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Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, Todi SK, Mohan A, Hegde A, Jagiasi BG, Krishna B, Rodrigues C, Govil D, Pal D, Divatia JV, Sengar M, Gupta M, Desai M, Rungta N, Prayag PS, Bhattacharya PK, Samavedam S, Dixit SB, Sharma S, Bandopadhyay S, Kola VR, Deswal V, Mehta Y, Singh YP, Myatra SN. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024; 28:S104-S216. [PMID: 39234229 PMCID: PMC11369928 DOI: 10.5005/jp-journals-10071-24677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 09/06/2024] Open
Abstract
How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.
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Affiliation(s)
- Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Subhash K Todi
- Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Ashit Hegde
- Department of Medicine & Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, India
| | - Camila Rodrigues
- Department of Microbiology, P D Hinduja National Hospital, Mumbai, India
| | - Deepak Govil
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Divya Pal
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mukesh Desai
- Department of Immunology, Pediatric Hematology and Oncology Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Narendra Rungta
- Department of Critical Care & Anaesthesiology, Rajasthan Hospital, Jaipur, India
| | - Parikshit S Prayag
- Department of Transplant Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Srinivas Samavedam
- Department of Critical Care, Ramdev Rao Hospital, Hyderabad, Telangana, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Sudivya Sharma
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Susruta Bandopadhyay
- Department of Critical Care, AMRI Hospitals Salt Lake, Kolkata, West Bengal, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Vikas Deswal
- Consultant, Infectious Diseases, Medanta - The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Yogendra P Singh
- Department of Critical Care, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Hoenigl M, Arastehfar A, Arendrup MC, Brüggemann R, Carvalho A, Chiller T, Chen S, Egger M, Feys S, Gangneux JP, Gold JAW, Groll AH, Heylen J, Jenks JD, Krause R, Lagrou K, Lamoth F, Prattes J, Sedik S, Wauters J, Wiederhold NP, Thompson GR. Novel antifungals and treatment approaches to tackle resistance and improve outcomes of invasive fungal disease. Clin Microbiol Rev 2024; 37:e0007423. [PMID: 38602408 PMCID: PMC11237431 DOI: 10.1128/cmr.00074-23] [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: 04/12/2024] Open
Abstract
SUMMARYFungal infections are on the rise, driven by a growing population at risk and climate change. Currently available antifungals include only five classes, and their utility and efficacy in antifungal treatment are limited by one or more of innate or acquired resistance in some fungi, poor penetration into "sequestered" sites, and agent-specific side effect which require frequent patient reassessment and monitoring. Agents with novel mechanisms, favorable pharmacokinetic (PK) profiles including good oral bioavailability, and fungicidal mechanism(s) are urgently needed. Here, we provide a comprehensive review of novel antifungal agents, with both improved known mechanisms of actions and new antifungal classes, currently in clinical development for treating invasive yeast, mold (filamentous fungi), Pneumocystis jirovecii infections, and dimorphic fungi (endemic mycoses). We further focus on inhaled antifungals and the role of immunotherapy in tackling fungal infections, and the specific PK/pharmacodynamic profiles, tissue distributions as well as drug-drug interactions of novel antifungals. Finally, we review antifungal resistance mechanisms, the role of use of antifungal pesticides in agriculture as drivers of drug resistance, and detail detection methods for antifungal resistance.
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Affiliation(s)
- Martin Hoenigl
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Amir Arastehfar
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Roger Brüggemann
- Department of Pharmacy and Radboudumc Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc-CWZ Center of Expertise in Mycology, Nijmegen, The Netherlands
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW South Wales Health Pathology, Westmead Hospital, Westmead, Australia
- The University of Sydney, Sydney, Australia
| | - Matthias Egger
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Simon Feys
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Jean-Pierre Gangneux
- Centre National de Référence des Mycoses et Antifongiques LA-AspC Aspergilloses chroniques, European Excellence Center for Medical Mycology (ECMM EC), Centre hospitalier Universitaire de Rennes, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) UMR_S 1085, Rennes, France
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andreas H. Groll
- Department of Pediatric Hematology/Oncology and Infectious Disease Research Program, Center for Bone Marrow Transplantation, University Children’s Hospital, Muenster, Germany
| | - Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Jeffrey D. Jenks
- Department of Public Health, Durham County, Durham, North Carolina, USA
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Robert Krause
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Frédéric Lamoth
- Department of Laboratory Medicine and Pathology, Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Medicine, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Juergen Prattes
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Sarah Sedik
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Nathan P. Wiederhold
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - George R. Thompson
- Department of Internal Medicine, Division of Infectious Diseases University of California-Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
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3
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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.
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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
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4
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Trubin PA, Azar MM. Current Concepts in the Diagnosis and Management of Pneumocystis Pneumonia in Solid Organ Transplantation. Infect Dis Clin North Am 2023:S0891-5520(23)00026-0. [PMID: 37142510 DOI: 10.1016/j.idc.2023.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Pneumocystis infection manifests predominantly as an interstitial pneumonia in immunocompromised patients. Diagnostic testing in the appropriate clinical context can be highly sensitive and specific and involves radiographic imaging, fungal biomarkers, nucleic acid amplification, histopathology, and lung fluid or tissue sampling. Trimethoprim-sulfamethoxazole remains the first-choice agent for treatment and prophylaxis. Investigation continues to promote a deeper understanding of the pathogen's ecology, epidemiology, host susceptibility, and optimal treatment and prevention strategies in solid organ transplant recipients.
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Affiliation(s)
- Paul A Trubin
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, 135 College Street, New Haven, CT 06510, USA.
| | - Marwan M Azar
- Department of Medicine, Section of Infectious Diseases; Department of Laboratory Medicine; Yale School of Medicine, 135 College Street, New Haven, CT 06510, USA
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5
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Sohani ZN, Butler-Laporte G, Aw A, Belga S, Benedetti A, Carignan A, Cheng MP, Coburn B, Costiniuk CT, Ezer N, Gregson D, Johnson A, Khwaja K, Lawandi A, Leung V, Lother S, MacFadden D, McGuinty M, Parkes L, Qureshi S, Roy V, Rush B, Schwartz I, So M, Somayaji R, Tan D, Trinh E, Lee TC, McDonald EG. Low-dose trimethoprim-sulfamethoxazole for the treatment of Pneumocystis jirovecii pneumonia (LOW-TMP): protocol for a phase III randomised, placebo-controlled, dose-comparison trial. BMJ Open 2022; 12:e053039. [PMID: 35863836 PMCID: PMC9310160 DOI: 10.1136/bmjopen-2021-053039] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection of immunocompromised hosts with significant morbidity and mortality. The current standard of care, trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 15-20 mg/kg/day, is associated with serious adverse drug events (ADE) in 20%-60% of patients. ADEs include hypersensitivity reactions, drug-induced liver injury, cytopenias and renal failure, all of which can be treatment limiting. In a recent meta-analysis of observational studies, reduced dose TMP-SMX for the treatment of PJP was associated with fewer ADEs, without increased mortality. METHODS AND ANALYSIS A phase III randomised, placebo-controlled, trial to directly compare the efficacy and safety of low-dose TMP-SMX (10 mg/kg/day of TMP) with the standard of care (15 mg/kg/day of TMP) among patients with PJP, for a composite primary outcome of change of treatment, new mechanical ventilation, or death. The trial will be undertaken at 16 Canadian hospitals. Data will be analysed as intention to treat. Primary and secondary outcomes will be compared using logistic regression adjusting for stratification and presented with 95% CI. ETHICS AND DISSEMINATION This study has been conditionally approved by the McGill University Health Centre; Ethics approval will be obtained from all participating centres. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04851015.
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Affiliation(s)
- Zahra N Sohani
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew Aw
- Division of Hematology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sara Belga
- Division of Infectious Diseases, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrea Benedetti
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alex Carignan
- Division of Microbiology and Infectious Diseases, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Matthew P Cheng
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Bryan Coburn
- Division of Infectious Diseases, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Cecilia T Costiniuk
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
| | - Nicole Ezer
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Respirology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan Gregson
- Departments of Pathology and Laboratory Medicine and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Johnson
- Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kosar Khwaja
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Department of Critical Care Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexander Lawandi
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Victor Leung
- Department of Laboratory Medicine & Pathology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sylvain Lother
- Department of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derek MacFadden
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michaeline McGuinty
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Leighanne Parkes
- Division of Medical Microbiology and Infectious Diseases, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Salman Qureshi
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Division of Respirology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Critical Care Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Valerie Roy
- Division of Microbiology and Infectious Diseases, Centre Hospitalier Universitaire de Sherbrooke Hôtel-Dieu, Sherbrooke, Quebec, Canada
| | - Barret Rush
- Department of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ilan Schwartz
- Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
| | - Ranjani Somayaji
- Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darrell Tan
- Division of Infectious Diseases, St Michael's Hospital, Toronto, Ontario, Canada
| | - Emilie Trinh
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Montreal, Quebec, Canada
| | - Emily G McDonald
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Montreal, Quebec, Canada
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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6
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Haseeb A, Abourehab MAS, Almalki WA, Almontashri AM, Bajawi SA, Aljoaid AM, Alsahabi BM, Algethamy M, AlQarni A, Iqbal MS, Mutlaq A, Alghamdi S, Elrggal ME, Saleem Z, Radwan RM, Mahrous AJ, Faidah HS. Trimethoprim-Sulfamethoxazole (Bactrim) Dose Optimization in Pneumocystis jirovecii Pneumonia (PCP) Management: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:2833. [PMID: 35270525 PMCID: PMC8910260 DOI: 10.3390/ijerph19052833] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Abstract
(1) Background: Pneumocystis jirovecii pneumonia (PCP) has a substantial impact on the morbidity and mortality of patients, especially those with autoimmune disorders, thus requiring optimal dosing strategies of Trimethoprim-Sulfamethoxazole (TMP-SMX). Therefore, to ensure the safety of TMP-SMX, there is a high demand to review current evidence in PCP patients with a focus on dose optimization strategies; (2) Methods: Various databases were searched from January 2000 to December 2021 for articles in English, focusing on the dose optimization of TMP-SMX. The data were collected in a specific form with predefined inclusion and exclusion criteria. The quality of each article was evaluated using a Newcastle-Ottawa Scale (NOS) for retrospective studies, Joanna Briggs Institute (JBI) critical checklist for case reports, and Cochrane bias tool for randomized clinical trials (RCTs); (3) Results: Thirteen studies met the inclusion criteria for final analysis. Of the 13 selected studies, nine were retrospective cohort studies, two case reports, and two randomized controlled trials (RCT). Most of the studies compared the high-dose with low-dose TMP-SMX therapy for PCP. We have found that a low dose of TMP-SMX provides satisfactory outcomes while reducing the mortality rate and PCP-associated adverse events. This strategy reduces the economic burden of illness and enhances patients' compliance to daily regimen plan; (4) Conclusions: The large-scale RCTs and cohort studies are required to improve dosing strategies to prevent initial occurrence of PCP or to prevent recurrence of PCP in immune compromised patients.
