A controlled trial of aerosolized pentamidine or trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection. The Dutch AIDS Treatment Group

Cotrimoxazole is effective as primary prophylaxis for toxoplasmic encephalitis in HIV-infected patients: a case control study

In a case-control study, prophylaxis with cotrimoxazole for toxoplasmic encephalitis (TE) in HIV-infected patients was evaluated. Cotrimoxazole had been given as PCP prophylaxis. 20 patients with TE were identified and 72 matching control cases were found. All patients had IgG-antibodies to Toxoplasma gondii and CD4+ T-cell counts < or = 100/microliter. The use and duration of cotrimoxazole prophylaxis were recorded. It was found that among the patients with TE, none had used cotrimoxazole for > 70% of the observation time, and that the 1-y incidence was 0% in the control group vs. 41% in those patients without sufficient cotrimoxazole use. The conclusion is that cotrimoxazole is effective as primary prophylaxis for TE, even in a dose of 480 mg daily.

Clinic HIV-focused features and prevention of Pneumocystis carinii pneumonia

OBJECTIVE

To examine the association of clinic HIV-focused features and advanced HIV care experience with Pneumocystis carinii pneumonia (PCP) prophylaxis and development of PCP as the initial AIDS diagnosis.

DESIGN

Nonconcurrent prospective study.

SETTING

New York State Medicaid Program.

PARTICIPANTS

Medicaid enrollees diagnosed with AIDS in 1990-1992.

MEASUREMENTS AND MAIN RESULTS

We collected patient clinical and health care data from Medicaid files, conducted telephone interviews of directors of 125 clinics serving as the usual source of care for study patients, and measured AIDS experience as the cumulative number of AIDS patients treated by the study clinics since 1986. Pneumocystis carinii pneumonia prophylaxis in the 6 months before AIDS diagnosis and PCP at AIDS diagnosis were the main outcome measures. Bivariate and multivariate analyses adjusted for clustering of patients within clinics. Of 1,876 HIV-infected persons, 44% had PCP prophylaxis and 38% had primary PCP. Persons on prophylaxis had 20% lower adjusted odds of developing PCP (95% confidence interval [CI] 0.64, 0.99). The adjusted odds of receiving prophylaxis rose monotonically with the number of HIV-focused features offered by the clinic, with threefold higher odds (95% CI 1.6, 5.7) for six versus two or fewer such features. Patients in clinics with three HIV-focused features had 36% lower adjusted odds of PCP than those in clinics with one or none. Neither clinic experience nor specialty had a significant association with prophylaxis or PCP.

CONCLUSIONS

PCP prevention in our study cohort appears to be more successful in clinics offering an array of HIV-focused features.

Pneumonia in AIDS patients in the critical care unit

Despite advances in prophylaxis and the reduction of mortality and morbidity resulting from highly active antiretroviral therapy, neumocystis pneumonia remains a common problem in HIV-infected patients. There are many possible causes for the continued prevalence of this condition. This article examines the characteristics, and some of the complex causes of P. carinii pneumonia in AIDS patients.

Preventing and treating major opportunistic infections in AIDS. What's new and what's still true

New highly active antiretroviral therapies are boosting the blood absolute CD4+ counts of many patients with AIDS and are decreasing the prevalence of AIDS-related opportunistic infections. Nevertheless, the prevention, diagnosis, and treatment of opportunistic infections remain important features of management of HIV infection. In recent years, significant advances have been made in the prevention and treatment of opportunistic diseases such as Pneumocystis carinii pneumonia, Cytomegalovirus retinitis, disseminated Mycobacterium avium-intracellulare infection, and mucosal candidiasis. Tuberculosis, cryptococcal meningitis, herpes simplex virus infection, shingles, and infectious enteritis also continue to be troublesome. Kaposi's sarcoma may be the newest AIDS-related opportunistic infection to be identified. The immune system effects of highly active antiretroviral therapy are as yet poorly understood. Therefore, an aggressive approach to diagnosis and treatment of opportunistic infections remains mandatory, and patients receiving antiretroviral therapy should continue to adhere to recommendations for prophylaxis against such infections.

Prevention of Pneumocystis carinii pneumonia: who are we missing?

OBJECTIVE

To obtain population-based information on the characteristics of persons who were not receiving chemoprophylaxis against Pneumocystis carinii pneumonia (PCP) by examining the use of primary and secondary PCP prophylaxis among San Francisco residents whose AIDS-defining opportunistic illness was PCP in 1993.

DESIGN

Retrospective medical record review.

SETTING

Medical charts were obtained from San Francisco hospitals and outpatient facilities at which AIDS patients received their initial AIDS diagnosis.

PARTICIPANTS

San Francisco residents whose AIDS-defining opportunistic illness was PCP in 1993.

MAIN OUTCOME MEASURES

Use of primary and secondary PCP prophylaxis.

RESULTS

Of the 326 eligible patients, 35% received primary PCP prophylaxis. Non-whites were significantly less likely to have received primary PCP prophylaxis than white patients [22 versus 40%, respectively; odds ratio (OR), 0.49; 95% confidence intervals (CI), 0.28-0.87]. Uninsured individuals-were also less likely to have received primary PCP prophylaxis than those with insurance (18 versus 41%; OR, 0.35; 95% CI, 0.17-0.73). The sociodemographic characteristics of patients who did and did not receive secondary PCP prophylaxis did not differ significantly. The most frequently cited reasons for not receiving primary PCP prophylaxis were that patients were unaware of their infection with HIV or were not receiving regular medical care.

CONCLUSIONS

Barriers to receipt of PCP prophylaxis exist and are resulting in cases of preventable disease and unnecessary medical costs. Interventions to increase counseling, testing, and referral to medical care for persons at high risk for HIV infection are needed.

