Second-line salvage treatment of AIDS-associated Pneumocystis jirovecii pneumonia: a case series and systematic review

J Acquir Immune Defic Syndr. 2008 May 1;48(1):63-7. doi: 10.1097/QAI.0b013e31816de84d.

Abstract

Background: Limited clinical data exist to guide the choice of second-line salvage treatment for AIDS-associated Pneumocystis jirovecii pneumonia (PCP).

Methods: We did a systematic search of MEDLINE for all randomized and observational studies of PCP treatment published up to August 2007 and included individual treatment data of AIDS-associated PCP from a tricenter study. We calculated pooled estimates of reported outcome of second-line treatment using averaged odds ratios (ORs).

Results: Twenty-nine studies with sufficient detail of second-line treatment and outcome, including data from 82 individual cases from the tricenter study, yielded a total of 468 PCP second-line treatment episodes. Response rates to second-line treatment were comparable for trimethoprim-sulfamethoxazole (TMP-SMX; 68%) and clindamycin-primaquine (73%) (OR for response = 2.1 [95% confidence interval (CI): 1.1 to 3.2] and 2.7 [95% CI: 1.3 to 4.0], respectively) but were considerably lower for intravenous pentamidine (44%; OR = 0.8 [95% CI: 0.6 to 1.0]).

Conclusions: Clindamycin-primaquine is an alternative to intravenous pentamidine as second-line treatment for PCP in patients who fail treatment with TMP-SMX. TMP-SMX should be used as a second-line treatment for those failing first-line treatments with regimens other than TMP-SMX.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • AIDS-Related Opportunistic Infections / drug therapy*
  • Clindamycin / administration & dosage
  • Clindamycin / therapeutic use*
  • Cohort Studies
  • Humans
  • Pentamidine / therapeutic use*
  • Pneumocystis carinii / isolation & purification*
  • Pneumonia, Pneumocystis / drug therapy*
  • Pneumonia, Pneumocystis / microbiology
  • Primaquine / administration & dosage
  • Primaquine / therapeutic use*
  • Salvage Therapy
  • Treatment Outcome
  • Trimethoprim, Sulfamethoxazole Drug Combination / therapeutic use*

Substances

  • Clindamycin
  • Pentamidine
  • Trimethoprim, Sulfamethoxazole Drug Combination
  • Primaquine