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Affiliation(s)
- Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (W.A.A.); (A.M.A.); (S.A.B.); (M.E.E.); (A.J.M.)
| | - Mohammed A. S. Abourehab
- Department of Pharmaceutics, Faculty of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia;
| | - Wesam Abdulghani Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (W.A.A.); (A.M.A.); (S.A.B.); (M.E.E.); (A.J.M.)
| | - Abdulrahman Mohammed Almontashri
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (W.A.A.); (A.M.A.); (S.A.B.); (M.E.E.); (A.J.M.)
| | - Sultan Ahmed Bajawi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (W.A.A.); (A.M.A.); (S.A.B.); (M.E.E.); (A.J.M.)
| | - Anas Mohammed Aljoaid
- Department of Internal Medicine, Alnoor Specialist Hospital, Makkah 21955, Saudi Arabia; (A.M.A.); (B.M.A.)
| | - Bahni Mohammed Alsahabi
- Department of Internal Medicine, Alnoor Specialist Hospital, Makkah 21955, Saudi Arabia; (A.M.A.); (B.M.A.)
| | - Manal Algethamy
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah 21955, Saudi Arabia;
| | - Abdullmoin AlQarni
- Infectious Diseases Department, Alnoor Specialist Hospital Makkah, Makkah 21955, Saudi Arabia;
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam bin Abdulaziz University, Alkharj 11942, Saudi Arabia;
| | - Alaa Mutlaq
- General Department of Pharmaceutical Care, Ministry of Health, Riyadh 12211, Saudi Arabia;
| | - Saleh Alghamdi
- Department of Clinical Pharmacy, Faculty of Clinical Pharmacy, Al Baha University, Al Baha 57911, Saudi Arabia;
| | - Mahmoud E. Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (W.A.A.); (A.M.A.); (S.A.B.); (M.E.E.); (A.J.M.)
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore 40050, Pakistan;
| | - Rozan Mohammad Radwan
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Makkah 21955, Saudi Arabia;
| | - Ahmad Jamal Mahrous
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (W.A.A.); (A.M.A.); (S.A.B.); (M.E.E.); (A.J.M.)
| | - Hani Saleh Faidah
- Department of Microbiology, Faculty of Medicine, Umm Al Qura University, Makkah 21955, Saudi Arabia;
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7
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McDonald EG, Butler-Laporte G, Del Corpo O, Hsu JM, Lawandi A, Senecal J, Sohani ZN, Cheng MP, Lee TC. On the Treatment of Pneumocystis jirovecii Pneumonia: Current Practice Based on Outdated Evidence. Open Forum Infect Dis 2021; 8:ofab545. [PMID: 34988242 PMCID: PMC8694206 DOI: 10.1093/ofid/ofab545] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 10/27/2021] [Indexed: 12/13/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) is a common opportunistic infection causing more than 400000 cases annually worldwide. Although antiretroviral therapy has reduced the burden of PCP in persons with human immunodeficiency virus (HIV), an increasing proportion of cases occur in other immunocompromised populations. In this review, we synthesize the available randomized controlled trial (RCT) evidence base for PCP treatment. We identified 14 RCTs that were conducted 25-35 years ago, principally in 40-year-old men with HIV. Trimethoprim-sulfamethoxazole, at a dose of 15-20 mg/kg per day, is the treatment of choice based on historical practice rather than on quality comparative, dose-finding studies. Treatment duration is similarly based on historical practice and is not evidence based. Corticosteroids have a demonstrated role in hypoxemic patients with HIV but have yet to be studied in RCTs as an adjunctive therapy in non-HIV populations. The echinocandins are potential synergistic treatments in need of further investigation.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada
| | - Olivier Del Corpo
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Jimmy M Hsu
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Alexander Lawandi
- Department of Critical Care Medicine, National Institutes of Health, Clinical Center, Bethesda, Maryland, USA
| | - Julien Senecal
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Zahra N Sohani
- Department of Medicine, McGill University, Montréal, Canada
| | - Matthew P Cheng
- Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montréal, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Canada
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Canada
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8
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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.
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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
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9
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Mutoh Y, Teruya K, Aoki T, Kikuchi Y, Gatanaga H, Oka S. Safety and efficacy of reduced-dose pentamidine as second-line treatment for HIV-related pneumocystis pneumonia. J Infect Chemother 2020; 26:1192-1197. [PMID: 32690376 DOI: 10.1016/j.jiac.2020.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 05/18/2020] [Accepted: 06/14/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Parenteral pentamidine isethionate (PM) 4 mg/kg/day is recommended as an alternative therapeutic regimen after failure of first-line treatment for pneumocystis pneumonia (PCP). However, the dose is often reduced to 3 mg/kg/day in clinical settings because of high rates of adverse events and drug toxicity. Although considered equally efficacious, this lower dose has not been well evaluated. METHODS This was a single-center, retrospective cohort study that analyzed 75 patients with HIV-PCP who were treated with trimethoprim-sulfamethoxazole, but discontinued treatment because of treatment failure or adverse events; they were then administered 3 mg/kg/day of intravenous PM as a salvage therapy. The primary outcomes were the regimen completion rate with the reduced PM dose. RESULTS AND CONCLUSIONS In total, 40 (53.3%) of the eligible patients completed PCP therapy with reduced-dose PM salvage treatment. The overall survival rate of PCP was 73 (97.3%). The median duration of second-line PM treatment was 8.0 days (interquartile range: 6.0-10.0). Although, the adverse events with reduced-dose PM were observed in 41 (54.7%), including 35 treatment-limiting adverse events, grade 3 or 4 adverse events occurred in only three patients (thrombocytopenia, one patient; neutropenia, two patients). Life-threating adverse events, such as hypoglycemia and arrhythmia, were not observed with reduced-dose PM. Salvage therapy with reduced-dose PM for patients with HIV-PCP is relatively safe and effective; moreover, life-threating adverse events did not occur. This therapy could be recommended for patients with HIV-PCP who fail to respond to first-line treatment with trimethoprim-sulfamethoxazole.
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Affiliation(s)
- Yoshikazu Mutoh
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Katsuji Teruya
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takahiro Aoki
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshimi Kikuchi
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroyuki Gatanaga
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
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10
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Butler-Laporte G, Smyth E, Amar-Zifkin A, Cheng MP, McDonald EG, Lee TC. Low-Dose TMP-SMX in the Treatment of Pneumocystis jirovecii Pneumonia: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2020; 7:ofaa112. [PMID: 32391402 PMCID: PMC7200085 DOI: 10.1093/ofid/ofaa112] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/01/2020] [Indexed: 12/20/2022] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) remains a common and highly morbid infection for immunocompromised patients. Trimethoprim-sulfamethoxazole (TMP-SMX) is the antimicrobial treatment of choice. However, treatment with TMP-SMX can lead to significant dose-dependent renal and hematologic adverse events. Although TMP-SMX is conventionally dosed at 15–20 mg/kg/d of trimethoprim for the treatment of PJP, reduced doses may be effective and carry an improved safety profile. Methods We conducted a systematic search in the Medline, Embase, and Cochrane Library databases from inception through March 2019 for peer-reviewed studies reporting on reduced doses of TMP-SMX (15 mg/kg/d of trimethoprim or less) for the treatment of PJP. PRISMA, MOOSE, and Cochrane guidelines were followed. Gray literature was excluded. Results Ten studies were identified, and 6 were included in the meta-analysis. When comparing standard doses with reduced doses of TMP-SMX, there was no statistically significant difference in mortality (absolute risk difference, –9% in favor of reduced dose; 95% confidence interval [CI], –27% to 8%). When compared with standard doses, reduced doses of TMP-SMX were associated with an 18% (95% CI, –31% to –5%) absolute risk reduction of grade ≥3 adverse events. Conclusions In this systematic review, treatment of PJP with doses of ≤10 mg/kg/d of trimethoprim was associated with similar rates of mortality when compared with standard doses and with significantly fewer treatment-emergent severe adverse events. Although limited by the observational nature of the studies included, this review provides the most current available evidence for the optimal dosing of TMP-SMX in the treatment of PJP.