The results of direct and indirect treatment comparisons in meta-analysis of randomized controlled trials

When little or no data directly comparing two treatments are available, investigators often rely on indirect comparisons from studies testing the treatments against a control or placebo. One approach to indirect comparison is to pool findings from the active treatment arms of the original controlled trials. This approach offers no advantage over a comparison of observational study data and is prone to bias. We present an alternative model that evaluates the differences between treatment and placebo in two sets of clinical trials, and preserves the randomization of the originally assigned patient groups. We apply the method to data on sulphamethoxazole-trimethoprim or dapsone/pyrimethamine as prophylaxis against Pneumocystis carinii in HIV infected patients. The indirect comparison showed substantial increased benefit from the former (odds ratio 0.37, 95% CI 0.21 to 0.65), while direct comparisons from randomized trials suggests a much smaller difference (risk ratio 0.64, 95% CI 0.45 to 0.90; p-value for difference of effect = 0.11). Direct comparisons of treatments should be sought. When direct comparisons are unavailable, indirect comparison meta-analysis should evaluate the magnitude of treatment effects across studies, recognizing the limited strength of inference.

Meta-analysis of prophylactic treatments against Pneumocystis carinii pneumonia and toxoplasma encephalitis in HIV-infected patients

In a meta-analysis, we examined the efficacy of aerosolized pentamidine, trimethoprim-sulfamethoxazole, and dapsone or dapsone/pyrimethamine for the prevention of Pneumocystis carinii pneumonia and toxoplasma encephalitis in patients with HIV infection. Of 22 trials, 13 compared trimethoprim-sulfamethoxazole with aerosolized pentamidine, nine compared dapsone alone or in combination with pyrimethamine with aerosolized pentamidine, and eight compared trimethoprim-sulfamethoxazole with dapsone/pyrimethamine. In total, 1484 patients were treated with trimethoprim-sulfamethoxazole, 1548 patients with dapsone/pyrimethamine or dapsone, and 1800 patients with aerosolized pentamidine. For dapsone/pyrimethamine versus aerosolized pentamidine, the risk ratio for P. carinii pneumonia was 0.90 (95% confidence interval [CI], 0.71-1.15), and for toxoplasma encephalitis it was 0.72 (95% CI, 0.54-0.97). For trimethoprim-sulfamethoxazole versus aerosolized pentamidine, the risk ratio of P. carinii pneumonia was 0.59 (95% CI, 0.45-0.76), and for toxoplasma encephalitis it was 0.78 (95% CI, 0.55-1.11). For trimethoprim-sulfamethoxazole versus dapsone/pyrimethamine, the risk ratio of P. carinii pneumonia was 0.49 (95% CI, 0.26-0.92), and for toxoplasma encephalitis it was 1.17 (95% CI, 0.68-2.04). Although current evidence does not allow a definitive recommendation, administration of trimethoprim-sulfamethoxazole for prophylaxis of P. carinii pneumonia and toxoplasmosis in patients with HIV infection is consistent with the available data.

Disposition of intravenous 123iodopentamidine in man

This study compared the disposition of the radiopharmaceutical [123I]iodopentamidine with that of pentamidine after intravenous infusion by measuring plasma concentrations of each using scintilation counting and high-performance liquid chromatography (HPLC), respectively. There was rapid hepatic uptake and biliary excretion of the 123I label. Distribution kinetics of the 123I label were similar to those of pentamidine, but its elimination half-life (41 +/- 27 h) was longer than that of pentamidine measured by HPLC (11 +/- 8 h). [123I]iodopentamidine distribution reflects that of pentamidine, but elimination of the radiopharmaceutical appears slower.

Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia (PCP) remains an important complication of AIDS. Advances have been made in establishing the taxonomy of the organism but the life cycle of the organism and pathogenetic mechanisms of disease remain obscure. In HIV patients the incidence of PCP has decreased because of widespread use of prophylaxis and survival of those with PCP has improved with use of adjunctive corticosteroid therapy. Less toxic drug therapies are still needed as well as better noninvasive diagnostic techniques.

Clinical features and outcomes of HIV-related cytomegalovirus pneumonia

OBJECTIVE

To describe the characteristics and outcomes of HIV-infected patients with biopsy-proven cytomegalovirus (CMV) pneumonia.

DESIGN

Retrospective study.

SETTING

A 900-bed acute facility in New York City.

PATIENTS

Eighteen HIV-infected patients with pathologically confirmed CMV inclusions in lung tissue without other pathogens and 36 control patients with biopsy-proven Pneumocystis carinii pneumonia (PCP) selected for comparisons by computer-generated random sequential numbers.

MAIN OUTCOME MEASURES

Demographic, clinical, laboratory, radiological findings, and in-hospital mortality.

RESULTS

Eighteen HIV-infected patients were found to have CMV lung infection alone. Pathologic findings were pneumonitis (n = 11); pneumonitis and pulmonary vasculitis (n = 1); and CMV inclusions alone (n = 6). All presented with respiratory symptoms (cough or dyspnea), 89% had fever, 83% had radiological abnormalities, and 56% had severe hypoxemia. The pulmonary presentation was similar except for higher lactate dehydrogenase (median, 449 versus 329 IU/l; P = 0.03) and presence of pleural effusions (33 versus 0%; P = 0.001) in CMV patients. Multivariate analysis showed that CD4 counts < or = 12 x 10(6)/l (odds ratio; 9.2; P = 0.029) and extrapulmonary CMV (odds ratio, 20.4; P = 0.039) were independently associated with CMV pneumonia. Seventeen patients received specific anti-CMV therapy for a mean of 22 +/- 13 days. In-hospital mortality was higher in patients with CMV pneumonia (odds ratio, 11.9; P = 0.002). The median time from admission to death was 31 days.

CONCLUSIONS

CMV lung infection was seen in severely immunosuppressed HIV-positive patients and associated with clinical pneumonitis with high early mortality. Although the clinical features resemble PCP, the presence of extrapulmonary CMV disease should suggest the diagnosis of CMV pneumonia.

