . Risks associated with elective Cesarean section in HIV-infected women are discussed in detail elsewhere. (See "Counseling and obstetrical management of the HIV-infected woman to reduce perinatal HIV transmission".)
Additional studies have found that the incidence of postoperative bacterial complications and sepsis is increased in patients with lower CD4 cell counts, but others have yielded contrary results.
There are no data showing that major surgery influences HIV disease progression. Two case-control studies reported no difference between HIV-infected patients who underwent surgery and those who did not .
TRANSPLANTATION — Organ transplantation in HIV-infected patients has become more common in the past few years with the advent of effective combination antiretroviral therapy and improvement in life expectancy. However, only a small proportion of US transplantation centers are participating in a multicenter study of transplantation in HIV-infected patients, so access is still limited . Also, many insurance companies have declined to pay for such medical interventions. This topic is discussed in detail elsewhere. (See "Solid organ transplantation in HIV-infected individuals".)
PREOPERATIVE ASSESSMENT — The general approach to the HIV-infected patient in need of surgery is similar to that used for any other patient in this setting.
General health status — Estimation of cardiac and pulmonary risk is important to review. The surgical team needs to be knowledgeable about management of diabetes mellitus and dyslipidemia, which are increasingly common in HIV-infected patients on long-term antiretroviral therapy.
There are also some data suggesting an increased risk of atherosclerotic disease in HIV-infected patients. (See "Estimation of cardiac risk prior to noncardiac surgery" and "Evaluation of preoperative pulmonary risk" and "Perioperative management of diabetes mellitus" and "Perioperative management of hypertension" and "Epidemiology, clinical manifestations, and diagnosis of HIV-associated lipodystrophy" and "Epidemiology and pathogenesis of dyslipidemia and cardiovascular disease in HIV-infected patients".)
HIV disease status — Past medical history should include history of opportunistic diseases and most recent CD4 cell count and HIV viral load results. A CD4 cell count and HIV viral load should be performed, if not available within the preceding three months. The CD4 cell count is a surrogate marker for degree of immune function and is used to determine whether antiretroviral therapy and opportunistic infection prophylaxis are indicated. Furthermore, advanced immunosuppression is a risk factor for infectious complications in some, but not all, studies. An HIV RNA level greater than 30,000 copies/mL was also demonstrated to be associated with increased post-surgical complications in one study. (See 'HIV infection and surgical morbidity and mortality' above.)
Although optimal management of a severely immunosuppressed patient who needs surgery includes the initiation of HIV therapy, it should be recognized that treatment will not lead to immediate immunologic improvement. Furthermore, initiation of antiretroviral therapy and may potentially lead to other complications, such as rash or hepatotoxicity. Therefore, any decision to start therapy will depend on several factors, including the need for surgery, the planned interval before the procedure, and the patient's level of immunosuppression. This complex decision should be made in consultation with an HIV clinician or infectious disease specialist. (See "Selecting antiretroviral regimens for the treatment naive HIV-infected patient".)
Patients with advanced immune dysfunction should also be on appropriate antimicrobial prophylaxis for opportunistic infections. (See "Primary prevention of opportunistic infections in HIV-infected patients".)
Acute medical conditions may transiently decrease the CD4 cell count and increase the viral load, so these results should be interpreted cautiously in this setting. (See "Techniques and interpretation of measurement of the CD4 cell count in HIV-infected patients" and "Techniques and interpretation of HIV-1 RNA quantitation".)
Drug interactions — Protease inhibitors and non-nucleoside reverse transcriptase inhibitors have significant drug-drug interactions, and some agents are contraindicated for coadministration (eg, midazolam and ritonavir).
Past medical history — Specific questions should be asked of the patient regarding a history of viral hepatitis, tuberculosis exposure, and alcohol and substance use, since these issues are prevalent in HIV-infected patients. A detailed sexual history is especially important in women undergoing surgery for possible tuboovarian abscess. Pregnancy testing should also be performed in women of child-bearing age.
Nutritional status — Nutritional status should be assessed by recent dietary history and comparison of body weights over time. HIV-infected patients with advanced immunosuppression are at risk for wasting and nutritional deficiencies.
Body morphology changes, such as thinning of the extremities and malar atrophy, are also highly prevalent in HIV-infected patients taking antiretroviral therapy. These changes need to be differentiated from those associated with wasting secondary to advanced HIV. (See "Management of tissue wasting in patients with HIV infection" and "Nutritional issues in the surgical patient" and "Epidemiology, clinical manifestations, and diagnosis of HIV-associated lipodystrophy".)
Advanced directives — Medical directives and health care proxy status should be discussed with the patient prior to surgery. (See "Ethical issues near the end of life", section on 'Advance care planning'.)
Laboratory assessment — Baseline laboratory studies should include a complete blood count, glucose, liver function tests, serum blood urea nitrogen (BUN), glucose, and creatinine. Any mild abnormality of serum creatinine should be accompanied by urinalysis to screen for proteinuria since HIV-associated nephropathy is prevalent in this patient population. (See "Collapsing FGS and other renal diseases associated with HIV infection".)
Determination of platelet count and prothrombin time are important in assessing risk of bleeding, particularly in those patients who have advanced liver disease secondary to hepatitis C or hepatitis B infection. Thrombocytopenia may also be immune-mediated (ITP) related to underlying HIV infection. HIV-related ITP is usually associated with mild to moderate thrombocytopenia, but occasionally platelet counts can drop below 10,000 to 20,000/mm3 with an associated increased risk of bleeding. In such instances, a combination antiretroviral regimen including zidovudine and a number of other agents (such as intravenous immune globulin, anti-D immunoglobulin, and corticosteroids) may be necessary. (See "Hematologic manifestations of HIV infection: Thrombocytopenia and coagulation abnormalities".)
