1
|
Dockrell DH, Breen R, Collini P, Lipman MCI, Miller RF. British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical management of pulmonary opportunistic infections 2024. HIV Med 2024; 25 Suppl 2:3-37. [PMID: 38783560 DOI: 10.1111/hiv.13637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 05/25/2024]
Affiliation(s)
- D H Dockrell
- University of Edinburgh, UK
- Regional Infectious Diseases Unit, NHS Lothian Infection Service, Edinburgh, UK
| | - R Breen
- Forth Valley Royal Hospital, Larbert, Scotland, UK
| | | | - M C I Lipman
- Royal Free London NHS Foundation Trust, UK
- University College London, UK
| | - R F Miller
- Royal Free London NHS Foundation Trust, UK
- Institute for Global Health, University College London, UK
- Central and North West London NHS Foundation Trust, UK
| |
Collapse
|
2
|
McDonald EG, Afshar A, Assiri B, Boyles T, Hsu JM, Khuong N, Prosty C, So M, Sohani ZN, Butler-Laporte G, Lee TC. Pneumocystis jirovecii pneumonia in people living with HIV: a review. Clin Microbiol Rev 2024; 37:e0010122. [PMID: 38235979 PMCID: PMC10938896 DOI: 10.1128/cmr.00101-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Pneumocystis jirovecii is a ubiquitous opportunistic fungus that can cause life-threatening pneumonia. People with HIV (PWH) who have low CD4 counts are one of the populations at the greatest risk of Pneumocystis jirovecii pneumonia (PCP). While guidelines have approached the diagnosis, prophylaxis, and management of PCP, the numerous studies of PCP in PWH are dominated by the 1980s and 1990s. As such, most studies have included younger male populations, despite PCP affecting both sexes and a broad age range. Many studies have been small and observational in nature, with an overall lack of randomized controlled trials. In many jurisdictions, and especially in low- and middle-income countries, the diagnosis can be challenging due to lack of access to advanced and/or invasive diagnostics. Worldwide, most patients will be treated with 21 days of high-dose trimethoprim sulfamethoxazole, although both the dose and the duration are primarily based on historical practice. Whether treatment with a lower dose is as effective and less toxic is gaining interest based on observational studies. Similarly, a 21-day tapering regimen of prednisone is used for patients with more severe disease, yet other doses, other steroids, or shorter durations of treatment with corticosteroids have not been evaluated. Now with the widespread availability of antiretroviral therapy, improved and less invasive PCP diagnostic techniques, and interest in novel treatment strategies, this review consolidates the scientific body of literature on the diagnosis and management of PCP in PWH, as well as identifies areas in need of more study and thoughtfully designed clinical trials.
Collapse
Affiliation(s)
- Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Avideh Afshar
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Bander Assiri
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tom Boyles
- Right to Care, NPC, Centurion, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jimmy M. Hsu
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Connor Prosty
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University of Toronto, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Zahra N. Sohani
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
3
|
Atkinson A, Zwahlen M, Barger D, d’Arminio Monforte A, De Wit S, Ghosn J, Girardi E, Svedhem V, Morlat P, Mussini C, Noguera-Julian A, Stephan C, Touloumi G, Kirk O, Mocroft A, Reiss P, Miro JM, Carpenter JR, Furrer H. Withholding Primary Pneumocystis Pneumonia Prophylaxis in Virologically Suppressed Patients With Human Immunodeficiency Virus: An Emulation of a Pragmatic Trial in COHERE. Clin Infect Dis 2021; 73:195-202. [PMID: 32448894 PMCID: PMC8516510 DOI: 10.1093/cid/ciaa615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/19/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Using data from the COHERE collaboration, we investigated whether primary prophylaxis for pneumocystis pneumonia (PcP) might be withheld in all patients on antiretroviral therapy (ART) with suppressed plasma human immunodeficiency virus (HIV) RNA (≤400 copies/mL), irrespective of CD4 count. METHODS We implemented an established causal inference approach whereby observational data are used to emulate a randomized trial. Patients taking PcP prophylaxis were eligible for the emulated trial if their CD4 count was ≤200 cells/µL in line with existing recommendations. We compared the following 2 strategies for stopping prophylaxis: (1) when CD4 count was >200 cells/µL for >3 months or (2) when the patient was virologically suppressed (2 consecutive HIV RNA ≤400 copies/mL). Patients were artificially censored if they did not comply with these stopping rules. We estimated the risk of primary PcP in patients on ART, using the hazard ratio (HR) to compare the stopping strategies by fitting a pooled logistic model, including inverse probability weights to adjust for the selection bias introduced by the artificial censoring. RESULTS A total of 4813 patients (10 324 person-years) complied with eligibility conditions for the emulated trial. With primary PcP diagnosis as an endpoint, the adjusted HR (aHR) indicated a slightly lower, but not statistically significant, different risk for the strategy based on viral suppression alone compared with the existing guidelines (aHR, .8; 95% confidence interval, .6-1.1; P = .2). CONCLUSIONS This study suggests that primary PcP prophylaxis might be safely withheld in confirmed virologically suppressed patients on ART, regardless of their CD4 count.