HIV risk screening in the primary care setting. Assessment of physicians skills

OBJECTIVE

To assess the content and extent of HIV risk assessment by primary care physicians across a diverse panel of patients with unidentified HIV risk behaviors.

DESIGN

Standardized patient examination to assess primary care physicians' skills at identifying and managing HIV infection and overall clinical skills. In a day of testing, physicians saw 13-16 standardized patients (SPs) with diverse case presentations. In analyses presented here, physician performance was examined with nine SPs who had unidentified risks for HIV, which they offered if asked.

SETTING

An academic clinic.

PARTICIPANTS

We randomly selected 134 paid volunteers (general internists and family/general practitioners) after stratifying by specialty, experience caring for patients with HIV infection, and year of medical school graduation.

MEASUREMENTS AND MAIN RESULTS

Performance at initiating HIV risk screening and identifying patients' HIV risk behaviors were the main outcome measures. Physicians performed variably at HIV risk screening with different patients and across different HIV risk screening topics. Although physicians initiated screening with 60% of patients, they identified only 49% of risk behaviors and included HIV in the differential diagnosis for less than half of at-risk patients. Physicians performed better with cases in which there was a higher probability of HIV infection based on symptoms, but often did not screen at-risk patients without obvious symptoms suggestive of HIV. Board-certified general internists initiated screening and identified risk behaviors with more patients than board-certified family practitioners. Medical school graduation year also influenced performance.

CONCLUSIONS

Our data suggest that primary care physicians do not routinely perform HIV risk assessments with patients who have risk behaviors for HIV infection. Methods are needed to develop, standardize, and disseminate better screening techniques to identify patients with or at risk of developing HIV infection, such as written HIV risk screening questions for use in medical intake forms.

Drug treatment of HIV-related opportunistic infections

The AIDS epidemic has led to the emergence of several disease entities which in the pre-AIDS era were rare or seemingly innocuous. Experience of treating these diseases varies. In some instances, such as Pneumocystis carinii pneumonia, there is an abundance of published literature to direct our course of action. However, for many of these newly recognised diseases our treatment experience is limited. Furthermore, in many instances, well controlled trials evaluating treatment modalities in the AIDS population are lacking. We have identified 13 disease entities (P. carinii pneumonia, toxoplasmosis, cryptococcosis, histoplasmosis, Mycobacterium tuberculosis, Mycobacterium avium complex, cytomegalovirus, coccidioidomycosis, isosporiasis, candidosis, Kaposi's sarcoma, herpes simplex virus, and varicella zoster virus) and have reviewed the current literature with regard to their treatment.

Comparisons of oxidative metabolism and reductive capacity in sulfonamide-tolerant and -intolerant patients with human immunodeficiency virus

Hypersensitivity reactions to trimethoprim/sulfamethoxazole occur with a high frequency in human immunodeficiency virus (HIV)-infected patients. This study tested whether differences in oxidative metabolism and plasma reductive capacity correlate with sulfonamide intolerance in patients with HIV. Eighteen stable outpatients with HIV were prospectively studied. Nine patients had documented histories of hypersensitivity reactions to trimethoprim/sulfamethoxazole and nine did not. Urinary caffeine metabolite ratios assessed the activity of two oxidative enzymatic pathways: cytochrome P-450 1A2 (demethylation) and 8-hydroxylation. Plasma cyst(e)ine was used as a measure of reductive capacity. The trimethoprim/sulfamethoxazole-intolerant group showed greater rates of 8-hydroxylation, lower rates of demethylation, and lower cyst(e)ine levels. The results of this pilot study extend previous observations of differences in oxidative metabolism and reductive capacity that exist within the population of HIV-infected individuals. In addition, these findings lay the groundwork for future interventional studies that could use agents to inhibit sulfonamide oxidation and increase reductive capacity in sulfonamide-intolerant patients with HIV when rechallenged with trimethoprim/sulfamethoxazole.

Pneumocystis carinii

Improved understanding of Pneumocystis carinii, in particular the widespread use of chemoprophylaxis, has resulted in a declining incidence of infection in patients infected with HIV since the late 1980s. Despite these advances, P. carinii pneumonia continues to represent an important cause of pulmonary disease in HIV-seropositive individuals who do not receive chemoprophylaxis or when breakthrough episodes occur. This article reviews the history, biology, clinical manifestations, prognostic markers, therapy, and chemoprophylaxis of P. carinii pneumonia in HIV-seropositive patients.

The diagnosis and management of HIV infection

In the past 15 years HIV infection and AIDS have become pandemic in the world. Infectious and neoplastic complications have evolved in response to medical advances and to the appearance of HIV infection in different populations. Because AIDS patients live longer with severe immunosuppression and new treatments have controlled opportunistic infections, the spectrum of complications of AIDS has changed. New and more effective antiretroviral drugs are being developed, and physicians are learning how to use them more effectively. Currently, medical management of HIV-infected patients focuses on the appropriate use of antiretrovirals and the prevention, early diagnosis, and treatment of complicating illnesses. A coordinated continuum of care and patient education and involvement are also key elements of effective management of HIV infection.

Successful oral desensitization to trimethoprim-sulfamethoxazole in acquired immune deficiency syndrome

OBJECTIVE

To study the outcome of a modified oral desensitization protocol for trimethoprim-sulfamethoxazole in human immunodeficiency virus infected patients with Pneumocystis carinii pneumonia and acquired immune deficiency syndrome.

DESIGN

A prospective study.

SETTING

Tertiary care referral center.

PATIENTS

Thirteen human immunodeficiency virus infected patients with Pneumocystis carinii pneumonia and allergy to sulfonamides who failed alternative therapy.

INTERVENTION

Oral desensitization to trimethoprim-sulfamethoxazole.