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Affiliation(s)
- Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Elizabeth Smyth
- Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | | | - Matthew P Cheng
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily G McDonald
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Research Institute of the McGill University Health Centre, Montréal, Québec, Canada.,McGill Interdisciplinary Initiative in Infection and Immunity, McGill University Health Centre, Montréal, Québec, Canada.,Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Research Institute of the McGill University Health Centre, Montréal, Québec, Canada.,McGill Interdisciplinary Initiative in Infection and Immunity, McGill University Health Centre, Montréal, Québec, Canada.,Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
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11
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Ohmura SI, Naniwa T, Tamechika SY, Miyamoto T, Shichi D, Kazawa N, Iwagaitsu S, Maeda S, Wada JI, Niimi A. Effectiveness and safety of lower dose sulfamethoxazole/trimethoprim therapy for Pneumocystis jirovecii pneumonia in patients with systemic rheumatic diseases: A retrospective multicenter study. J Infect Chemother 2019; 25:253-261. [PMID: 30642768 DOI: 10.1016/j.jiac.2018.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/08/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To evaluate the effectiveness and safety of lower-dose sulfamethoxazole/trimethoprim therapy (SMX/TMP) for Pneumocystis jirovecii pneumonia (PCP) in patients with systemic rheumatic diseases. METHODS In this multicenter retrospective study, we compared effectiveness and safety of SMX/TMP for the treatment of PCP among patients divided into three groups according to the initial dosage of SMX/TMP: the low, ≤10 mg/kg/day; the intermediate, 10-15 mg/kg/day; and the high and conventional, 15-20 mg/kg/day for TMP dose. RESULTS Eighty-one patients, including 22, 30, and 29 patients in the low-, the intermediate- and the high-dose group could be analyzed and the 30-day survival rate were 100%, 93.3%, and 96.7%, respectively (P = 0.28). There were significant dose-dependent increasing trends of severe adverse drug reactions (ADRs) for SMX/TMP that were graded as ≥3 according to the Common Terminology Criteria for Adverse Events. When stratified by presence of severe hypoxemia defined by alveolar-arterial O2 gradient ≥45 mmHg, the 30-day survival and treatment modification rate were similar among the three groups, but frequency of severe ADRs were significantly decreased in the low-dose group. The low-dose group was independently and negatively associated with treatment modification within 14 days and severe ADRs. CONCLUSIONS Lower dose SMX/TMP therapy with ≤10 mg/kg/day for TMP was as effective as higher dose therapy for the treatment of PCP and associated with lower rates of treatment modification and severe ADRs in patients with systemic rheumatic diseases.
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Affiliation(s)
- Shin-Ichiro Ohmura
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan; Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Taio Naniwa
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan; Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan.
| | - Shin-Ya Tamechika
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan; Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Toshiaki Miyamoto
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Daisuke Shichi
- Department of Infectious Diseases and Rheumatology, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Nobukata Kazawa
- Department of Radiology, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Shiho Iwagaitsu
- Department of Internal Medicine, Division of Rheumatology and Nephrology, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Shinji Maeda
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan; Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Jun-Ichi Wada
- Division of Rheumatology, Department of Internal Medicine, Nagoya City University Hospital, Nagoya, Aichi, Japan; Department of Internal Medicine, Toyokawa City Hospital, Toyokawa, Aichi, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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12
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Kulkarni, AP, Sengar, M, Chinnaswamy, G, Hegde, A, Rodrigues, C, Soman, R, Khilnani, GC, Ramasubban, S, Desai, M, Pandit, R, Khasne, R, Shetty, A, Gilada, T, Bhosale, S, Kothekar, A, Dixit, S, Zirpe, K, Mehta, Y, Pulinilkunnathil, JG, Bhagat, V, Khan, MS, Narkhede, AM, Baliga, N, Ammapalli, S, Bamne, S, Turkar, S, K, VB, Choudhary, J, Kumar, R, Divatia JV. Indian Antimicrobial Prescription Guidelines in Critically Ill Immunocompromised Patients. Indian J Crit Care Med 2019; 23:S64-S96. [PMID: 31516212 PMCID: PMC6734470 DOI: 10.5005/jp-journals-10071-23102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
How to cite this article: Kulkarni AP, Sengar M, Chinnaswamy G, Hegde A, Rodrigues C, Soman R, Khilnani GC, Ramasubban S, Desai M, Pandit R, Khasne R, Shetty A, Gilada T, Bhosale S, Kothekar A, Dixit S, Zirpe K, Mehta Y, Pulinilkunnathil JG, Bhagat V, Khan MS, Narkhede AM, Baliga N, Ammapalli S, Bamne S, Turkar S, Bhat KV, Choudhary J, Kumar R, Divatia JV. Indian Journal of Critical Care Medicine 2019;23(Suppl 1): S64-S96.
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Affiliation(s)
- Atul P Kulkarni,
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Manju Sengar,
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy,
- Department of Paediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Ashit Hegde,
- Consultant in Medicine and Critical Care, PD Hinduja National Hospital, Mahim, Mumbai, Maharashtra, India
| | - Camilla Rodrigues,
- Consultant Microbiologist and Chair Infection Control, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Rajeev Soman,
- Consultant ID Physician, Jupiter Hospital, Pune, DeenanathMangeshkar Hospital, Pune, BharatiVidyapeeth, Deemed University Hospital, Pune, Courtsey Visiting Consultant, Hinduja Hospital Mumbai, Maharashtra, India
| | - Gopi C Khilnani,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Suresh Ramasubban,
- Pulmomary and Critical Care Medicine, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata, West Bengal, India
| | - Mukesh Desai,
- Department of Immunology, Prof of Pediatric Hematology and Oncology, Bai Jerbaiwadia Hospital for Children, Consultant, Hematologist, Nanavati Superspeciality Hospital, Director of Pediatric Hematology, Surya Hospitals, Mumbai, Maharashtra, India
| | - Rahul Pandit,
- Intensive Care Unit, Fortis Hospital, Mulund Goregaon Link Road, Mulund (W), Mumbai, Maharashtra, India
| | - Ruchira Khasne,
- Critical Care Medicine, Ashoka - Medicover Hospital, Indira Nagar, Wadala Nashik, Maharashtra, India
| | - Anjali Shetty,
- Microbiology Section, 5th Floor, S1 Building, PD Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Trupti Gilada,
- Consultant Physician in Infectious Disease, Unison Medicare and Research Centre and Prince Aly Khan Hospital, Maharukh Mansion, Alibhai Premji Marg, Grant Road, Mumbai, Maharashtra, India
| | - Shilpushp Bhosale,
- Intensive Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Amol Kothekar,
- Division of Critical Care Medicine, Departemnt of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Subhal Dixit,
- Consultant in Critical Care, Director, ICU Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Kapil Zirpe,
- Neuro-Trauma Unit, Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Yatin Mehta,
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Jacob George Pulinilkunnathil,
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr E Borges Road, Mumbai, Maharashtra, India
| | - Vikas Bhagat,
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, HomiBhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Mohammad Saif Khan,
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Amit M Narkhede,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Nishanth Baliga,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Srilekha Ammapalli,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Shrirang Bamne,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Siddharth Turkar,
- Department of Medical Oncology, Tata Memorial Hospital, HomiBhabha National Institute, Mumbai, Maharashtra, India
| | - Vasudeva Bhat K,
- Department of Pediatric Oncology, Tata Memorial Hospital, HomiBhabha National Institute, Dr E. Borges Marg, Parel, Mumbai, Maharashtra, India
| | - Jitendra Choudhary,
- Critical Care, Fortis Hospital, 102, Nav Sai Shakti CHS, Near Bhoir Gymkhana, M Phule Road, Dombivali West Mumbai, Maharashtra, India
| | - Rishi Kumar,
- Critical Care Medicine, PD Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
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Huang YS, Yang JJ, Lee NY, Chen GJ, Ko WC, Sun HY, Hung CC. Treatment of Pneumocystis jirovecii pneumonia in HIV-infected patients: a review. Expert Rev Anti Infect Ther 2017; 15:873-892. [PMID: 28782390 DOI: 10.1080/14787210.2017.1364991] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Pneumocystis pneumonia is a potentially life-threatening pulmonary infection that occurs in immunocompromised individuals and HIV-infected patients with a low CD4 cell count. Trimethoprim-sulfamethoxazole has been used as the first-line agent for treatment, but mutations within dihydropteroate synthase gene render potential resistance to sulfamide. Despite advances of combination antiretroviral therapy (cART), Pneumocystis pneumonia continues to occur in HIV-infected patients with late presentation for cART or virological and immunological failure after receiving cART. Areas covered: This review summarizes the diagnosis and first-line and alternative treatment and prophylaxis for Pneumocystis pneumonia in HIV-infected patients. Articles for this review were identified through searching PubMed. Search terms included: 'Pneumocystis pneumonia', 'Pneumocystis jirovecii pneumonia', 'Pneumocystis carinii pneumonia', 'trimethoprim-sulfamethoxazole', 'primaquine', 'trimetrexate', 'dapsone', 'pentamidine', 'atovaquone', 'echinocandins', 'human immunodeficiency virus infection', 'acquired immunodeficiency syndrome', 'resistance to sulfamide' and combinations of these terms. We limited the search to English language papers that were published between 1981 and March 2017. We screened all identified articles and cross-referenced studies from retrieved articles. Expert commentary: Trimethoprim-sulfamethoxazole will continue to be the first-line agent for Pneumocystis pneumonia given its cost, availability of both oral and parenteral formulations, and effectiveness or efficacy in both treatment and prophylaxis. Whether resistance due to mutations within dihydropteroate synthase gene compromises treatment effectiveness remains controversial. Continued search for effective alternatives with better safety profiles for Pneumocystis pneumonia is warranted.