Collapse
Affiliation(s)
- Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Diana Barger
- University of Bordeaux, ISPED, Inserm Bordeaux Population Health, Team MORPH3EUS, UMR 1219, Bordeaux, France
| | | | - Stephane De Wit
- Department of Infectious Diseases, Saint Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jade Ghosn
- APHP, Nord-Université de Paris, Service des Maladies Infectieuses et Tropicales, Hôpital Bichat, Paris, France
- INSERM UMR 1137 IAME, Université de Paris, Faculté de Médecine, Paris, France
| | - Enrico Girardi
- Clinical Epidemiology Unit, National Institute for Infectious Diseases L. Spallanzani–IRCCS, Rome, Italy
| | - Veronica Svedhem
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Philippe Morlat
- University of Bordeaux, ISPED, Inserm Bordeaux Population Health, Team MORPH3EUS, UMR 1219, Bordeaux, France
- Centre Hospitalier Universitaire de Bordeaux (CHU), Services de Médecine Interne et Maladies Infectieuses, Bordeaux, France
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Unitat d´Infeccions, Servei de Pediatria, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Barcelona, Spain
- Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
- Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Christoph Stephan
- Infectious Diseases Unit at Medical Center No. 2, Frankfurt University Hospital, Goethe University, Frankfurt, Germany
| | - Giota Touloumi
- Department of Hygiene, Epidemiology, and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ole Kirk
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark
| | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling, and Evaluation (CREME), Institute for Global Health, University College London, London, United Kingdom
| | - Peter Reiss
- HIV Monitoring Foundation, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic–IDIBAPS, University of Barcelona, Barcelona, Spain
| | - James R Carpenter
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| |
Collapse
|
4
|
Atkinson A, Miro JM, Mocroft A, Reiss P, Kirk O, Morlat P, Ghosn J, Stephan C, Mussini C, Antoniadou A, Doerholt K, Girardi E, De Wit S, Kraus D, Zwahlen M, Furrer H. No need for secondary Pneumocystis jirovecii pneumonia prophylaxis in adult people living with HIV from Europe on ART with suppressed viraemia and a CD4 cell count greater than 100 cells/µL. J Int AIDS Soc 2021; 24:e25726. [PMID: 34118121 PMCID: PMC8196713 DOI: 10.1002/jia2.25726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/31/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Since the beginning of the HIV epidemic in resource-rich countries, Pneumocystis jirovecii pneumonia (PjP) is one of the most frequent opportunistic AIDS-defining infections. The Collaboration of Observational HIV Epidemiological Research Europe (COHERE) has shown that primary Pneumocystis jirovecii Pneumonia (PjP) prophylaxis can be safely withdrawn in patients with CD4 counts of 100 to 200 cells/µL if plasma HIV-RNA is suppressed on combination antiretroviral therapy. Whether this holds true for secondary prophylaxis is not known, and this has proved difficult to determine due to the much lower population at risk. METHODS We estimated the incidence of secondary PjP by including patient data collected from 1998 to 2015 from the COHERE cohort collaboration according to time-updated CD4 counts, HIV-RNA and use of PjP prophylaxis in persons >16 years of age. We fitted a Poisson generalized additive model in which the smoothed effect of CD4 was modelled by a restricted cubic spline, and HIV-RNA was stratified as low (<400), medium (400 to 10,000) or high (>10,000copies/mL). RESULTS There were 373 recurrences of PjP during 74,295 person-years (py) in 10,476 patients. The PjP incidence in the different plasma HIV-RNA strata differed significantly and was lowest in the low stratum. For patients off prophylaxis with CD4 counts between 100 and 200 cells/µL and HIV-RNA below 400 copies/mL, the incidence of recurrent PjP was 3.9 (95% CI: 2.0 to 5.8) per 1000 py, not significantly different from patients on prophylaxis in the same stratum (1.9, 95% CI: 0.1 to 3.7). CONCLUSIONS HIV viraemia importantly affects the risk of recurrent PjP. In virologically suppressed patients on ART with CD4 counts of 100 to 200/µL, the incidence of PjP off prophylaxis is below 10/1000 py. Secondary PjP prophylaxis may be safely withheld in such patients. While European guidelines recommend discontinuing secondary PjP prophylaxis only if CD4 counts rise above 200 cells/mL, the latest US Guidelines consider secondary prophylaxis discontinuation even in patients with a CD4 count above 100 cells/µL and suppressed viral load. Our results strengthen and support this US recommendation.