MEASUREMENTS

Nature of allergic reactions, toxicity of alternate medications, indication as well as outcome of trimethoprim-sulfamethoxazole desensitization and routine laboratory determinations.

RESULTS

The most common reaction to trimethoprim-sulfamethoxazole was generalized, pruritic maculopapular rash (n = 10, 76.9%) followed by urticaria/angioedema in two patients (15.38%). Two patients had generalized pruritus without rash. All patients (n = 13) tolerated oral desensitization to trimethoprim-sulfamethoxazole without any adverse reactions including three patients who were critically ill and on mechanical ventilation. Thus the success rate of our protocol was 100%. No patient had received antihistamines prior to or during the protocol. Four patients (5, 6, 7, and 9) were receiving prednisone for severe Pneumocystis carinii pneumonia. Total followup has ranged from 4 to 84 weeks. Two patients died during followup due to causes unrelated to desensitization. All other patients are tolerating trimethoprim-sulfamethoxazole without any allergic reactions.

CONCLUSIONS

Oral desensitization to trimethoprim-sulfamethoxazole, as per this protocol is safe, in that there were no systemic or cutaneous reactions during desensitization as well as followup. It is well tolerated in all patients, including the three critically ill patients. As judged by the outcome and ability to tolerate trimethoprim-sulfamethoxazole after desensitization, the procedure is successful in all patients in this study. Equipped with this protocol one can evaluate possible mechanisms of desensitization such as oral tolerance or mediator depletion in a controlled fashion.

Combination of PS-15, epiroprim, or pyrimethamine with dapsone in prophylaxis of Toxoplasma gondii and Pneumocystis carinii dual infection in a rat model

In a rat model of dual infection, we studied such dihydrofolate reductase (DHFR) inhibitors as PS-15 (25 mg/kg of body weight), epiroprim (100 mg/kg), and pyrimethamine (3 mg/kg) alone or in combination with various doses of dapsone (50, 25, or 5 mg/kg) for the prevention of pneumocystosis and toxoplasmosis. Rats latently infected with Pneumocystis carinii were immunosuppressed by corticosteroids for 7 weeks, and the drugs were administered from the initiation of the corticosteroid treatment. At week 5, the rats were inoculated intraperitoneally with the RH strain of Toxoplasma gondii. Infections were monitored by the counting of P. carinii cysts in lung homogenates and the titration of T. gondii in organs by quantitative culture and an indirect immunofluorescence assay. Fourteen of the 15 untreated rats died after T. gondii challenge, with P. carinii infection in the lungs and T. gondii infection in the lungs, liver, spleen, and brain. Of the three tested DHFR inhibitors, only PS-15 exhibited anti-P. carinii activity; none prevented toxoplasmosis in 100% of the rats. After the DHFR inhibitors were combined with dapsone (50 or 25 mg/kg), both pneumocystosis and toxoplasmosis were completely prevented. On the basis of these results, PS-15 and epiroprim combined with dapsone are candidates for use for the prevention of both pneumocystosis and toxoplasmosis.

Twice-weekly dapsone for primary prophylaxis against Pneumocystis carinii pneumonia in HIV-1 infection: efficacy, safety and pharmacokinetic data

OBJECTIVES: In this study we evaluated the pharmacokinetics, efficacy and safety of dapsone given 100 mg twice weekly as primary prophylaxis against Pneumocystis carinii pneumonia (PCP) in patients with HIV-1 infection. METHODS: This was a prospective open trial, evaluating a total of 55 HIV-1-infected patients with CD4 cell counts below 200/mm3 and without previous episodes of PCP. Plasma concentrations of dapsone were determined with high-performance liquid chromatography (HPLC). After a mean follow-up of 471 days, the PCP rates per year of observation were 6.79%. Discontinuation of treatment as a result of severe side effects was required in four patients (7.5%). At steady state, mean plasma concentrations 24, 72, 96 and 144 h following the administration of dapsone were 1.46plus minus0.8, 0.28plus minus0.20, 0.30plus minus0.21 and 0.37plus minus0.27 mg/L, respectively. Dapsone plasma levels showed a high interpatient variability. The values for the pharmacokinetic parameters were comparable to those described for healthy volunteers. CONCLUSIONS: The administration of 100 mg twice weekly of dapsone seems appropriate to maintain effective plasma concentrations of the drug and to prevent PCP with good safety in patients with HIV-1-related immunodeficiency.

An effectiveness community-based clinical trial of Respirgard II and Fisoneb nebulizers for Pneumocystis carinii prophylaxis with aerosol pentamidine in HIV-infected individuals. Toronto Aerosol Pentamidine Study (TAPS) Group

STUDY OBJECTIVE

To compare the effectiveness of a standard jet nebulizer, Respirgard II, and a standard ultrasonic nebulizer, Fisoneb, for the administration of aerosolized pentamidine (AP) as primary and secondary prophylaxis against Pneumocystis carinii pneumonia (PCP) in HIV-infected individuals.

DESIGN

A retrospective, nonrandomized, parallel group comparative study.

SETTING

Patients were enrolled in a community-based AP program (APP) between May 1989 and April 1992 in Ontario, Canada. They received AP in either (1) a centralized treatment facility ("clinic") or (2) their attending physician's office or regionalized centers ("nonclinic"). Clinic administration of pentamidine was via Fisomeb; nonclinic via Respirgard II.

PATIENTS

The study group comprised of 1,762 HIV-infected individuals requiring AP for either primary (CD4 < 200/mm3) or secondary PCP prophylaxis. Of these, 1,151 used Fisoneb (clinic) and 611 used Respirgard II (nonclinic).

RESULTS

In the primary prophylaxis group, 41 of the 892 patients using Fisoneb (4.6%; mean follow-up, 18 months) compared with 16 of 435 patients using Respirgard II (3.7%; mean follow-up, 14.6 months) developed PCP (p = 0.44). A total of 28 of 259 (10.8%; mean follow-up, 15.3 months) patients using Fisoneb for secondary prophylaxis compared with 11 of 176 (6.3%; mean follow-up, 14.4 months) patients using Respirgard II for secondary prophylaxis developed PCP (p = 0.1).

