Comparison of Three Regimens for Treatment of Mild to Moderate
Pneumocystis carinii Pneumonia in Patients with AIDS [Safrin S, et al. Ann
Intern Med 1996;124:792]: This is ACTG trial 108 comparing
trimethoprim-sulfamethoxazole, dapsone-trimethoprim and clindamycin-primaquine
for the treatment of P. carinii pneumonia in patients with an (A-a)O2 gradient
of <45 mm Hg. Treatment failure at day 21 was defined as death, requirement
for intubation, change in therapy for reasons other than toxicity, lack of
resolution of baseline signs and symptoms, or an increase in A-a gradient
mm Hg. There were 181 patients evaluated. Comparison between groups showed no
statistically significant differences in rates of survival,therapeutic failure
or dose-limiting toxicity. Hepatotoxicity, indicated by elevation of serum
aminotransferase levels exceeding five times baseline levels, was significantly
more frequent with TMP-SMX. Hematologic toxicity with neutropenia, anemia,
thrombocytopenia or methemoglobinemia was significantly more frequent with the
clindamycin-primaquine regimen. Therapeutic failure rates for the three
regimens at day 21 ranged from 6.9% (clindamycin-primaquine) to 11.9%
(dapsone-trimethoprim). The rate of dose-limiting toxicity ranged from 24%
(dapsone-trimethoprim) to 36% (TMP-SMX). Rash was the most frequent dose
limiting toxicity in all three groups. The overall mortality rate was 4.4%. The
authors concluded that the choice of treatment for patients with mild to
moderate PCP may ultimately depend on anticipated side effects. In patients with
hepatic insufficiency, alternatives to TMP-SMX should be considered, and it may
be preferable to treat patients with baseline myelosuppression with a regimen
other than clindamycin-primaquine.
AdvertisementAntiretroviral Therapy for HIV Infection in 1996: Recommendations
of an International Panel
Comparison of Sputum Induction and Fiberoptic Bronchoscopy in the
Diagnosis of Tuberculosis [Anderson C, et al. Am J Respir Crit Care Med
1995;152:1570]: The authors compared sputum induction with bronch- oscopy for
detection of M. tuberculosis in 101 patients with suspected TB who had negative
sputum smears or who could not produce an expectorated sample. In 27 patients
eventually diagnosed with TB, there were 19 positive cultures from bronchoscopy
compared to 20 from induced sputa. The yield of acid-fast organisms detected on
smears was low in both groups: five from bronchoscopy and seven from induced
sputa. The yield by culture was different for the two procedures in individual
patients since only 14 had positive results from both procedures. The authors
conclude that induced sputum is preferred because it is less expensive and less
invasive, but bronchoscopy will increase the yield by about 20% if both
procedures are performed.
Serologic Response to Treatment of Syphilis in Patients with HIV
Infection [Yinnon AM, et al. Arch Intern Med 1996;156:321]: The authors
compared serologic response in 52 patients with HIV infection and syphilis and
52 with syphilis and negative HIV serology. The groups were matched by age, sex,
race, RPR titer and stage of syphilis. There were 26 matched patients with early
syphilis and 26 with late syphilis. Early syphilis in patients with HIV
infection was usually treated with three doses of benzathine penicillin G; the
standard treatment for early syphilis in HIV-negative patients was a single
dose of benzathine penicillin. Overall, 56% of the HIV-infected patients failed
to achieve a four-fold reduction in RPR titer at six months compared to 38% in
the HIV-negative patients (p = 0.06). At 12 months the rates were 44% and 29%,
respectively (p = 0.07). These differences in response rates reached
statistical significance in patients with RPR titers of 1:32 or less (p <0.005).
There were no apparent distinguishing clinical features for non-responders. The
authors concluded that HIV-infected patients with syphilis are less likely to
demonstrate serologic improvement after recommended treatment with penicillin.
[Carpenter CC, et al. JAMA 1996;276:146]: The
recommendations are from a 13-member panel representing the International AIDS
Society-U.S.A. by group consensus in January 1996 with revisions by group
consensus through May 1996.
When to initiate treatment:
- Symptomatic disease: all patients.
- Asymptomatic with CD4 cell count <500/mm3: treat all patients, but some
would reserve this for patients with CD4 cell counts <350/mm3 and/or HIV RNA
levels above 5-10,000 copies/ml.
- Asymptomatic with CD4 cell count >500/mm3: therapy recommended for
patients with HIV RNA levels exceeding 30,000-50,000 copies/ml or a rapidly
declining CD4 cell count.
Recommended initial regimen:AZT plus ddI, AZT plus ddC, AZT plus 3TC
or ddI monotherapy.
When to switch:
- Treatment failure: indicated by increase in viral load (return toward
or within 0.3-0.5 log of pretreatment levels), decrease in CD4 cell count or
- Toxicity, intolerance or non-adherence.
- Current use of a suboptimal treatment regimen such as AZT monotherapy.