Effects of long-term aerosol pentamidine for Pneumocystis carinii prophylaxis on pulmonary function

Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors: 2020 updated guidelines of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO/DGHO)

Hematologic and oncologic patients with chemo- or immunotherapy-related immunosuppression are at substantial risk for bacterial infections and Pneumocystis jirovecii pneumonia (PcP). As bacterial resistances are increasing worldwide and new research reshapes our understanding of the interactions between the human host and bacterial commensals, administration of antibacterial prophylaxis has become a matter of discussion. This guideline constitutes an update of the 2013 published guideline of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO). It gives an overview about current strategies for antibacterial prophylaxis in cancer patients while taking into account the impact of antibacterial prophylaxis on the human microbiome and resistance development. Current literature published from January 2012 to August 2020 was searched and evidence-based recommendations were developed by an expert panel. All recommendations were discussed and approved in a consensus conference of the AGIHO prior to publication. As a result, we present a comprehensive update and extension of our guideline for antibacterial and PcP prophylaxis in cancer patients.

Fatal bilateral pneumothoraces following administration of aerosolised pentamidine

Aerosolised pentamidine (AP) is used for prophylaxis against infection with Pneumocystis jiroveci (carinii), a significant cause of morbidity and mortality for people with human immunodeficiency virus (HIV). In this article we report a 55 year old man with HIV and a background history of asthma since childhood, who suffered respiratory arrest and died within an hour of commencing AP prophylaxis. Autopsy revealed bilateral pneumothoraces. Common side effects of AP therapy include bronchospasm and coughing. Pneumothorax has been reported in several cases. To our knowledge, this is the first reported fatality from bilateral pneumothoraces.

The pulmonary effects of long-term exposure to aerosol pentamidine: a 5-year surveillance study in HIV-infected patients

STUDY OBJECTIVES

To assess the effects of long-term exposure to aerosolized pentamidine (AP) for the prophylaxis of Pneumocystis carinii pneumonia on the pulmonary function.

DESIGN

The results of pulmonary function tests (PFTs) over a period of 5 years were retrospectively analyzed in a cohort of HIV-infected individuals.

SETTING

A government-funded AP clinic in a large metropolitan center in Canada.

PATIENTS

Among the cohort of 1,850 HIV-positive patients who received regular AP prophylaxis between 1989 and 2001 at the AP clinic, 83 received AP for >or= 5 years. Of these 83 patients, baseline and long-term follow-up PFT data were available for 79. These subjects formed the study population for this analysis.

RESULTS

The cohort was divided according to smoking status (smokers, 48%). The rate of decline of FEV(1) in the smokers over the 5-year period was statistically significant but was comparable to that expected of healthy smokers. As for the nonsmokers, there was no significant reduction in FEV(1). Flow rates at low lung volumes (ie, forced expiratory flow at 50% and 75% of FEV(1)) and low FEV(1)/FVC ratios showed significant declines in both smokers and nonsmokers. On the other hand, no significant changes in FVC, total lung capacity, residual volume, or diffusing capacity of the lung for carbon monoxide were observed. The apparent slight reduction in flow rates seems to be at the level of the small airways.

CONCLUSIONS

The PFT data suggest that AP can be well-tolerated over a 5-year period in HIV-infected patients with only modest reduction in flow rates at the level of the small airways, especially in smokers.

Aerosolized pentamidine prophylaxis against AIDS-related Pneumocystis carinii pneumonia and its short- and long-term effects on pulmonary function in the Japanese

We evaluated the incidence of prophylaxis failure with aerosolized pentamidine (AP) for Pneumocystis carinii pneumonia (PCP) in Japanese patients with human immunodeficiency virus (HIV) infection, and we examined the short- and long-term effects of AP on pulmonary function. The patients inhaled 300 mg of pentamidine by ultrasonic nebulizer, after the inhalation of procaterol (80 micrograms), every 4 weeks. PCP developed in 2 of 16 patients receiving primary prophylaxis with AP, and in 4 of 13 patients with secondary prophylaxis. The CD4(+) T-lymphocyte count was very low in the patients with prophylaxis failure. The chest radiographic presentations were atypical in 4 of the 6 patients with prophylaxis failure. There were no significant changes in the vital capacity (VC), VC/predictive VC (%VC), forced expiratory volume in 1 s (FEV(1.0)), FEV(1.0)/forced vital capacity (FEV(1.0)%), and maximum expiratory flow rate at 25% of vital capacity (MEF(25))/height comparing values before and after initial AP treatment. However, a reduction of oxygen saturation (SpO(2)) of over 3% was noted in 4 patients during the initial AP administration. In 9 patients receiving AP prophylaxis for more than 36 months, we compared the pulmonary function parameters between the baseline and final observations (mean, 52.7 months). There were no changes in VC, %VC, FEV(1.0,) FEV(1.0)%, and SpO(2), but there was a statistically significant decline in MEF(25)/height after long-term AP treatment. We concluded that the incidence of prophylaxis failure with AP for PCP in Japanese patients was similar to that in Western patients, and that long-term AP treatment affected MEF(25)/height in spite of the safe pulmonary effects in short-term AP inhalation.

Risk Factors for Prophylaxis Failure in Patients Receiving Aerosol Pentamidine for Pneumocystis carinii Pneumonia Prophylaxis

OBJECTIVE

The purposes of this study were (1) to determine the incidence of prophylaxis failure in HIV-infected patients receiving aerosol pentamidine (AP) for Pneumocystis carinii pneumonia (PCP) prophylaxis, and (2) to identify risk factors for PCP prophylaxis failure.

SETTING AND DESIGN

In Ontario, Canada, AP has been made available for outpatient PCP prophylaxis through a centralized government program, the Ontario Drug Distribution and Monitoring Program. Data from this administrative observational database were extracted for 2,227 patients who received AP between May 1989 and December 1998.

OUTCOME MEASUREMENTS

The incidence of breakthrough PCP (BPCP) was calculated from the database. A Cox regression model with time-varying covariates was created to examine factors associated with BPCP. The follow-up time was divided into three eras: 1989 to 1991, 1992 to 1994, and 1995 to 1998. These eras were meant to reflect major changes in antiretroviral medication regimens.

RESULTS

The overall risk of BPCP was 16.2% over a mean follow-up of 1.67 years. The overall BPCP rate was 9.7/100 patient-years, with rates of 8.8/100, 13.1/100, and 6.3/100 patient-years in each of the three treatment eras. In the multivariate analysis, significant risk factors for prophylaxis failure were low CD4 count, previous diagnosis of PCP, history of AIDS-defining conditions other than PCP, and antiretroviral treatment era defined above.

CONCLUSION

The overall rate of PCP prophylaxis failure has decreased significantly after 1995, coincident with the era of highly active antiretroviral therapies. Initiation of PCP prophylaxis remains necessary in patients with risk factors.