Collapse
Affiliation(s)
- Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic - IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, UCL, London, UK
| | - Peter Reiss
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, and HIV Monitoring Foundation, Amsterdam, The Netherlands
| | - Ole Kirk
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Philippe Morlat
- Internal Medicine and Infectious Diseases Department, University Hospital of Bordeaux, Bordeaux, France
| | - Jade Ghosn
- Service des Maladies Infectieuses et Tropicales, Groupe Hospitalier Universitaire Bichat-Claude Bernard, Paris, France.,INSERM U 1137 IAME, Université de Paris, Paris, France
| | - Christoph Stephan
- Infectious Diseases Unit at Medical Center no.2, Frankfurt University Hospital, Goethe University, Frankfurt, Germany
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Anastasia Antoniadou
- Fourth Department of Internal Medicine, ATTIKON University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Katja Doerholt
- Paediatric Infectious Diseases Unit, St. George's University Hospital, London, UK
| | - Enrico Girardi
- Clinical Epidemiology Unit, National Institute for Infectious Diseases L. Spallanzani-IRCCS, Rome, Italy
| | - Stéphane De Wit
- Department of Infectious Diseases, St Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - David Kraus
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.,Department of Mathematics and Statistics, Masaryk University, Brno, Czech Republic
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | | |
Collapse
|
5
|
Weyant RB, Kabbani D, Doucette K, Lau C, Cervera C. Pneumocystis jirovecii: a review with a focus on prevention and treatment. Expert Opin Pharmacother 2021; 22:1579-1592. [PMID: 33870843 DOI: 10.1080/14656566.2021.1915989] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Pneumocystis jirovecii (PJ) is an opportunistic fungal pathogen that can cause severe pneumonia in immunocompromised hosts. Risk factors for Pneumocystis jirovecii pneumonia (PJP) include HIV, organ transplant, malignancy, certain inflammatory or rheumatologic conditions, and associated therapies and conditions that result in cell-mediated immune deficiency. Clinical signs of PJP are nonspecific and definitive diagnosis requires direct detection of the organism in lower respiratory secretions or tissue. First-line therapy for prophylaxis and treatment remains trimethoprim-sulfamethoxazole (TMP-SMX), though intolerance or allergy, and rarely treatment failure, may necessitate alternate therapeutics, such as dapsone, pentamidine, atovaquone, clindamycin, primaquine and most recently, echinocandins as adjunctive therapy. In people living with HIV (PLWH), adjunctive corticosteroid use in treatment has shown a mortality benefit.Areas covered: This review article covers the epidemiology, pathophysiology, diagnosis, microbiology, prophylaxis indications, prophylactic therapies, and treatments.Expert opinion: TMP-SMX has been first-line therapy for treating and preventing pneumocystis for decades. However, its adverse effects are not uncommon, particularly during treatment. Second-line therapies may be better tolerated, but often sacrifice efficacy. Echinocandins show some promise for new combination therapies; however, further studies are needed to define optimal antimicrobial therapy for PJP as well as the role of corticosteroids in those without HIV.