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Affiliation(s)
- Yu-Shan Huang
- a Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu Branch , Hsin-Chu , Taiwan
| | - Jen-Jia Yang
- b Department of Internal Medicine , Po Jen General Hospital , Taipei , Taiwan
| | - Nan-Yao Lee
- c Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan.,d Department of Medicine , College of Medicine, National Cheng Kung University , Tainan , Taiwan
| | - Guan-Jhou Chen
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan
| | - Wen-Chien Ko
- c Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan.,d Department of Medicine , College of Medicine, National Cheng Kung University , Tainan , Taiwan
| | - Hsin-Yun Sun
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan
| | - Chien-Ching Hung
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan.,f Department of Parasitology , National Taiwan University College of Medicine , Taipei , Taiwan.,g Department of Medical Research , China Medical University Hospital , Taichung , Taiwan.,h China Medical University , Taichung , Taiwan
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14
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Avino LJ, Naylor SM, Roecker AM. Pneumocystis jirovecii Pneumonia in the Non–HIV-Infected Population. Ann Pharmacother 2016; 50:673-9. [DOI: 10.1177/1060028016650107] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Objective: Summarize data on the pathophysiology, treatment, and prevention options for non–AIDS immunocompromised patients who have Pneumocystis jirovecii pneumonia (PJP); review the epidemiology of patients presenting with PJP; and discuss the first and second-line pharmacological options for treatment and prophylaxis of PJP in this population. Data Sources: MEDLINE (1989-February 2016) searched. Terms searched included combinations of Pneumocystis jirovecii, Pneumocystis carinii, non-HIV, infected, patients, prevention, prophylaxis, Bactrim, treatment, AIDS, opportunistic, immunocompromised, cancer, and pathophysiology. Study Selection and Data Extraction: Articles included had the most relevant information on PJP pathophysiology, and first-/second-line treatment and prophylactic options. Inclusion criteria were met and evaluated with 43 sources. Data Synthesis: P jirovecii has a complicated life-cycle; it seeks to find compromised immune systems in order to replicate, causing life-threatening complications. With immunosuppressive medications coming to market for immunomodulating diseases, PJP has become a prevalent opportunistic infection in the non-HIV population. CD4+ lymphocyte count <200 cells/µL is the primary risk factor for PJP presentation in these patients. With data from clinical trials, trimethoprim/sulfamethoxazole (TMP/SMX) has become the primary treatment and prophylaxis of PJP in the non-HIV population, although second-line options are available. Conclusion: PJP is a health problem that may result in an increased concern as more immunomodulating medications to treat various disease states are developed. Patients on these drugs or those with immunosuppressive diseases should have their CD4+ count monitored. Health care providers should continue to use TMP/SMX as the primary option in non-HIV, immunocompromised patients for treatment and prophylaxis of PJP.
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15
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WANG LI, LIANG HAO, YE LI, JIANG JUNJUN, LIANG BINGYU, HUANG JIEGANG. Adjunctive corticosteroids for the treatment of Pneumocystis jiroveci pneumonia in patients with HIV: A meta-analysis. Exp Ther Med 2016; 11:683-687. [PMID: 26893666 PMCID: PMC4734213 DOI: 10.3892/etm.2015.2929] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 11/05/2015] [Indexed: 11/06/2022] Open
Abstract
The present study aimed to evaluate the effects of adjunctive corticosteroid treatment on Pneumocystis jiroveci pneumonia in patients with human immunodeficiency virus (HIV). A literature search of relevant randomized controlled trials (RCTs) published prior to March 2014 was performed using a number of websites, including PubMed, EMbase and Ovid, using the following keywords: Corticosteroids, glucocorticoide, cortisol, corticosterone, HIV/acquired immunodeficiency syndrome, P. jiroveci pneumonia, and PCP. All RCTs investigating the use of adjunctive corticosteroids for the treatment of P. jiroveci pneumonia in patients with HIV were evaluated in the present study. Stata 11.0 software was used to calculate the relative risk (RR) and 95% confidence interval (CI) following tests for consistency and potential biases. Six RCTs investigating a total of 548 patients were evaluated in the present meta-analysis. The experimental groups (n=270) demonstrated a mortality rate of 15.2% (n=41); as compared with 27.7% (n=77) in the control groups (n=278). The present meta-analysis demonstrated that the RR and 95% CI were 0.55 and 0.35-0.85 (P<0.05), respectively, following treatment with adjunctive corticosteroids. This result indicated that patients in the experimental group had a 0.55 times reduced risk of mortality compared with the control group. Therefore, the results of the present meta-analysis demonstrated that the administration of adjunctive corticosteroids for the treatment of P. jiroveci pneumonia in patients with HIV may reduce the mortality rate of patients in the early phase of the disease.
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Affiliation(s)
- LI WANG
- Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - HAO LIANG
- Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
- School of Public Health, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - LI YE
- Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
- School of Public Health, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - JUNJUN JIANG
- Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
- School of Public Health, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - BINGYU LIANG
- Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
- School of Public Health, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - JIEGANG HUANG
- Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
- School of Public Health, Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
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Creemers-Schild D, Kroon FP, Kuijper EJ, de Boer MGJ. Treatment of Pneumocystis pneumonia with intermediate-dose and step-down to low-dose trimethoprim-sulfamethoxazole: lessons from an observational cohort study. Infection 2015; 44:291-9. [PMID: 26471512 PMCID: PMC4889633 DOI: 10.1007/s15010-015-0851-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/07/2015] [Indexed: 11/29/2022]
Abstract
Background The recommended treatment of Pneumocystis jirovecii pneumonia (PCP) is high-dose trimethoprim–sulfamethoxazole (TMP–SMX) in an equivalent of TMP 15–20 mg/kg/day and SMX 75–100 mg/kg/day for 2 or 3 weeks. High rates of adverse events are reported with this dose, which raises the question if lower doses are possible. Methods All adult patients diagnosed with PCP in various immune dysfunctions and treated with TMP–SMX between January 1, 2003 and July 1, 2013 in a tertiary university hospital were included. Per institutional protocol, patients initiated treatment on intermediate-dose TMP–SMX (TMP 10–15 mg/kg/day) and could be stepped down to low-dose TMP–SMX (TMP 4–6 mg/kg/day) during treatment. Clinical variables at presentation, relapse rate and mortality rates were compared between intermediate- and step-down treatment groups by uni- and multivariate analyses. Results A total of 104 patients were included. Twenty-four patients (23 %) were switched to low-dose TMP–SMX after a median of 4.5 days (IQR 2.8–7.0 days). One relapse (4 %) occurred in the step-down group versus none in the intermediate-dose group. The overall 30-day mortality was 13 %. There was 1 death in the step-down group (4 %) compared to 13 deaths (16 %) in the intermediate-dose group. Conclusions We observed high cure rates of PCP by treatment with intermediate-dose TMP–SMX. In addition, a step-down strategy to low-dose TMP–SMX during treatment in selected patients appears to be safe and does not compromise the outcome of treatment.
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Affiliation(s)
- Dina Creemers-Schild
- Department of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Frank P Kroon
- Department of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Iriart X, Bouar ML, Kamar N, Berry A. Pneumocystis Pneumonia in Solid-Organ Transplant Recipients. J Fungi (Basel) 2015; 1:293-331. [PMID: 29376913 PMCID: PMC5753127 DOI: 10.3390/jof1030293] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/01/2015] [Accepted: 09/02/2015] [Indexed: 12/27/2022] Open
Abstract
Pneumocystis pneumonia (PCP) is well known and described in AIDS patients. Due to the increasing use of cytotoxic and immunosuppressive therapies, the incidence of this infection has dramatically increased in the last years in patients with other predisposing immunodeficiencies and remains an important cause of morbidity and mortality in solid-organ transplant (SOT) recipients. PCP in HIV-negative patients, such as SOT patients, harbors some specificity compared to AIDS patients, which could change the medical management of these patients. This article summarizes the current knowledge on the epidemiology, risk factors, clinical manifestations, diagnoses, prevention, and treatment of Pneumocystis pneumonia in solid-organ transplant recipients, with a particular focus on the changes caused by the use of post-transplantation prophylaxis.
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Affiliation(s)
- Xavier Iriart
- Department of Parasitology-Mycology, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Institut Fédératif de biologie (IFB), 330 avenue de Grande Bretagne, TSA 40031, Toulouse 31059, France.
- INSERM U1043, Toulouse F-31300, France.
- CNRS UMR5282, Toulouse F-31300, France.
- Université de Toulouse, UPS, Centre de Physiopathiologie de Toulouse Purpan (CPTP), Toulouse F-31300, France.
| | - Marine Le Bouar
- Department of Parasitology-Mycology, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Institut Fédératif de biologie (IFB), 330 avenue de Grande Bretagne, TSA 40031, Toulouse 31059, France.
- INSERM U1043, Toulouse F-31300, France.
- CNRS UMR5282, Toulouse F-31300, France.
- Université de Toulouse, UPS, Centre de Physiopathiologie de Toulouse Purpan (CPTP), Toulouse F-31300, France.
| | - Nassim Kamar
- INSERM U1043, Toulouse F-31300, France.
- Université de Toulouse, UPS, Centre de Physiopathiologie de Toulouse Purpan (CPTP), Toulouse F-31300, France.
- Department of Nephrology and Organ Transplantation, CHU Rangueil, TSA 50032, Toulouse 31059, France.
| | - Antoine Berry
- Department of Parasitology-Mycology, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Institut Fédératif de biologie (IFB), 330 avenue de Grande Bretagne, TSA 40031, Toulouse 31059, France.
- INSERM U1043, Toulouse F-31300, France.
- CNRS UMR5282, Toulouse F-31300, France.
- Université de Toulouse, UPS, Centre de Physiopathiologie de Toulouse Purpan (CPTP), Toulouse F-31300, France.
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Mori S, Sugimoto M. Pneumocystis jirovecii Pneumonia in Rheumatoid Arthritis Patients: Risks and Prophylaxis Recommendations. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:29-40. [PMID: 26396551 PMCID: PMC4562607 DOI: 10.4137/ccrpm.s23286] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 01/05/2023]
Abstract
Pneumocystis jirovecii infection causes fulminant interstitial pneumonia (Pneumocystis pneumonia, PCP) in patients with rheumatoid arthritis (RA) who are receiving biological and/or nonbiological antirheumatic drugs. Recently, we encountered a PCP outbreak among RA outpatients at our institution. Hospital-acquired, person-to-person transmission appears to be the most likely mode of this cluster of P. jirovecii infection. Carriage of P. jirovecii seems a time-limited phenomenon in immunocompetent hosts, but in RA patients receiving antirheumatic therapy, clearance of this organism from the lungs is delayed. Carriers among RA patients can serve as sources and reservoirs of P. jirovecii infection for other susceptible patients in outpatient facilities. Development of PCP is a matter of time in such carriers. Considering the poor survival rates of PCP cases, prophylactic antibiotics should be considered for RA patients who are scheduled to receive antirheumatic therapy. Once a new case of PCP occurs, we should take prompt action not only to treat the PCP patient but also to prevent other patients from becoming new carriers of P. jirovecii. Short-term prophylaxis with trimethoprim-sulfamethoxazole is effective in controlling P. jirovecii infection and preventing future outbreaks of PCP among RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Mineharu Sugimoto
- Division of Respiratory Medicine, Department of Medicine, Social Insurance Omuta Tenryo Hospital, Fukuoka, Japan
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Cooley L, Dendle C, Wolf J, Teh BW, Chen SC, Boutlis C, Thursky KA. Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. Intern Med J 2015; 44:1350-63. [PMID: 25482745 DOI: 10.1111/imj.12599] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pneumocystis jirovecii infection (PJP) is a common cause of pneumonia in patients with cancer-related immunosuppression. There are well-defined patients who are at risk of PJP due to the status of their underlying malignancy, treatment-related immunosuppression and/or concomitant use of corticosteroids. Prophylaxis is highly effective and should be given to all patients at moderate to high risk of PJP. Trimethoprim-sulfamethoxazole is the drug of choice for prophylaxis and treatment, although several alternative agents are available.