CONCLUSIONS

Despite the difference in dosage (120 mg/mo vs 300 mg/mo), type of nebulizer (ultrasonic vs jet), and frequency of administration (twice vs once monthly), the results of this study indicate that both regimens of AP provide comparable protection against PCP. This study further supports the effectiveness of AP as a solid second-line prophylaxis for HIV-infected individuals who are intolerant to trimethoprim/sulfamethoxazole or dapsone.

In vitro and in vivo immunomodulatory effects of anti-Pneumocystis carinii drugs

The anti-Pneumocystis carinii drug effects on mitogen-, antigen-, and interleukin-2-induced proliferative responses and on natural killer (NK) cell-mediated activity were analyzed in vivo (rats) and in vitro (normal human peripheral blood mononuclear cells). Splenocytes derived from in vivo piritrexim- and clindamycin-treated rats showed a significant inhibition of mitogen-induced proliferative responses. In vitro exposure to clindamycin, piritrexim, and pyrimethamine caused an inhibition of human T lymphocyte proliferation in response to mitogen, antigen, and interleukin-2 stimulation. Rat NK cell-mediated cytotoxic activity was not affected by the drugs, and human NK cell activity was reduced only at the highest concentration (10 micrograms/ml) of the drugs. The potential immunotoxicity of the long-term administration of these agents in humans needs further investigation.

Primary care of the HIV patient: standard practice and new developments in the era of managed care

It is easy when taking care of the patient with AIDS to lose sight of the whole person and become focused on the details of micromanagement, distracted by the array of new therapies, and overwhelmed by the financial risks of the disease. It is therefore critical that a healing and respectful relationship is developed with patients and they are engaged in the decisions regarding their care. Physicians must also continue the search for new therapies and struggle to ensure that patients have access to state-of-the-art treatment. In this, the primary care physician plays a critical role, through identifying study centers, becoming an investigator in expanded access programs, and using referrals to clinical trials to provide new therapies to patients and improve understanding of HIV treatment. Finally, quality of life must be at the forefront of physicians' medical conscience. Ultimately, the physician must know when the best treatment he of she can offer is the assurance of a dignified and comfortable death.

Risks and benefits of aerosolized pentamidine and cotrimoxazole in primary prophylaxis of Pneumocystis carinii pneumonia in HIV-1-infected patients: a two-year Italian multicentric randomized controlled trial. The Italian PCP Study Group

We randomized 220 HIV-1-infected subjects to receive aerosolized pentamidine (300 mg/4 weeks) or orally trimethoprim-sulfamethoxazole (320-1600 mg/day) for primary prophylaxis of Pneumocystis carinii pneumonia (PCP), and evaluated PCP and toxoplasmic encephalitis (TE) occurrence and survival. Patients developing toxicity switched to the other regimen. Analysis was on intention-to-treat. At 1 year of study, we observed in the pentamidine group a non-significant excess of PCP (4 vs. 1) and TE (7 vs. 3), and a significant increased death rate (15 vs. 2). After 2 years, no significant differences were observed: adjusted RR estimates for pentamidine vs. cotrimoxazole were 1.20 (95% CI, 0.33-4.37) for PCP (6 cases vs. 5), 1.23 (95% CI, 0.46-3.29) for TE (10 vs. 8) and 1.52 (95% CI, 0.83-2.79) for death (30 vs. 18). Crossovers were more frequent in the cotrimoxazole group (41 vs. 4, P < 0.001). Aerosolized pentamidine and cotrimoxazole were equally effective in preventing PCP, and no major differences were observed in TE occurrence and survival after 2 years follow-up.

Azithromycin in the prophylaxis of opportunistic infections in AIDS

Prevention of opportunistic infections contributes to improved quality of life and survival in individuals with acquired immunodeficiency syndrome (AIDS). Agents which are more effective and convenient, less costly, and better tolerated are needed for multiple organism primary prophylaxis. Azithromycin, azalide with high and prolonged intracellular levels, promise to provide to protection against Mycobacterium avium complex (MAC) disease in those with advanced AIDS when given weekly. A large trail comparing rifabutin (300 mg daily), a currently approved primary prophylactic agent for MAC, with azithromycin (1200 mg weekly) has been completed and is under analysis. If weekly azithromycin provides equivalent or better protection from disseminated MAC, the cost effectiveness and convenience of MAC prophylaxis may be improved.

Lifetime hospitalization profiles for symptomatic, HIV-infected persons

We explored the relationship between the incidence of hospitalization and disease progression in a group of 140 symptomatic, HIV infected patients by linking hospitalizations to the time of diagnosis, the time of death, or both. The relationship could best be described by positively skewed U-patterns or (weak) J-patterns with a high use of resources immediately following diagnosis and preceding death. The lifetime hospitalization profiles differed according to the type of insurance, age, the initial diagnosis in the CDC-IV stage and the length of survival. The results not only confirm general hypotheses posed by other research groups, but also demonstrate the existence of variations among subgroups of patients. The results can be used to improve economic assessments of the impact of AIDS in The Netherlands and the European Union. The method used has the advantage of being based on a bottom-up approach to resource utilization, involving the use pf prospective data for the patients' full lifespans, and can easily be applied to other areas of health services research.