Collapse
Affiliation(s)
- R Benson Weyant
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Doucette
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cecilia Lau
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
6
|
Wang H, Chang Y, Cui ZZ, Liu ZJ, Ma SF. Admission C-Reactive Protein-to-Albumin Ratio Predicts the 180-Day Mortality of AIDS-Related Pneumocystis Pneumonia. AIDS Res Hum Retroviruses 2020; 36:753-761. [PMID: 32580561 DOI: 10.1089/aid.2020.0057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Assessment tools are necessary for the adequate stratification of patients with AIDS-related pneumocystis pneumonia (PCP). The aim of this study was to evaluate the ability of severity assessment scores and inflammation- and nutrition-based parameters for predicting the 180-day mortality of AIDS-related PCP. This was a retrospective cohort study of patients with AIDS-related PCP admitted at the Beijing Di-Tan Hospital. The CURB-65 score, Pneumonia Severity Index (PSI) score, Acute Physiology And Chronic Health Evaluation II (APACHE II) score, C-reactive protein-to-albumin ratio (CAR), procalcitonin, neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and platelet-to-lymphocyte ratio during the first 24 h of intensive care unit admission were analyzed. The prognostic values of the severity assessment scores and biomarkers for 180-day mortality were evaluated using receiver operating characteristic (ROC) curves and integrated discrimination improvement (IDI) indexes. A total of 123 patients with AIDS-related PCP were included. Fifty-five patients were dead, and 68 were still alive at 180 days after admission. CAR, CURB-65, PSI, and APACHE II were independent predictors of 180-day mortality. The optimal cutoff value of CAR was 2.0 mg/g [area under the ROC curve = 0.844, 95% credential interval (CI) = 0.776-0.913], and CAR >2.0 mg/g increased the prognostic value of all three severity assessment scores, with an IDI index of 5.1% for the CURB-65 score, 8.1% for the PSI score, and 4.1% for the APACHE II score (all p < .05). Combining CAR >2.0 mg/g enhanced the capability of CURB-65, APACHE II, and PSI in predicting the 180-day mortality of patients with AIDS-related PCP.
Collapse
Affiliation(s)
- Hui Wang
- Department of Emergency Medicine, Beijing Di-Tan Hospital, Capital Medical University, Beijing, China
| | - Yufei Chang
- Department of Emergency Medicine, Beijing Di-Tan Hospital, Capital Medical University, Beijing, China
| | - Zhi-Zhang Cui
- Department of Emergency Medicine, Beijing Di-Tan Hospital, Capital Medical University, Beijing, China
| | - Zhi-Juan Liu
- Department of Emergency Medicine, Beijing Di-Tan Hospital, Capital Medical University, Beijing, China
| | - Shan-Fang Ma
- Department of Emergency Medicine, Beijing Di-Tan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
7
|
Abstract
BACKGROUND Progressive disseminated histoplasmosis (PDH) is a serious fungal infection that affects people living with HIV. The best way to treat the condition is unclear. OBJECTIVES We assessed evidence in three areas of equipoise. 1. Induction. To compare efficacy and safety of initial therapy with liposomal amphotericin B versus initial therapy with alternative antifungals. 2. Maintenance. To compare efficacy and safety of maintenance therapy with 12 months of oral antifungal treatment with shorter durations of maintenance therapy. 3. Antiretroviral therapy (ART). To compare the outcomes of early initiation versus delayed initiation of ART. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; Cochrane CENTRAL; MEDLINE (PubMed); Embase (Ovid); Science Citation Index Expanded, Conference Proceedings Citation Index-Science, and BIOSIS Previews (all three in the Web of Science); the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the ISRCTN registry, all up to 20 March 2020. SELECTION CRITERIA We evaluated studies assessing the use of liposomal amphotericin B and alternative antifungals for induction therapy; studies assessing the duration of antifungals for maintenance therapy; and studies assessing the timing of ART. We included randomized controlled trials (RCT), single-arm trials, prospective cohort studies, and single-arm cohort studies. DATA COLLECTION AND ANALYSIS Two review authors assessed eligibility and risk of bias, extracted data, and assessed certainty of evidence. We used the Cochrane 'Risk of bias' tool to assess risk of bias in randomized studies, and ROBINS-I tool to assess risk of bias in non-randomized studies. We summarized dichotomous outcomes using risk ratios (RRs), with 95% confidence intervals (CI). MAIN RESULTS We identified 17 individual studies. We judged eight studies to be at critical risk of bias, and removed these from the analysis. 1. Induction We found one RCT which compared liposomal amphotericin B to deoxycholate amphotericin B. Compared to deoxycholate amphotericin B, liposomal amphotericin B may have higher clinical success rates (RR 1.46, 95% CI 1.01 to 2.11; 1 study, 80 participants; low-certainty evidence). Compared to deoxycholate amphotericin B, liposomal amphotericin B has lower rates of nephrotoxicity (RR 0.25, 95% CI 0.09 to 0.67; 1 study, 77 participants; high-certainty evidence). We found very low-certainty evidence to inform comparisons between amphotericin B formulations and azoles for induction therapy. 2. Maintenance We found no eligible study that compared less than 12 months of oral antifungal treatment to 12 months or greater for maintenance therapy. For both induction and maintenance, fluconazole performed poorly in comparison to other azoles. 3. ART We found one study, in which one out of seven participants in the 'early' arm and none of the three participants in the 'late' arm died. AUTHORS' CONCLUSIONS Liposomal amphotericin B appears to be a better choice compared to deoxycholate amphotericin B for treating PDH in people with HIV; and fluconazole performed poorly compared to other azoles. Other treatment choices for induction, maintenance, and when to start ART have no evidence, or very low certainty evidence. PDH needs prospective comparative trials to help inform clinical decisions.