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Affiliation(s)
- L Cooley
- Department of Microbiology and Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania
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20
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Grubbs JA, Baddley JW. Pneumocystis jirovecii pneumonia in patients receiving tumor-necrosis-factor-inhibitor therapy: implications for chemoprophylaxis. Curr Rheumatol Rep 2015; 16:445. [PMID: 25182673 DOI: 10.1007/s11926-014-0445-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an important opportunistic infection that has been increasingly reported in patients with rheumatic disease. Reported incidence among patients taking TNF inhibitors (TNFi) has varied, but has usually been low. Still, disease causes significant mortality among those affected and must be considered in patients with rheumatological disease presenting with dyspnea and cough. Diagnosis can be difficult in the non-HIV population, and our understanding of the epidemiology and natural history after exposure is changing. Trimethoprim-sulfamethoxazole is believed to be the most effective agent for treatment and prophylaxis, but is associated with significant adverse effects. Given the low incidence reported in most studies of patients on TNFi, prophylaxis is probably not beneficial for this patient population as a whole.
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Affiliation(s)
- James A Grubbs
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, 1900 University Boulevard, 229 Tinsley Harrison Tower, Birmingham, AL, 35294-0006, USA
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Khodavaisy S, Mortaz E, Mohammadi F, Aliyali M, Fakhim H, Badali H. Pneumocystis jirovecii colonization in Chronic Obstructive Pulmonary Disease (COPD). Curr Med Mycol 2015; 1:42-48. [PMID: 28680980 PMCID: PMC5490321 DOI: 10.18869/acadpub.cmm.1.1.42] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with a chronic inflammatory response in airways and lung parenchyma that results in significant morbidity and mortality worldwide. Cigarette smoking considered as an important risk factor plays a role in pathogenesis of disease. Pneumocystis jirovecii is an atypical opportunistic fungus that causes pneumonia in immunosuppressed host, although the low levels of its DNA in patients without signs and symptoms of pneumonia, which likely represents colonization. The increased prevalence of P. jirovecii colonization in COPD patients has led to an interest in understanding its role in the disease. P. jirovecii colonization in these patients could represent a problem for public health since colonized patients could act as a major reservoir and source of infection for susceptible subjects. Using sensitive molecular techniques, low levels of P. jirovecii DNA have been detected in the respiratory tract of certain individuals. It is necessary to elucidate the role of P. jirovecii colonization in the natural history of COPD patients in order to improve the clinical management of this disease. In the current review paper, we discuss P. jirovecii colonization in COPD patients.
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Affiliation(s)
- S Khodavaisy
- Department of Medical Parasitology and Mycology, Kurdistan University of Medical Sciences, Sanandaj, Iran.,Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - E Mortaz
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - F Mohammadi
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - M Aliyali
- Pulmonary and Critical Care Division, Mazandaran University of Medical Sciences, Sari, Iran
| | - H Fakhim
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - H Badali
- Department of Medical Mycology and Parasitology/Invasive Fungi Research Center, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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Multicenter study of trimethoprim/sulfamethoxazole-related hepatotoxicity: incidence and associated factors among HIV-infected patients treated for Pneumocystis jirovecii pneumonia. PLoS One 2014; 9:e106141. [PMID: 25184238 PMCID: PMC4153565 DOI: 10.1371/journal.pone.0106141] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/28/2014] [Indexed: 12/13/2022] Open
Abstract
The incidence of hepatotoxicity related to trimethoprim/sulfamethoxazole (TMP/SMX) administered at a therapeutic dose may vary among study populations of different ethnicities and hepatotoxic metabolites of TMP/SMX may be decreased by drug-drug interaction with fluconazole. We aimed to investigate the incidence of hepatotoxicity and the role of concomitant use of fluconazole in HIV-infected patients receiving TMP/SMX for Pneumocystis jirovecii pneumonia. We reviewed medical records to collect clinical characteristics and laboratory data of HIV-infected patients who received TMP/SMX for treatment of P. jirovecii pneumonia at 6 hospitals around Taiwan between September 2009 and February 2013. Hepatotoxicity was defined as 2-fold or greater increase of aminotransferase or total bilirubin level from baselines. Roussel UCLAF Causality Assessment Method (RUCAM) was used to analyze the causality of drug-induced liver injuries. NAT1 and NAT2 acetylator types were determined with the use of polymerase-chain-reaction (PCR) restriction fragment length polymorphism to differentiate common single-nucleotide polymorphisms (SNPs) predictive of the acetylator phenotypes in a subgroup of patients. During the study period, 286 courses of TMP/SMX treatment administered to 284 patients were analyzed. One hundred and fifty-two patients (53.1%) developed hepatotoxicity, and TMP/SMX was considered causative in 47 (16.4%) who had a RUCAM score of 6 or greater. In multivariate analysis, concomitant use of fluconazole for candidiasis was the only factor associated with reduced risk for hepatotoxicity (adjusted odds ratio, 0.372; 95% confidence interval, 0.145–0.957), while serostatus of hepatitis B or C virus, NAT1 and NAT2 acetylator types, or receipt of combination antiretroviral therapy was not. The incidence of hepatotoxicity decreased with an increasing daily dose of fluconazole up to 4.0 mg/kg. We conclude that the incidence of TMP/SMX-related hepatotoxicity was 16.4% in HIV-infected Taiwanese patients who received TMP/SMX for pneumocystosis. Concomitant use of fluconazole was associated with decreased risk for TMP/SMX-related hepatotoxicity.
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23
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Lee KY, Huang CH, Tang HJ, Yang CJ, Ko WC, Chen YH, Lee YC, Hung CC. Acute psychosis related to use of trimethoprim/sulfamethoxazole in the treatment of HIV-infected patients with Pneumocystis jirovecii pneumonia: a multicentre, retrospective study. J Antimicrob Chemother 2012; 67:2749-54. [DOI: 10.1093/jac/dks283] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Muñoz C, Zuluaga A, Restrepo A, Tobón A, Cano LE, Gonzalez A. Molecular diagnosis and detection of Pneumocystis jirovecii DHPS and DHFR genotypes in respiratory specimens from Colombian patients. Diagn Microbiol Infect Dis 2012; 72:204-13. [PMID: 22321995 DOI: 10.1016/j.diagmicrobio.2011.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 11/17/2011] [Accepted: 11/19/2011] [Indexed: 11/16/2022]
Abstract
A total of 98 respiratory specimens from 88 patients suspected of having Pneumocystis jirovecii pneumonia (PcP) were evaluated using a previously reported nested polymerase chain reaction (PCR) assay for mitochondrial large subunit rRNA (mtLSUrRNA). In addition, samples from patients with other pulmonary infections and a sizeable DNA collection from other fungal pathogens were studied. A panfungal PCR assay amplifying the ITS1-ITS2 regions were also used to identify all fungal DNAs. All samples positive for mtLSUrRNA-PCR were evaluated to determine mutations in dihydropteroate synthase (DHPS) and dihydrofolate reductase (DHFR) genes. All PCR-amplified products were sequenced. Of the 98 clinical specimens, 13 (13.2%) were positive by GMS stain and mtLSUrRNA-PCR, while 32 (32.6%) that were GMS stain-negative gave positive results with mtLSUrRNA-PCR. All the sequences corresponding to the 45 products amplified by mtLSUrRNA-PCR showed 99% or greater identity with P. jirovecii. The mtLSUrRNA-PCR exhibited 86% sensitivity and 98% and 96.6% specificity when results were compared to those corresponding to negative controls and other proven clinical entities, respectively. We found mutations in the DHPS gene in 3 (7.7%) patients, 2 located at codon 55 and 1 at codon 57. One patient showed a synonymous substitution at nucleotide position 312 in the DHFR gene. These results suggest that mtLSUrRNA-PCR is a useful test for diagnosing PcP. In contrast to other studies, this study found a low prevalence of mutations in the DHPS and DHFR genes in Colombian patients.
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Affiliation(s)
- Cesar Muñoz
- Medical and Experimental Mycology Group, Corporación para Investigaciones Biológicas, Medellín, Colombia
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25
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Seddon J, Bhagani S. Antimicrobial therapy for the treatment of opportunistic infections in HIV/AIDS patients: a critical appraisal. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2011; 3:19-33. [PMID: 22096404 PMCID: PMC3218711 DOI: 10.2147/hiv.s9274] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The widespread use of antiretroviral therapy (ART) has entirely changed the management of human immunodeficiency virus (HIV) infection and dramatically reduced the rates of opportunistic infections (OI). However, OI continue to cause significant morbidity and mortality in both developed countries, where presentation with advanced HIV infection is common, and also in developing countries where ART is less widely available. Evidence to direct OI guidelines is partly limited by the fact that many large-scale studies date from the pre-ART era and more recent studies are sometimes poorly powered due to the falling rates of OI. Treatment of OI is now known to be as much about antimicrobials as about immune reconstitution with ART, and recent studies help guide the timing of initiation of ART in different infections. OI have also become complicated by the immune reconstitution inflammatory syndrome phenomenon which may occur once successful immune recovery begins. Trimethoprim-sulfamethoxazole has long been one of the most important antibiotics in the treatment and prevention of OI and remains paramount. It has a broad spectrum of activity against Pneumocystis jiroveci, toxoplasmosis, and bacterial infections and has an important role to play in preventing life-threatening OI. New advances in treating OI are coming from a variety of quarters: in cytomegalovirus eye disease, the use of oral rather than intravenous drugs is changing the face of therapy; in cryptococcal meningitis, improved drug formulations and combination therapy is improving clearance rates and reducing drug toxicities; and in gut disease, the possibility of rapid immune restitution with ART is replacing the need for antimicrobials against cryptosporidia and microsporidia.