PERIOPERATIVE MANAGEMENT — Medical therapies, including all antiretroviral medications the patient is receiving, generally should be continued through the perioperative period. However, if clinically necessary, stopping antiretroviral drugs for a few days should not have a deleterious impact on their effectiveness.
When altered mental status or gastrointestinal tract dysfunction interfere with the ability of the patient to take oral medications, all antiretroviral drugs should be held and parenteral alternatives sought for agents used for antimicrobial prophylaxis. (See "Primary prevention of opportunistic infections in HIV-infected patients".)
Viral resistance is most likely to occur when doses of some antiretroviral medications are missed or not absorbed for an extended period of time. (See "HIV protease inhibitors", section on 'Resistance'.) Liquid preparations are available for many antiretroviral agents. (See "Liquid preparations of antiretroviral agents for adults".)
POSTOPERATIVE MANAGEMENT — Most postoperative complications, including delayed healing, wound infection, and bacterial sepsis, occur in HIV-infected patients with advanced disease (as manifested by low CD4 cell count), poor nutrition (as manifested by low serum albumin), and/or neutropenia. One early study identified HIV infection as a risk factor for unplanned postoperative admission to a critical care unit for mechanical ventilation [38]. However, in the era of highly active antiretroviral therapy, HIV-infected patients with immune reconstitution appear to have excellent outcomes .
Nutrition — Nutritional consultation may be warranted postoperatively if oral intake is inadequate.
Hypoadrenalism — The stress of surgery may unmask previously unsuspected hypoadrenalism. Many of the symptoms of adrenal dysfunction are nonspecific; electrolyte changes (eg, hyponatremia or hyperkalemia) or hypotension may raise suspicion of the presence of hypoadrenalism in the postoperative setting; a cosyntropin stimulation test is indicated in this circumstance. This condition is seen more commonly in patients with advanced HIV disease who have concomitant infections with Mycobacterium avium complex or cytomegalovirus. (See "Clinical manifestations of adrenal insufficiency in adults" and "Diagnosis of adrenal insufficiency in adults" and "Pituitary and adrenal gland dysfunction in HIV-infected patients".)
Medication side effects — Medication side effects, including fever, rash, gastrointestinal symptoms, and hepatotoxicity, are common in HIV disease.
Fever — The evaluation of post-operative fever in the HIV-infected patient will depend on the timing of infection and the immune status of the host .
Post-operative infections — The approach to the HIV-infected patient with fever is determined by the presence and nature of accompanying symptoms and the level of immunodeficiency as measured by CD4 cell count and viral load. Most postoperative fevers in patients with HIV disease are from common causes, such as pneumonia, infected intravascular catheter site, urinary tract infection, hepatitis, thrombophlebitis, and drug toxicity. However, consideration should be given to an opportunistic infection in the patient with a CD4 cell count less than 200/mm3.
It is important to distinguish between true postoperative complications and development of an opportunistic infection. In addition to a thorough history and physical examination, evaluation should include a complete blood count with differential, liver function tests, two blood culture sets, urinalysis, and chest x-ray. In addition, an isolator blood culture should be drawn if a patient has advanced immunosuppression. An infectious disease consult should be considered for assistance in the diagnostic evaluation and management.
It is important to remember that HIV-infected patients with pre-existing leukopenia may not mount a leukocyte response despite the presence of serious infection or bacteremia.
Pulmonary complications — Postoperative pulmonary complications are among the most frequently encountered in HIV disease. The initial diagnostic management will heavily rely on knowledge of the patient's degree of immune dysfunction. An infectious disease consultation should be considered for assistance in the evaluation and management of the immunosuppressed HIV-infected patient with fever and pulmonary infiltrates.
Nosocomial pneumonia in HIV–infected patients is most commonly caused by S. aureus and gram negative organisms, including P. aeruginosa, K. pneumoniae, and Enterobacter species [39,40]. These infections almost always occur late in the course of HIV infection (eg, with a CD4 cell count <100/mm3) and in patients with additional host factors predisposing to bacterial infections, such as neutropenia [41]. (See "Epidemiology, pathogenesis, microbiology, and diagnosis of hospital-acquired, ventilator-associated, and healthcare-associated pneumonia in adults".)
The HIV-infected patient who has dyspnea or cough should undergo a careful assessment that is guided by the clinical presentation and CD4 cell count. A complete blood and differential count, two blood culture sets, chest x-ray, and oximetry should be performed. (See "Approach to the HIV-infected patient with pulmonary symptoms" and "Bacterial pulmonary infections in HIV-infected patients".)
If the chest x-ray reveals lobar or segmental infiltrates, induced sputum examination for Gram stain and culture should be ordered, and empiric therapy for bacterial pneumonia should be started pending results. The clinical presentation and radiologic appearance of bacterial pneumonia in HIV disease are generally similar to those in immunocompetent patients.
In a patient at risk for tuberculosis exposure, a PPD should be placed, and multiple samples for acid-fast bacilli should be obtained. (See "Clinical features and diagnosis of tuberculosis in HIV-infected patients".) If the chest x-ray shows diffuse or patchy infiltrates, an induced sputum examination for Pneumocystis jirovecii pneumonia, as well as for Gram stain, acid-fast bacilli stain, special stains for Legionella and fungi, and appropriate cultures, should be performed. Treatment is generally based upon the results of these tests. However, if the patient appears acutely ill or is hypoxemic, empiric therapy for PCP should be initiated promptly. Treatment started prior to the sputum examination will not adversely affect its sensitivity for this infection.
by Howard Libman, MD & al