Collapse
Affiliation(s)
- Marylou Murray
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Paul Hine
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
8
|
Prevalence of opportunistic infections in insured patients with HIV and their association with socioeconomic and clinical factors in Colombia, 2012. BIOMEDICA 2019; 39:186-204. [PMID: 31021557 DOI: 10.7705/biomedica.v39i1.4508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Indexed: 01/22/2023]
Abstract
Introduction: Despite advances in treatment, opportunistic infections are the major cause of morbidity and mortality among patients with the human immunodeficiency virus (HIV).
Objectives: To estimate the prevalence of opportunistic infections among insured HIV patients, and to establish its association with socio-demographic and clinical factors.
Materials and methods: This was an observational study with an analytical focus. We analysed 37,325 records of insured people with HIV. A bivariate analysis using chi square and ANOVA, adjusted by Bonferroni, and multiple logistic regression for the adult population were carried out to explore the association among any opportunistic infections as the response variable and socio-demographic and clinical factors.
Results: From the total, at least 18% experienced an opportunistic infection. The most frequent were tuberculosis and brain toxoplasmosis for adults, and pneumonia and diarrhea for patients under 13 years of age. The prevalence of any opportunistic infection was significantly higher in men (OR=1.5; CI95% 1.4-1.6), in those more than 40 years of age (OR=1.6; CI95% 1.3-2.0), in people subjected to forced displacement (OR=1.7; CI95% 1.5-1.9), and in those belonging to the subsidized or exception health affiliation regimes (OR= 2.7; CI95% 2.1-3.4). Regarding clinical factors, opportunistic infections were significantly associated to time since diagnosis (>10 years) (OR=1.6; CI95% 1.5-1.7), administration of antiretroviral treatment (OR=4.4; CI95% 3.9-5.1), and discontinuity of treatment (OR=1.7; CI95% 1.6-1.8). The multivariate analysis for adults in clinical stage A showed similar results.
Conclusions: Despite the preventable nature of opportunistic infections, their prevalence is high and they predominantly affect the most disadvantaged people.
Collapse
|
9
|
Awotiwon AA, Johnson S, Rutherford GW, Meintjes G, Eshun‐Wilson I. Primary antifungal prophylaxis for cryptococcal disease in HIV-positive people. Cochrane Database Syst Rev 2018; 8:CD004773. [PMID: 30156270 PMCID: PMC6513489 DOI: 10.1002/14651858.cd004773.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cryptococcal disease remains one of the main causes of death in HIV-positive people who have low cluster of differentiation 4 (CD4) cell counts. Currently, the World Health Organization (WHO) recommends screening HIV-positive people with low CD4 counts for cryptococcal antigenaemia (CrAg), and treating those who are CrAg-positive. This Cochrane Review examined the effects of an approach where those with low CD4 counts received regular prophylactic antifungals, such as fluconazole. OBJECTIVES To assess the efficacy and safety of antifungal drugs for the primary prevention of cryptococcal disease in adults and children who are HIV-positive. SEARCH METHODS We searched the CENTRAL, MEDLINE PubMed, Embase OVID, CINAHL EBSCOHost, WHO International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, conference proceedings for the International AIDS Society (IAS) and Conference on Retroviruses and Opportunistic Infections (CROI), and reference lists of relevant articles up to 31 August 2017. SELECTION CRITERIA Randomized controlled trials of adults and children, who are HIV-positive with low CD4 counts, without a current or prior diagnosis of cryptococcal disease that compared any antifungal drug taken as primary prophylaxis to placebo or standard care. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and risk of bias, and extracted and analysed data. The primary outcome was all-cause mortality. We summarized all outcomes using risk ratios (RR) with 95% confidence intervals (CI). Where appropriate, we pooled data in meta-analyses. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Nine trials, enrolling 5426 participants, met the inclusion criteria of this review. Six trials administered fluconazole, while three trials administered itraconazole.Antifungal prophylaxis may make little or no difference to all-cause mortality (RR 1.07, 95% CI 0.80 to 1.43; 6 trials, 3220 participants; low-certainty evidence). For cryptococcal specific outcomes, prophylaxis probably reduces the risk of developing cryptococcal disease (RR 0.29, 95% CI 0.17 to 0.49; 7 trials, 5000 participants; moderate-certainty evidence), and probably reduces deaths due to cryptococcal disease (RR 0.29, 95% CI 0.11 to 0.72; 5 trials, 3813 participants; moderate-certainty evidence). Fluconazole prophylaxis may make no clear difference to the risk of developing clinically resistant Candida disease (RR 0.93, 95% CI 0.56 to 1.56; 3 trials, 1198 participants; low-certainty evidence); however, there may be an increased detection of fluconazole-resistant Candida isolates from surveillance cultures (RR 1.25, 95% CI 1.00 to 1.55; 3 trials, 539 participants; low-certainty evidence). Antifungal prophylaxis was generally well-tolerated with probably no clear difference in the risk of discontinuation of antifungal prophylaxis compared with placebo (RR 1.01, 95% CI 0.91 to 1.13; 4 trials, 2317 participants; moderate-certainty evidence). Antifungal prophylaxis may also make no difference to the risk of having any adverse event (RR 1.07, 95% CI 0.88 to 1.30; 4 trials, 2317 participants; low-certainty evidence), or a serious adverse event (RR 1.08, 95% CI 0.83 to 1.41; 4 trials, 888 participants; low-certainty evidence) when compared to placebo or standard care. AUTHORS' CONCLUSIONS Antifungal prophylaxis reduced the risk of developing and dying from cryptococcal disease. Therefore, where CrAG screening is not available, antifungal prophylaxis may be used in patients with low CD4 counts at diagnosis and who are at risk of developing cryptococcal disease.
Collapse
Affiliation(s)
- Ajibola A Awotiwon
- Knowledge Translation Unit, University of Cape Town Lung InstituteGeorge streetObservatory, Cape TownWestern CapeSouth Africa7700
- Stellenbosch UniversityCentre for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Samuel Johnson
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
| | - George W Rutherford
- University of California, San FranciscoGlobal Health Sciences550 16th StreetBox 1224San FranciscoCaliforniaUSA94143‐1224
| | - Graeme Meintjes
- University of Cape TownDepartment of MedicineCape TownSouth Africa
| | - Ingrid Eshun‐Wilson
- Stellenbosch UniversityCentre for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | | |
Collapse
|
10
|
Jung Y, Song KH, Choe PG, Park WB, Bang JH, Kim ES, Kim HB, Park SW, Kim NJ, Oh MD. Incidence of disseminated Mycobacterium avium-complex infection in HIV patients receiving antiretroviral therapy with use of Mycobacterium avium-complex prophylaxis. Int J STD AIDS 2017; 28:1426-1432. [PMID: 28592210 DOI: 10.1177/0956462417713432] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The incidence of disseminated Mycobacterium avium complex (MAC) infection in HIV patients has fallen markedly since the introduction of effective antiretroviral therapy (ART). However, current guidelines still recommend primary prophylaxis. We conducted a retrospective cohort study in a university-affiliated hospital from January 1998 to January 2014. During that period, HIV patients who had at least one CD4 cell count below 50 cells/mm3 and had been treated with ART were enrolled. We compared incidence of disseminated MAC infection in the 12 months after the first CD4 cell count below 50 cells/mm3 between prophylaxis and nonprophylaxis groups. A total of 157 patients were enrolled and the total observation period was 144 patient-years (PY). Thirty-three patients (21%) received primary MAC prophylaxis. The initial CD4 cell count of the prophylaxis group was lower than that of the nonprophylaxis group ( P = 0.024), but the proportion of patients who reached a CD4 cell count >100 cells/mm3 ( P = 0.234) and were virologically suppressed ( P = 0.513) 12 months after ART commencement was not different in the prophylaxis and nonprophylaxis groups. The incidence of MAC did not differ significantly between the groups (3.4/100 PY versus 0.8/100 PY, P = 0.368). Routine MAC prophylaxis may be not required in the era of effective ART.