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Affiliation(s)
- Jo Seddon
- Department of Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
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Catherinot E, Lanternier F, Bougnoux ME, Lecuit M, Couderc LJ, Lortholary O. Pneumocystis jirovecii Pneumonia. Infect Dis Clin North Am 2010; 24:107-38. [PMID: 20171548 DOI: 10.1016/j.idc.2009.10.010] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pneumocystis jirovecii has gained attention during the last decade in the context of the AIDS epidemic and the increasing use of cytotoxic and immunosuppressive therapies. This article summarizes current knowledge on biology, pathophysiology, epidemiology, diagnosis, prevention, and treatment of pulmonary P jirovecii infection, with a particular focus on the evolving pathophysiology and epidemiology. Pneumocystis pneumonia still remains a severe opportunistic infection, associated with a high mortality rate.
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Affiliation(s)
- Emilie Catherinot
- Université Paris Descartes, Service de Maladies Infectieuses et Tropicales, 149 Rue de Sèvres, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris 75015, France
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Castro JG, Morrison-Bryant M. Management of Pneumocystis Jirovecii pneumonia in HIV infected patients: current options, challenges and future directions. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2010; 2:123-34. [PMID: 22096390 PMCID: PMC3218692 DOI: 10.2147/hiv.s7720] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The discovery of the Human Immunodeficiency Virus (HIV) was led by the merge of clustered cases of Pneumocystis jirovecii Pneumonia (PCP) in otherwise healthy people in the early 80’s.1,2 In the face of sophisticated treatment now available for HIV infection, life expectancy approaches normal limits. It has dramatically changed the natural course of HIV from a nearly fatal infection to a chronic disease.3–5 However, PCP still remains a relatively common presentation of uncontrolled HIV. Despite the knowledge and advances gained in the prevention and management of PCP infection, it continues to have high morbidity and mortality rates. Trimethoprim-sulfamethoxazole (TMP-SMZ) remains as the recommended first-line treatment. Alternatives include pentamidine, dapsone plus trimethoprim, clindamycin administered with primaquine, and atovaquone. For optimal management, clinicians need to be familiar with the advantages and disadvantages of the available drugs. The parameters used to classify severity of infection are also important, as it is well known that the adjunctive use of steroids in moderate to severe cases have been shown to significantly improve outcome. Evolving management practices, such as the successful institution of early antiretroviral therapy, may further enhance overall survival rates.
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Affiliation(s)
- Jose G Castro
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
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Helweg-Larsen J, Benfield T, Atzori C, Miller RF. Clinical efficacy of first- and second-line treatments for HIV-associated Pneumocystis jirovecii pneumonia: a tri-centre cohort study. J Antimicrob Chemother 2009; 64:1282-90. [PMID: 19858161 DOI: 10.1093/jac/dkp372] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES First-line therapy for Pneumocystis jirovecii pneumonia (PCP) is trimethoprim/sulfamethoxazole. Few data exist to guide the choice of second-line therapy for patients failing or developing toxicity to first-line therapy. METHODS A case note review of 1122 patients with 1188 episodes of HIV-associated PCP from three observational cohorts in Copenhagen, London and Milan, between 1989 and 2004, was conducted. RESULTS Trimethoprim/sulfamethoxazole (962 PCP episodes, 81%) was the most frequently used first-line therapy, followed by intravenous pentamidine (87 episodes, 7%), clindamycin/primaquine (72 episodes, 6%) and 'other' (atovaquone, dapsone/pyrimethamine, trimetrexate or inhaled pentamidine; 67 episodes, 6%). Rates of unchanged therapy were trimethoprim/sulfamethoxazole = 79%, clindamycin/primaquine = 65% and pentamidine = 60% (P < 0.001). First-line therapy was changed because of failure in 82 (7%) episodes and because of toxicity in 198 (17%) episodes. Three month survival rates were trimethoprim/sulfamethoxazole = 85%, clindamycin/primaquine = 81% and pentamidine = 76% (P = 0.09). After adjustment for possible confounders, pentamidine was associated with a significantly greater risk of death at 3 months [hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.2-3.4]. Second-line therapy survival rates differed: trimethoprim/sulfamethoxazole = 85%; clindamycin/primaquine = 87%; and pentamidine = 60% (P = 0.01). Multivariable time-updated Cox regression analysis showed a greater risk of death associated with pentamidine (HR = 3.3, 95% CI = 2.2-5.0), but not for clindamycin/primaquine, when both were compared with trimethoprim/sulfamethoxazole. CONCLUSIONS Pentamidine was associated with a greater risk of death when used as first- and second-line therapy for HIV-associated PCP, and was associated with more treatment changes. Clindamycin/primaquine appeared superior to pentamidine as second-line therapy for PCP in patients failing or developing toxicity with trimethoprim/sulfamethoxazole. In patients failing first-line treatment with non-trimethoprim/sulfamethoxazole regimens, second-line therapy should be trimethoprim/sulfamethoxazole.
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Affiliation(s)
- Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark.
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Fisk M, Sage EK, Edwards SG, Cartledge JD, Miller RF. Outcome from treatment of Pneumocystis jirovecii pneumonia with co-trimoxazole. Int J STD AIDS 2009; 20:652-3. [DOI: 10.1258/ijsa.2009.008470] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A retrospective case-notes audit of 359 HIV-1-infected adult patients with first-episode laboratory-confirmed Pneumocystis jirovecii pneumonia treated with co-trimoxazole (from 1987 adjuvant steroids were used if PaO2 <9.3 kPa) showed that only 230/359 (64%) patients completed treatment; 104 (29%) patients had treatment-limiting toxicity; rash occurred in 4/60 (6.7%) patients in 1985–1988 and in 15/47 (31.9%) in 2005–2008. Twenty-five patients (7%) failed co-trimoxazole treatment. Overall mortality was 13.6% (49/359); mortality among patients who failed co-trimoxazole treatment was 48% (12/25) and by contrast mortality was 4.8% (5/104) among patients with treatment-limiting toxicity.
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Affiliation(s)
- M Fisk
- Department of Genitourinary Medicine, Camden Provider Services PCT, Mortimer Market Centre, London WC1E 6JB
- T8, University College London Hospitals, London NW1 8BU
| | - E K Sage
- T8, University College London Hospitals, London NW1 8BU
| | - S G Edwards
- Department of Genitourinary Medicine, Camden Provider Services PCT, Mortimer Market Centre, London WC1E 6JB
| | - J D Cartledge
- Department of Genitourinary Medicine, Camden Provider Services PCT, Mortimer Market Centre, London WC1E 6JB
- T8, University College London Hospitals, London NW1 8BU
| | - R F Miller
- T8, University College London Hospitals, London NW1 8BU
- Department of Infection and Population Health, University College London Medical School, University College London, London W1E 6JB, UK
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Abstract
The best management strategy for HIV patients who fail to respond to first-line therapy for Pneumocystis jirovecii pneumonia is currently unclear. We identified all patients who were treated with trimetrexate and folinic acid who failed 7 or more days of cotrimoxazole, clindamycin-primaquine or dapsone-trimethoprim between 1996 and 2006. Trimetrexate was tolerated in 100% of cases with no treatment termination secondary to adverse drug reactions. Despite severe disease, 71% of patients were alive after 12 weeks.
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Shibayama M, Rivera-Aguilar V, Barbosa-Cabrera E, Rojas-Hernández S, Jarillo-Luna A, Tsutsumi V, Pacheco-Yepez J, Campos-Rodríguez R. Innate immunity prevents tissue invasion by Entamoeba histolytica. Can J Microbiol 2009; 54:1032-42. [PMID: 19096458 DOI: 10.1139/w08-106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although innate and adaptive immunity both play a role in amoebiasis, the mechanisms involved in the elimination of Entamoeba histolytica are poorly understood. To provide more information about the innate immune mechanisms that may confer protection against invasive amoebiasis, we administered inflammatory substances (bacillus Calmette-Guérin, lipopolysaccharide, complete Freund's adjuvant, or mineral oil) into the peritoneum of hamsters. The animals were then challenged with pathogenic trophozoites of E. histolytica and, after 7 days, the protective host response was analysed. We found that the nonspecific inflammatory response induced in the peritoneum was sufficient to prevent liver invasion by E. histolytica. In vitro experiments showed that the killing of trophozoites was mediated by peritoneal macrophages and a protein of 68 kDa with peroxidase activity.
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Affiliation(s)
- Mineko Shibayama
- Department of Experimental Pathology, CINVESTAV-IPN, Av. IPN No.2508 Zacatenco, CP07360, Mexico, DF
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Severe and long lasting cholestasis after high-dose co-trimoxazole treatment for Pneumocystis pneumonia in HIV-infected patients--a report of two cases. Int J Infect Dis 2009; 13:e467-9. [PMID: 19299179 DOI: 10.1016/j.ijid.2008.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2008] [Revised: 11/25/2008] [Accepted: 12/15/2008] [Indexed: 01/22/2023] Open
Abstract
Pneumocystis pneumonia (PCP), a common opportunistic infection in HIV-infected individuals, is generally treated with high doses of co-trimoxazole. However, treatment is often limited by adverse effects. Here, we report two cases of severely immunocompromised HIV-infected patients who developed severe intrahepatic cholestasis, and in one patient lesions mimicking liver abscess formation on radiologic exams, during co-trimoxazole treatment for PCP. Whereas patient 1 showed lesions of up to 1 cm readily detectable on magnetic resonance imaging under prolonged co-trimoxazole treatment, therapy of patient 2 was switched early.