[Pneumocystis carinii pneumonia in AIDS: retrospective analysis of 80 documented cases (1985-1993)]

Eighty initial episodes of HIV-associated Pneumocystis carinii pneumonia (PCP) diagnosed at Bordeaux hospital between 1985 and 1993 are reported (57 were men and 23 women). PCP revealed HIV infection in 29 patients (36%). Others cases were patients with poor medical follow up (10%), with a CD4+ lymphocyte count above 200/mm3 at last follow-up (9%), non compliant with PCP prophylaxis (9%), or using aerolized pentamidine (AP+) (20%). The main clinical symptoms were fever (90%), dyspnea (68%), non productive (63%) and productive (17%) cough. Radiographic infiltrates were purely interstitial (59%), acinar and interstitial (25%), purely acinar (5%) and absent (11%). Thirty-eight percent of AP+ had upper lobe preferential involvement and 13% a pleural effusion. In all cases, Pneumocystis carinii was detected in bronchoalveolar lavage. Extrapulmonary localizations of pneumocystosis were noticed (eye, liver, spleen, ascitis) in two AP+. Mean CD4+ count was 54/mm3 in patients not having received aerolized pentamidine (AP-) and 22/mm3 in AP+. P24 antigenemia was positive in 53% (AP-) and 88% (AP+). PaO2 LDH and albuminemia were similar in both groups. Antimicrobial therapy (Cotrimoxazole in 91% of the cases) was combined with corticosteroids in 45% and mechanic ventilation in 19%. After 30 days of follow-up, 17 deaths were observed (21%) and 14 attributed to PCP: mortality was worse in AP+ (31%) than in AP- (19%). The main conclusions of our study are the followings: HIV related PCP is still in 1995 frequent and severe; atypical features should not rule out diagnosis; preventive measures are neither sufficient nor efficient. PCP remains in 1995 a priority in HIV related public health and therapeutical research.

Survival differences in Austrian patients with the acquired immunodeficiency syndrome

We investigated the association of clinical and demographic factors on survival of the 901 AIDS cases diagnosed until 31 December 1992 and reported to the Austrian Health Authorities up to 20 January 1994. The overall estimated median survival of patients with AIDS increased substantially from 8 months in 1987 to 16 months in 1988, although this increase was not significant by the log-rank test. However, the differences in hazard rates were larger at the beginning of the survival curve: between 1987 and 1988 the proportion surviving at 1 year increased from 41 to 62%, compared to an increase of the proportion surviving at 2 years from 30 to 35% (Breslow test, p value 0.008). AIDS patients diagnosed between 1988 and 1992 (n = 755) were analyzed in more detail. Multivariate survival analysis revealed a shorter survival for those with residence in Eastern Austria, recipients of blood products, individuals with unknown transmission risk, those presenting with two AIDS indicator diseases and those with higher age at AIDS diagnosis. Candidal esophagitis as AIDS indicator disease was associated with longer survival. One hundred eighty-eight of the 755 AIDS patients (24.9%) died within the first 3 months after diagnosis of AIDS. We conclude that the survival time for AIDS patients has improved considerably after 1987, but survival is still very poor. Several factors have been shown to predict survival of patients with AIDS in Austria. Death within the first 3 months after the diagnosis of AIDS occurred at a relatively high frequency in Austrian AIDS patients. This may be caused by difficulties in the use of health care facilities or by the lack of awareness of HIV infection before diagnosis of AIDS either by patient or care provider.

Bacterial pneumonia in persons infected with the human immunodeficiency virus. Pulmonary Complications of HIV Infection Study Group

BACKGROUND

Patients with human immunodeficiency virus (HIV) infection are at increased risk for bacterial pneumonia in addition to opportunistic infection. However, the risk factors for bacterial pneumonia and its incidence in this population are not well defined.

METHODS

In a multicenter, prospective, observational study, we monitored 1130 HIV-positive and 167 HIV-negative participating adults for up to 64 months for pulmonary disease. The HIV-positive group comprised 814 homosexual or bisexual men, 261 injection-drug users, and 55 female partners of HIV-infected men.

RESULTS

There were 237 episodes of bacterial pneumonia among the HIV-positive participants (rate, 5.5 per 100 person-years), as compared with 6 episodes among the HIV-negative participants (rate, 0.9 per 100 person-years; P < 0.001). The rate of bacterial pneumonia increased with decreasing CD4 lymphocyte counts (2.3, 6.8, and 10.8 episodes per 100 person-years in the strata with more than 500, 200 to 500, and fewer than 200 cells per cubic millimeter, respectively; P < or = 0.022 for each comparison). Injection-drug users had a higher rate of bacterial pneumonia than did homosexual or bisexual men or female partners. In the stratum with the fewest CD4 lymphocytes, cigarette smoking was associated with an increased rate of pneumonia. Mortality was almost four times higher among participants with an episode of pneumonia than among the others. Prophylaxis with trimethoprim-sulfamethoxazole was associated with a 67 percent reduction in confirmed episodes of bacterial pneumonia (P = 0.007).

CONCLUSIONS

Bacterial pneumonia is more frequent in HIV-positive persons than in seronegative controls, and the risk is highest among those with CD4 lymphocyte counts below 200 per cubic millimeter and among injection-drug users.

Better efficacy of twice-monthly than monthly aerosolised pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with AIDS. An Italian multicentric randomised controlled trial. The Italian PCP Study Group

The aim of this multicentric randomised controlled trial was to evaluate long-term efficacy and safety of once-monthly versus twice-monthly 300 mg aerosolized pentamidine (AP) as secondary prophylaxis of Pneumocystis carinii pneumonia (PCP). We randomised 205 patients with a previous confirmed episode of PCP (107 treated with 300 mg once-monthly AP, and 98 with 300 mg twice monthly AP); the median review period was 232 days. Kaplan-Meier method and Cox's hazard regression model were used for analysis. The main outcome assessments were PCP recurrence, survival and incidence of drug toxicity. The two groups were balanced for prognostic predictors. In the once-monthly AP group, 14 relapses of confirmed PCP were observed, while five occurred in the twice-monthly AP group; the crude relative risk (RR) was 2.69 (95% CI 1.002-7.236, P=0.0496) and the adjusted RR accounting for prognostic predictors was 2.62 (95% CI 0.92-7.5, P=0.071). Death occurred in 36 of 26 patients respectively (adjusted RR 1.32, 95% CI 0.8-2.18, P=0.28). Two patients interrupted the study because of intolerance to AP (one in each group), and severe coughing occurred in two patients (one in each group). At the end of the study, pulmonary function tests were not changed compared with baseline and were the same between the two groups. Our study suggests that 300 mg twice-monthly AP is more effective than 300 mg once-monthly AP as secondary prophylaxis of PCP.