Collapse
Affiliation(s)
- Younghee Jung
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,2 Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Kyoung-Ho Song
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Pyoeng Gyun Choe
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Wan Beom Park
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hwan Bang
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eu Suk Kim
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Bin Kim
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Won Park
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Nam Joong Kim
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Myoung-Don Oh
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
11
|
Lin X, Garg S, Mattson CL, Luo Q, Skarbinski J. Prescription of Pneumocystis Jiroveci Pneumonia Prophylaxis in HIV-Infected Patients. J Int Assoc Provid AIDS Care 2016; 15:455-458. [PMID: 27629868 DOI: 10.1177/2325957416667486] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The US treatment guidelines recommend Pneumocystis jiroveci pneumonia (PCP) prophylaxis for all HIV-infected persons with a CD4 count <200 cells/mm3 (ie, eligible for PCP prophylaxis). However, some studies suggest PCP prophylaxis may be unnecessary in virally suppressed patients. Using national data of HIV-infected adults receiving medical care in the United States during 2009 to 2012, the authors assessed the weighted percentage of eligible patients who were prescribed PCP prophylaxis and the independent association between PCP prophylaxis prescription and viral suppression. Overall, 81% of eligible patients were prescribed PCP prophylaxis. Virally suppressed eligible patients were less likely to be prescribed PCP prophylaxis (prevalence ratio: 0.84; 95% confidence interval: 0.80-0.89). Although guidelines recommend PCP prophylaxis for all eligible patients, some HIV care providers might not prescribe PCP prophylaxis to virally suppressed patients. Additional data on the risk for PCP among virally suppressed patients are needed to clarify this controversy.
Collapse
Affiliation(s)
- Xia Lin
- Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA .,Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA, USA
| | - Shikha Garg
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA, USA
| | - Christine L Mattson
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA, USA
| | | | - Jacek Skarbinski
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA, USA
| |
Collapse
|
12
|
Sidhu VK, Foisy MM, Hughes CA. Discontinuing Pneumocystis jirovecii Pneumonia Prophylaxis in HIV-Infected Patients With a CD4 Cell Count <200 cells/mm3. Ann Pharmacother 2015; 49:1343-8. [PMID: 26358129 DOI: 10.1177/1060028015605113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review the evidence for discontinuing primary and secondary Pneumocystis jirovecii pneumonia (PJP) prophylaxis in HIV-infected patients with a CD4 count <200 cells/mm(3). DATA SOURCES We conducted a literature search in MEDLINE, EMBASE, Cochrane Library, Google Scholar, and the International Aids Society Library (up to August 2015) using the following key search terms: Pneumocystis jirovecii, pneumonia, human immunodeficiency virus, primary prophylaxis, secondary prophylaxis, and discontinuation. STUDY SELECTION AND DATA EXTRACTION All English-language studies that evaluated discontinuation of primary and/or secondary PJP prophylaxis in HIV-infected patients with CD4 count <200 cells/mm(3) were included. DATA SYNTHESIS Five studies were identified, which varied in design, sample size, outcomes, and duration of follow-up. Three studies examined discontinuation of primary and secondary PJP prophylaxis; 1 study evaluated discontinuing primary PJP prophylaxis; and 1 study evaluated stopping secondary PJP prophylaxis. Two out of the 5 studies pooled data for all opportunistic infections. Overall, there was a low incidence of PJP among HIV-infected patients who discontinued primary PJP prophylaxis and were well controlled on antiretroviral therapy (ART). CONCLUSIONS Discontinuation of primary PJP prophylaxis appears to be safe in patients on combination ART with a suppressed HIV viral load and a CD4 count >100 cells/mm(3). Additional data are needed to support the safety of discontinuing secondary PJP prophylaxis. Decisions to discontinue PJP prophylaxis in patients with a CD4 count <200 cells/mm(3) should be done on an individual patient basis, taking into consideration clinical factors, including ongoing adherence to ART.