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Kim T, Kim SH, Park KH, Cho O, Choi SH, Jeong JY, Woo JH, Kim YS, Lee SO, Sung H, Kim MN. Clindamycin-primaquine versus pentamidine for the second-line treatment of pneumocystis pneumonia. J Infect Chemother 2009; 15:343-6. [DOI: 10.1007/s10156-009-0710-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 06/12/2009] [Indexed: 01/15/2023]
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[Treatment of opportunistic infections in adolescent and adult patients infected with the human immunodeficiency virus during the era of highly active antiretroviral therapy. AIDS Study Group (GESIDA) and National AIDS Plan Expert Committee]. Enferm Infecc Microbiol Clin 2008; 26:356-79. [PMID: 18588819 DOI: 10.1157/13123842] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite the huge advance that highly active antiretroviral therapy has represented for the prognosis of infection by human immunodeficiency virus (HIV), opportunistic infections continue to be a cause of morbidity and mortality in HIV-infected patients. This is often the case because of severe immunodepression, poor adherence to antiretroviral therapy, failure of therapy, or the fact that patients are unaware of their HIV-positive status and debut with an opportunistic infection. This article updates the guidelines on treatment of acute episodes of various opportunistic infections in HIV-infected patients, including infections due to parasites, fungi, viruses, mycobacteria, and bacteria. This edition has a new chapter on imported parasite infections as well as additional information on endemic mycoses in the chapter on fungal infections, taking into account the growing number of immigrants in our setting. Lastly, the chapter on the immune reconstitution syndrome has also been updated, providing relevant data on a phenomenon that has clinical and diagnostic repercussions in patients who start antiretroviral therapy while they are severely immunodepressed (English version available at http://www.gesida.seimc.org).
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35
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Second-Line Salvage Treatment of AIDS-Associated Pneumocystis jirovecii Pneumonia. J Acquir Immune Defic Syndr 2008; 48:63-7. [DOI: 10.1097/qai.0b013e31816de84d] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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36
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Chen D, Marsh R, Aberg JA. Pafuramidine for Pneumocystis jiroveci pneumonia in HIV-infected individuals. Expert Rev Anti Infect Ther 2008; 5:921-8. [PMID: 18039076 DOI: 10.1586/14787210.5.6.921] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pneumocystis jiroveci pneumonia remains one of the major worldwide contributors to the morbidity and mortality of those with HIV infection. The mainstay of therapy for treatment is trimethoprim-sulfamethoxazole (TMP-SMX); however TMP-SMX may be associated with significant side effects and intolerability. In addition, TMP-SMX has a moderate pill burden with three- to four-times daily dosing schedule. Patients unable to tolerate TMP-SMX are confronted with either parenteral therapy or other oral agents that may be less efficacious or are associated with potential serious adverse reactions. Pafuramidine (DB289) is an orally bioavailable prodrug of furamidine (DB75), an investigational diamidine that is less toxic than previous diamidines such as pentamidine. To date, human trials suggest that pafuramidine is well tolerated overall and has clinical activity against Pneumocystis pneumonia. In this article, we review the available data for the use of pafuramidine in Pneumocystis pneumonia.
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Affiliation(s)
- Donald Chen
- New York University, Department of Medicine, Division of Infectious Disease, AIDS Clinical Trials Unit, Bellevue C and D Building, Room 558, 550 First Avenue, New York, NY 10016-6481, USA
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Abstract
Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) is a serious opportunistic infection in children and adolescents with cancer. It was the most common cause of death among children receiving chemotherapy prior to the inclusion of PCP prophylaxis as part of standard care for children with leukemia. The incidence of PCP has decreased significantly since initiation of prophylaxis; however, breakthrough cases continue to occur. Hematologic malignancies, brain tumors necessitating prolonged corticosteroid therapy, hematopoietic stem cell transplantation, prolonged neutropenia, and lymphopenia are the most important risk factors for PCP in children not infected with HIV. Of children with leukemia, 15-20% may develop PCP in the absence of prophylaxis. Infection with P. jiroveci occurs early in life in most individuals. However, clinically apparent disease occurs almost exclusively in immunocompromised persons. Dyspnea, cough, hypoxia, and fever are the most common presenting symptoms of PCP. Chest radiography and high-resolution CT scans of the chest demonstrate a characteristic ground-glass pattern. Induced sputum analysis and bronchoalveolar lavage are the diagnostic procedures of choice. Gomori's methenamine-silver stain, Geimsa or Wright's stain, and monoclonal immunofluorescent antibody stains are most commonly used to make a diagnosis. However, identification of P. jiroveci DNA using polymerase chain reaction assays in bronchoalveolar lavage fluid is more sensitive. Trimethoprim-sulfamethoxazole (TMP-SMZ; cotrimoxazole) is the recommended drug for the treatment of PCP. Patients who are intolerant of TMP-SMZ or who have not responded to treatment after 5-7 days of therapy with TMP-SMZ should be treated with pentamidine. A short course of corticosteroids is recommended for moderate to severe cases of PCP within the first 72 hours after diagnosis. Mutations in the dihydropteroate synthetase gene may confer resistance to TMP-SMZ; however, the clinical relevance of these mutations is not well established. TMP-SMZ is the most commonly used agent for prophylaxis. Myelosuppression is the most important adverse effect of TMP-SMZ and the most frequent cause for choosing alternative prophylactic agents in children undergoing chemotherapy. Alternative agents for chemoprophylaxis include dapsone, aerosolized pentamidine, and atovaquone. Alternative prophylactic agents must be used in patients developing myelosuppression secondary to TMP-SMZ or dapsone.
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Affiliation(s)
- Sadhna M Shankar
- Division of Pediatric Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-6310, USA.
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38
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Abstract
BACKGROUND Amebiasis cutis (AC) is reported infrequently. This study assesses the clinicopathological spectrum, co-existent visceral involvement and impact of human immunodeficiency virus (HIV) co-infection on AC. METHODS An 8-year prospective clinicopathological evaluation of patients with AC. RESULTS Thirty-one biopsies of ulcers, fistulae, fissures, abscesses, polypoid and warty lesions in perianal, penile, scrotal, vulval, buttock, chest and abdominal wall sites were evaluated. Of these, 11 had a 'superficial' (superficial AC) and 20 a 'deep' (deep AC), histopathological pattern. Superficial AC showed predominant epidermal spongiosis, liquefactive necrosis, ulceration and fissures with hematophagous amebic trophozoites (HATs). Deep AC had confluent deep dermal and subcutaneous liquefactive, coagulative or suppurative necrosis and HATs. Seven biopsies showed vasculitis or thrombosis with luminal HATs. OUTCOME Fourteen patients died; 9 had concomitant visceral amebiasis, 5 had other co-infections. Six who died were HIV seropositive, three were seronegative; all had deep AC. Of the 17 survivors, 11 (8 HIV positive) had superficial AC that healed with metronidazole treatment; the remaining 6 (one HIV seropositive) required additional surgical intervention. CONCLUSION Deep AC is predictive of co-existent, contiguous visceral disease. The effective management, histopathological mimickers and diagnostic pitfalls of superficial and deep AC differ. The outcome in HIV-infected patients is dependent on co-existent systemic diseases.
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Affiliation(s)
- Pratistadevi K Ramdial
- Department of Pathology, Nelson R Mandela School of Medicine, University of KwaZulu Natal and Inkosi Albert Luthuli Central Hospital, Congella 4013, Durban, KwaZulu Natal, South Africa
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39
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Bress JN, Hulgan T, Lyon JA, Johnston CP, Lehmann H, Sterling TR. Agreement of decision analyses and subsequent clinical studies in infectious diseases. Am J Med 2007; 120:461.e1-9. [PMID: 17466659 PMCID: PMC1909755 DOI: 10.1016/j.amjmed.2006.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 07/13/2006] [Accepted: 08/08/2006] [Indexed: 11/17/2022]
Abstract
PURPOSE Decision analysis techniques can compare management strategies when there are insufficient data from clinical studies to guide decision making. We compared the outcomes of decision analyses and subsequent clinical studies in the infectious disease literature to assess the validity of the conclusions of the decision analyses. METHODS A search strategy to identify decision analyses in infectious disease topics published from 1990 to 2005 was developed and performed using PubMed. Abstracts of all identified articles were reviewed, and infectious disease-related decision analyses were retained. Subsequent clinical trials and observational studies that corresponded to these decision analyses were identified using prespecified search strategies. Clinical studies were considered a match for the decision analysis if they assessed the same patient population, intervention, and outcome. Agreement or disagreement between the conclusions of the decision analysis and clinical study were determined by author review. RESULTS The initial PubMed search yielded 318 references. Forty decision analyses pertaining to 29 infectious disease topics were identified. Of the 40, 16 (40%) from 13 infectious disease topics had matching clinical studies. In 12 of 16 (75%), conclusions of at least 1 clinical study agreed with those of the decision analysis. Three of the 4 decision analyses in which conclusions disagreed were from the same topic (management of febrile children). CONCLUSIONS There was substantial agreement between the conclusions of decision analyses and clinical studies in infectious diseases, supporting the validity of decision analysis and its utility in guiding management decisions.