Therapeutic progress. IV: Treatment and prophylaxis of Pneumocystis carinii infection

Co-trimoxazole presently remains the first choice for prophylaxis and treatment of Pneumocystis carinii infections. The high incidence of adverse reactions experienced by patients taking co-trimoxazole has led to a number of trials comparing it with other antipneumocystis agents. Adjuvant therapy with corticosteroids may benefit patients with severe P. carinii pneumonia. This paper reviews the standard treatments for P. carinii pneumonia, some of the newer agents such as atovaquone, recently licensed in the U.K., and a variety of novel agents being assessed for treatment and prophylaxis. Current recommendations may change over the new few years.

An analysis of forty-two Wegener's granulomatosis patients treated with methotrexate and prednisone

OBJECTIVE

To determine the efficacy of low-dose methotrexate (MTX) plus prednisone in the treatment of Wegener's granulomatosis (WG).

METHODS

An open-label study of weekly low-dose MTX plus prednisone for the treatment of WG was performed. Forty-two patients who did not have immediately life-threatening disease were enrolled into the study. Outcome was determined by clinical characteristics and pathologic, laboratory, and radiographic findings.

RESULTS

Weekly administration of MTX and prednisone resulted in remission of disease in 30 of the 42 patients (71%). The median time to remission was 4.2 months. The estimated median time to relapse for all patients in whom remission was achieved was 29 months. Eight patients who had relapses were treated with a second course of MTX plus prednisone, and a second remission was induced in 6 of the 8 (75%).

CONCLUSION

Weekly low-dose MTX was shown in this study to be an acceptable alternative form of therapy for selected patients with WG who do not have immediately life-threatening disease or who have developed serious cyclophosphamide-associated toxicity.

Hyperkalemia and high-dose trimethoprim/sulfamethoxazole

Evidence from the literature strongly supports that high doses of TMP, as used in the treatment of PCP in AIDS patients, have the propensity to cause hyperkalemia by inhibiting sodium channels in the distal nephron, thereby impairing potassium secretion. The mechanism of TMP-induced hyperkalemia is believed to be similar to that of triamterene and amiloride because of the structural similarity of these agents. It is also possible that declining renal function, which is a natural progression of HIV disease, may contribute to the hyperkalemia seen in this patient population. In addition, patients with AIDS also may exhibit a defect in adrenal function, potentiating the hyperkalemic effect of TMP therapy. Therefore, it is crucial for clinicians to monitor closely the serum potassium concentration in this patient population, especially during therapy with high doses of TMP.

The impact of prophylaxis on outcome and resource utilization in Pneumocystis carinii pneumonia

STUDY OBJECTIVE

Pneumocystis carinii pneumonia (PCP) is a major late complication of HIV infection associated with morbidity and mortality. Because chemoprophylaxis is highly effective, cases of PCP can be viewed as failures in the management of HIV disease.

METHODS

We reviewed demographic, clinical, and cost data for all cases of confirmed HIV-related PCP at The Johns Hopkins Hospital in 1991 to determine consequences of missed prophylaxis. We also analyzed hospital discharge data for Maryland in 1991 to assess hospital charges, length of stay, and outcome for all patients with a principal diagnosis of HIV-related PCP.

RESULTS

Pneumocystis carinii pneumonia was diagnosed in 79 patients. Of the 79 patients, 61 (77%) did not receive prophylaxis, including 26 who were not previously known to have HIV infection, 17 who did not have prophylaxis prescribed, and 18 who had prophylaxis prescribed, but were not compliant with the regimen. Patients not taking prophylaxis accounted for all 12 deaths ascribed to PCP. This group also accounted for 85% of the hospital days, 100% of the ICU days, and 89% of the inpatient charges. The total hospital charges were $849,540. Extrapolation of these figures for the state of Maryland suggest that the failure to receive prophylaxis in 1991 resulted in 62 patient deaths and a cost of approximately $4.7 million.

CONCLUSION

Patients who developed PCP despite prophylaxis had a better outcome and used fewer resources than patients not receiving preventive therapy. This study emphasizes the impact of PCP prophylaxis on the morbidity, mortality, and economics of HIV health care.

A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group

BACKGROUND

We evaluated the effectiveness of three treatment strategies for the prevention of a first episode of Pneumocystis carinii pneumonia in patients infected with the human immunodeficiency virus (HIV).

METHODS

In an open-label trial, 843 patients with HIV infection and fewer than 200 CD4+ cells per cubic millimeter received zidovudine plus one of three randomly assigned prophylactic agents, beginning with trimethoprim-sulfamethoxazole, dapsone, or aerosolized pentamidine and followed by a defined sequence of other drugs to be used in cases of intolerance.

RESULTS

The estimated 36-month cumulative risks of P. carinii pneumonia were 18 percent, 17 percent, and 21 percent in the trimethoprim-sulfamethoxazole, dapsone, and aerosolized-pentamidine groups, respectively (P = 0.22). The difference in risk among treatment strategies was negligible in patients entering the study with 100 or more CD4+ lymphocytes per cubic millimeter. In those entering with fewer than 100 CD4+ cells per cubic millimeter, the risk was 33 percent with aerosolized pentamidine, as compared with 19 percent with trimethoprim-sulfamethoxazole and 22 percent with dapsone (P = 0.04). The lowest failure rates occurred in patients receiving trimethoprim-sulfamethoxazole, and failures were more common with 50 mg of dapsone than with 100 mg. Toxoplasmosis developed in less than 3 percent of patients. Of the patients assigned to the two systemic therapies, only 23 percent were receiving their assigned drug and dose when they completed the study. The median survival was approximately 39 months in all three groups, and the mortality attributable to P. carinii pneumonia was only 1 percent.