Collapse
|
13
|
Suthar AB, Vitoria MA, Nagata JM, Anglaret X, Mbori-Ngacha D, Sued O, Kaplan JE, Doherty MC. Co-trimoxazole prophylaxis in adults, including pregnant women, with HIV: a systematic review and meta-analysis. Lancet HIV 2015; 2:e137-50. [PMID: 26424674 DOI: 10.1016/s2352-3018(15)00005-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 01/14/2015] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Co-trimoxazole prophylaxis is used to reduce morbidity and mortality in people with HIV. We systematically reviewed three topics related to co-trimoxazole prophylaxis to update WHO guidelines: initiation, discontinuation, and dose. METHODS We searched PubMed, Embase, WHO Global Index Medicus, and clinical trial registries in November, 2013, for randomised controlled trials and observational studies including co-trimoxazole prophylaxis and a comparator group. Studies were eligible if they reported death, WHO clinical stage 3 or 4 events, admittance to hospital, severe bacterial infections, tuberculosis, pneumonia, diarrhoea, malaria, or treatment-limiting adverse events. Infant mortality, low birthweight, and placental malaria were additional outcomes for the comparison of co-trimoxazole prophylaxis and intermittent preventive treatment for malaria in pregnant women (IPTp). We compared a dose of 480 mg co-trimoxazole once a day with one of 960 mg co-trimoxazole once a day. We used a 10% margin for non-inferiority and equivalence analyses. We used random-effects models for all meta-analyses. This study is registered with PROSPERO, number CRD42014007163. FINDINGS 19 articles, published from 1995 to 2014 and including 35 328 participants, met the inclusion criteria. Co-trimoxazole prophylaxis reduced rates of death (hazard ratio [HR] 0·40, 95% CI 0·26-0·64) when started at CD4 counts of 350 cells per μL or lower with antiretroviral therapy (ART) worldwide. Co-trimoxazole prophylaxis started at higher than 350 cells per μL without ART reduced rates of death (0·50, 0·30-0·83) and malaria (0·25, 0·10-0·57) in Africa. Co-trimoxazole prophylaxis was non-inferior to IPTp with respect to infant mortality (risk difference [RD] -0·05, 95% CI -0·12 to 0·02), low birthweight (0·00, -0·07 to 0·07), and placental malaria (0·00, -0·10 to 0·10). Co-trimoxazole prophylaxis continuation after ART-induced recovery with CD4 counts higher than 350 cells per μL reduced admittances to hospital (HR 0·42, 95% CI 0·22-0·80), pneumonia (0·73, 0·61-0·88), malaria (0·03, 0·01-0·10), and diarrhoea (0·61, 0·48-0·78) in Africa. A dose of 480 mg co-trimoxazole prophylaxis once a day did not reduce treatment-limiting adverse events compared with 960 mg once a day (RD -0·07, 95% CI -0·52 to 0·39). INTERPRETATION Co-trimoxazole prophylaxis should be given with ART in people with CD4 counts of 350 cells per μL or lower in low-income and middle-income countries. Co-trimoxazole prophylaxis should be provided irrespective of CD4 count in settings with a high burden of infectious diseases. Pregnant women with HIV in Africa should use co-trimoxazole rather than IPTp to prevent malaria complications in infants. Further research is needed to inform dose optimisation and co-trimoxazole use in the context of expanded ART in different epidemiological settings. FUNDING None.
Collapse
Affiliation(s)
- Amitabh B Suthar
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
| | - Marco A Vitoria
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Jason M Nagata
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Xavier Anglaret
- INSERM Centre 897, Université Victor Segalen, Bordeaux, France
| | - Dorothy Mbori-Ngacha
- Eastern and Southern Africa Regional Office, United Nations Children's Fund, Pretoria, South Africa
| | - Omar Sued
- Clinical Research Department, Fundación Huésped, Buenos Aires, Argentina
| | - Jonathan E Kaplan
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Meg C Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| |
Collapse
|
14
|
Yangco BG, Buchacz K, Baker R, Palella FJ, Armon C, Brooks JT. Is primary mycobacterium avium complex prophylaxis necessary in patients with CD4 <50 cells/μL who are virologically suppressed on cART? AIDS Patient Care STDS 2014; 28:280-3. [PMID: 24833016 PMCID: PMC4657747 DOI: 10.1089/apc.2013.0270] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We analyzed 369 patients with no prior Mycobacterium avium complex (MAC) infection and CD4 <50 cells/μL (baseline), while on combination antiretroviral therapy(cART), for incidence rates of primary MAC infection during the 6 months after baseline, by prophylaxis status. Of participants (median age, 40 years old), most were male (81%) and about half were non-white; at baseline, 81% of participants were on cART >60 days and 19% had HIV RNA <1000 copies/mL, whereas 65% had HIV RNA >10,000 copies/mL. Eleven patients had MAC infection within 6 months baseline (rate=0.6/100 person months): 4/175 on MAC prophylaxis vs. 7/194, no MAC prophylaxis (p=0.64). Of the 11 patients, seven had HIV RNA >10,000, and three >1000-9999 copies/mL at baseline (one missing). Median time to MAC infection was 62 days (IQR 43-126, maximum 139 days). No MAC infection occurred among 71 (19%) patients virologically suppressed (HIV RNA <1000 copies/mL) at baseline, including 41 patients with no MAC prophylaxis during follow-up. A small number of eligible virologically suppressed participants and the lack of data on cART/MAC prophylaxis adherence limited our observational nonrandomized study. Primary MAC prophylaxis may not be required for cART-virologically suppressed patients with CD4 <50 cells/mL.
Collapse
Affiliation(s)
| | - Kate Buchacz
- Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | | | - Frank J. Palella
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - John T. Brooks
- Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | | |
Collapse
|