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Affiliation(s)
| | - Todd Hulgan
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN
- Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN
| | - Jennifer A. Lyon
- Eskind Biomedical Library, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Harold Lehmann
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy R. Sterling
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN
- Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN
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40
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Hui M, Kwok WT. Pneumocystis carinii pneumonia in Hong Kong: a 10 year retrospective study. J Med Microbiol 2006; 55:85-88. [PMID: 16388034 DOI: 10.1099/jmm.0.45893-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A retrospective review was performed of patients diagnosed with Pneumocystis carinii pneumonia (PCP) from 1994 to 2003 at the Prince of Wales Hospital in Hong Kong. Eighteen patients were identified. Six (33·3 %) were co-infected with human immunodeficiency virus (HIV). The remaining 12 non-HIV-infected patients had underlying diseases: three post-renal transplant recipients, three with haematological malignancies, two with auto-immune diseases, two with renal diseases, one with hepatocellular carcinoma and one with congenital cytomegalovirus disease. Cytomegalovirus co-infection was observed in four patients. All patients received cotrimoxazole therapy, with intolerance observed in four of them, including one with glucose-6-phosphate dehydrogenase deficiency, two with repeated vomiting and one with renal impairment. Overall crude mortality was 33·3 %. The results suggested that, apart from being a common infection for patients with HIV infection, PCP can occur during the course of many immunosuppressive diseases and therapies. The mortality of PCP was high despite appropriate treatment. Chemoprophylaxis should be considered in populations at risk.
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Affiliation(s)
- M Hui
- Department of Microbiology, The Chinese University of Hong Kong, The Prince of Wales Hospital, Shatin, Hong Kong SAR
| | - W T Kwok
- Department of Microbiology, The Chinese University of Hong Kong, The Prince of Wales Hospital, Shatin, Hong Kong SAR
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41
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Benson CA, Kaplan JE, Masur H, Pau A, Holmes KK. Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clin Infect Dis 2005. [DOI: 10.1086/427906] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Abstract
Pneumocystis jiroveci (P. carinii) is an opportunistic pathogen that has gained particular prominence since the onset of the AIDS epidemic. Among several important advances in diagnosis and management, appropriately targeting chemoprophylaxis to HIV-infected patients at high clinical risk for P. jiroveci pneumonia and the introduction of effective combination anti-retroviral therapy (including highly active antiretroviral therapy [HAART]) have contributed to the reduced incidence of P. jiroveci pneumonia. Despite the success of these clinical interventions, P. jiroveci pneumonia remains the most common opportunistic pneumonia and the most common life-threatening infectious complication in HIV-infected patients. Trimethoprim/sulfamethoxazole (cotrimoxazole) remains the first-line agent for effective therapy and chemoprophylaxis, and corticosteroids represent an important adjunctive agent in the treatment of moderate-to-severe P. jiroveci pneumonia. However, problems of chemoprophylaxis and treatment failures, high rates of adverse drug reactions and drug intolerance to first-line antimicrobials, high rates of relapse or recurrence with second-line agents, and newer concerns about the development of P. jiroveci drug resistance represent formidable challenges to the management and treatment of AIDS-related P. jiroveci pneumonia. With the expanding global problem of HIV infection, the intolerance or unavailability of HAART to many individuals and limited access to healthcare for HIV-infected patients, P. jiroveci pneumonia will remain a major worldwide problem in the HIV-infected population. New drugs under development as anti-Pneumocystis agents such as echinocandins and pneumocandins, which inhibit beta-glucan synthesis, or sordarins, which inhibit fungal protein synthesis, show promise as effective agents. Continued basic research into the biology and genetics of P. jiroveci and host defense response to P. jiroveci will allow the development of newer antimicrobials and immunomodulatory therapeutic agents to more effectively treat life-threatening pneumonia caused by this organism.
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Affiliation(s)
- Naimish Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, 330 Brookline Avenue, Boston, MA 02115, USA
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43
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Santamauro JT, Aurora RN, Stover DE. Pneumocystis carinii pneumonia in patients with and without HIV infection. COMPREHENSIVE THERAPY 2002; 28:96-108. [PMID: 12085467 DOI: 10.1007/s12019-002-0047-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Advances in the prevention and treatment of Pneumocystis carinii pneumonia in HIV infected patients have led to a decrease in the incidence and improved outcomes. Pneumocystis carinii pneumonia continues to be problematic in non-HIV infected immunocompromised patients.
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Affiliation(s)
- Jean T Santamauro
- Pulmonary Service, Memorial Sloan-Kettering Cancer Center, Room MRI 1013, 1275 York Avenue, New York, NY 10021, USA
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Podzamczer D, Ramón Arribas J, Mallolas J, María Peña J, Pulido F. [Treatment of opportunistic infections among adult and adolescent patients infected with the human immunodeficiency virus in the era of highly active anti-retroviral therapy]. Enferm Infecc Microbiol Clin 2001; 19:376-92. [PMID: 11602139 DOI: 10.1016/s0213-005x(01)72670-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D Podzamczer
- Ciutat Sanitària i Universitària de Bellvitge, Barcelona, Spain.
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45
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Barry SM, Johnson MA. Pneumocystis carinii pneumonia: a review of current issues in diagnosis and management. HIV Med 2001; 2:123-32. [PMID: 11737389 DOI: 10.1046/j.1468-1293.2001.00062.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- S M Barry
- Department of Thoracic and HIV Medicine, Royal Free Hospital, London, UK.
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Helweg-Larsen J, Eugen-Olsen J, Lundgren B. Rapid detection of dihydropteroate polymorphism in AIDS-related Pneumocystis carinii pneumonia by restriction fragment length polymorphism. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2001; 32:481-3. [PMID: 11055650 DOI: 10.1080/003655400458730] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Sulpha agents, which act by inhibiting the enzyme dihydropteroate synthase (DHPS), are used widely for the treatment and prophylaxis of Pneumocystis carinii pneumonia (PCP). Recently, we have shown that mutations in the dihydropteroate synthase (DHPS) gene of Pneumocystis carinii f.sp hominis are associated with failure of sulpha prophylaxis and increased mortality in HIV-1 positive patients with PCP, suggesting that DHPS mutations may cause sulpha resistance. To facilitate detection of DHPS mutations we developed a restriction fragment length polymorphism (RFLP) assay, detecting mutations at codon 55 and 57 of the P. carinii DHPS gene. The RFLP-assay was compared with direct DNA sequencing on 27 PCP isolates from HIV-1 positive patients with a mixture of wildtype and mutant DHPS types. In all samples the RFLP-assay correctly identified wildtype or DHPS mutation at codon 55 or 57. Combined with DNA extraction by a Chelex-based method, this method can be performed within 1 d and allows a fast, cost-efficient and reliable method of detection of DHPS mutations in P. carinii.
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Affiliation(s)
- J Helweg-Larsen
- Department of Infectious Diseases, University of Copenhagen, Hvidovre Hospital, Denmark
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47
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Purdy BD. Management and Prevention of Opportunistic Infections in the HIV-Infected Patient. J Pharm Pract 2000. [DOI: 10.1106/jdyc-jyvc-xjaa-lj1f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
With the introduction of potent antiretroviral therapy, the incidence of opportunistic infections (OIs) as well as death has dramatically decreased since 1996. Opportunistic infections are seen mainly in three groups: (1) newly diagnosed patients not receiving antiretroviral therapy and presenting with an OI, (2) patients nonadherent to antiretroviral and OI treatment regimens or (3) patients whose antiretroviral therapy has failed. This article will review the most common opportunistic infections (OIs) seen in the HIV-infected individual and their treatment. The current guidelines for the prophylaxis against these OIs will also be discussed.
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Affiliation(s)
- Bonnie D. Purdy
- Albany Medical Center, Mail-code 85, 43 New Scotland Avenue, Albany, New York 12208,
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Abstract
Acute pancreatitis is a clinical condition that develops when active pancreatic inflammation is induced by stimuli noxious to the pancreas. Patients infected with human immunodeficiency virus (HIV) often have histologic abnormalities of the pancreas, and acute pancreatitis is much more common in HIV-infected patients than in the general population. This article reviews the epidemiology and etiology of acute pancreatitis in HIV-infected patients. The clinical presentation and treatment of acute pancreatitis in HIV-infected patients are also reviewed.
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Affiliation(s)
- T Dassopoulos
- Department of Medicine, University of Chicago Hospitals, Illinois 60637, USA
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49
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Klinker H, Langmann P, Zilly M, Richter E. Drug monitoring during the treatment of AIDS-associated Pneumocystis carinii pneumonia with trimethoprim-sulfamethoxazole. J Clin Pharm Ther 1998; 23:149-54. [PMID: 9786102 DOI: 10.1046/j.1365-2710.1998.00152.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To monitor trimethoprim and sulfamethoxazole plasma levels in patients with AIDS-associated Pneumocystis carinii pneumonia. METHOD Trimethoprim-sulfamethoxazole steady-state plasma concentrations were measured by high-pressure liquid chromatography during 37 episodes of Pneumocystis carinii pneumonia in patients with AIDS. Initially, 15-23 mg/kg/day trimethoprim and 75-115 mg/kg/day sulfamethoxazole were given i.v. Assuming a therapeutic range for trimethoprim from 4 to 10 microg/ml, the doses were adjusted if trimethoprim levels were found to be outside this range. RESULTS Mean concentrations were 6.7+/-3.3 g/ml for trimethoprim and 187+/-56 microg/ml for sulfamethoxazole. A widespread inter-patient range was found and could be decreased after dose adjustment. Enzyme inducing co-medication did not influence plasma concentrations. In patients with coexisting chronic liver disease, significantly increased sulfamethoxazole plasma levels were observed. A correlation could be demonstrated between serum creatinine and trimethoprim plasma levels. Adverse reactions associated with co-trimoxazole occurred during 65% of treatment periods and increased with increasing trimethoprim-sulfamethoxazole levels, as well as increasing length of treatment. Therapy only had to be prematurely discontinued in one patient. Overall mortality was 2.7% CONCLUSION Monitoring of co-trimoxazole levels during the treatment of P. carinii pneumonia in AIDS may help in reducing the high variability of plasma-concentrations and in avoiding severe side-effects especially associated in patients with chronic liver disease or renal failure.
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Affiliation(s)
- H Klinker
- Klinikum der Universität, Medizinische Klinik, Schwerpunkt Hepatologie/Infektiologie, Würzburg, Germany
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Abstract
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.
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Affiliation(s)
- C F Decker
- Division of Infectious Diseases, National Naval Medical Center, Bethesda, Maryland, USA
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