CONCLUSIONS

In patients with advanced HIV infection, the three treatment strategies we examined have similar effectiveness in preventing P. carinii pneumonia. Strategies that start with trimethoprim-sulfamethoxazole or with high-dose dapsone, rather than aerosolized pentamidine, are superior in patients with fewer than 100 CD4+ lymphocytes per cubic millimeter.

A randomized trial comparing fluconazole with clotrimazole troches for the prevention of fungal infections in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group

BACKGROUND

Cryptococcal meningitis and other serious fungal infections are common complications in patients infected with the human immunodeficiency virus (HIV). Fluconazole is effective for long-term suppression of many fungal infections, but its effectiveness as primary prophylaxis had not been adequately evaluated.

METHODS

We conducted a prospective, randomized trial that compared fluconazole (200 mg per day) with clotrimazole troches (10 mg taken five times daily) in patients who were also participating in a randomized trial of primary prophylaxis for Pneumocystis carinii pneumonia.

RESULTS

After a median follow-up of 35 months, invasive fungal infections had developed in 4.1 percent of the patients in the fluconazole group (9 of 217) and in 10.9 percent of those in the clotrimazole group (23 of 211; relative hazard, as adjusted for the CD4+ count, 3.3; 95 percent confidence interval, 1.5 to 7.6). Of the 32 invasive fungal infections, 17 were cryptococcosis (2 in the fluconazole group and 15 in the clotrimazole group; adjusted relative hazard, 8.5; 95 percent confidence interval, 1.9 to 37.6). The benefit of fluconazole was greater for the patients with 50 or fewer CD4+ cells per cubic millimeter than for the patients with higher counts. Fluconazole was also effective in preventing esophageal candidiasis (adjusted relative hazard, 5.8; 95 percent confidence interval, 1.7 to 20.0; P = 0.004) and confirmed and presumed oropharyngeal candidiasis (5.7 and 38.1 cases per 100 years of follow-up in the fluconazole and clotrimazole groups, respectively; P < 0.001). Survival was similar in the two groups.

CONCLUSIONS

Fluconazole taken prophylactically reduces the frequency of cryptococcosis, esophageal candidiasis, and superficial fungal infections in HIV-infected patients, especially those with 50 or fewer CD4+ lymphocytes per cubic millimeter, but the drug does not reduce overall mortality.

The tolerance for zidovudine plus thrice weekly or daily trimethoprim-sulfamethoxazole with and without leucovorin for primary prophylaxis in advanced HIV disease. California Collaborative Treatment Group

PURPOSE

Trimethoprim-sulfamethoxazole (TMP/SMX) is the preferred agent for prophylaxis of Pneumocystis carinii pneumonia (PCP) in patients with HIV infection, but frequent adverse events limit its usefulness. Intermittent dosing and supplementation with leucovorin have been tried in attempts to improve tolerance. We evaluated these strategies in persons with advanced HIV disease.

METHOD

One hundred seven patients were enrolled. All had HIV infection, < 200 CD4+ lymphocytes per mm3, and no history of PCP. Fifty-two were randomized to TMP/SMX twice daily (BID); of these, 26 were randomized to leucovorin with each dose. Fifty-five patients were randomized to TMP/SMX (BID) 3 times per week; of these, 27 were randomized to leucovorin with each dose. All patients took zidovudine concurrently.

RESULTS

The 24-week risk of discontinuation due to protocol-defined limiting toxicity was 24% with thrice-weekly TMP/SMX versus 42% with daily TMP/SMX (risk ratio 0.4; 95% CI 0.2 to 1.0). The risks of discontinuation for any reason were 41% and 59% (risk ratio 0.4; 95% CI 0.2 to 0.8). Clinical toxicity, such as headache and gastrointestinal distress, accounted for the observed difference in tolerance between dosing regimens. The 24-week risk of discontinuation due to protocol-defined toxicity was 33% in both the leucovorin and non-leucovorin groups (risk ratio 1.1; 95% CI 0.5 to 2.5). The risks of discontinuation for any reason were 53% and 47% (risk ratio 0.8; 95% CI 0.3 to 1.7).

CONCLUSION

Intermittent therapy with TMP/SMX BID thrice weekly is better tolerated than daily BID therapy. Leucovorin use does not improve tolerance for chronic TMP/SMX dosing in AIDS, even among patients taking tablets daily.

Randomized study of sulfamethoxazole-trimethoprim versus aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with AIDS

In a prospective, randomized open-label trial, the efficacy of sulfamethoxazole-trimethoprim (SMX-TMP) 400/80 mg b.i.d. was compared with the efficacy of aerosolized pentamidine (AP) 60 mg every 2nd week as secondary prophylaxis (SP) against recurrence of Pneumocystis carinii pneumonia (PCP) in AIDS patients. 94 patients participated in the study, 47 in each group. The patients were observed for a mean period of 17.2 months. PCP recurred in the AP group in 8 cases, while 1 relapse occurred in the SMX-TMP group. The one-year cumulative relapse rate was 9.0% (95% CI 0-19%) in the AP group compared with 2.4% (95% CI 0-8%) in the SMX-TMP group (p < 0.05). The odds ratio was 4.2 (95% CI 0.5-39.8) in favour of SMX-TMP. Furthermore, we found a tendency towards a protective effect against toxoplasmosis in the SMX-TMP group, though there was no difference in survival between the two groups. There was no statistical difference in frequency of crossover from one therapy form to the other. Based on these data we recommend SMX-TMP for secondary PCP prophylaxis.