Second-line salvage treatment of AIDS-associated Pneumocystis jirovecii pneumonia: a case series and systematic review.
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.
Benfield
Thomas
T
Department of Infectious Diseases, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark. tlb@dadlnet.dk
Atzori
Chiara
C
Miller
Robert F
RF
Helweg-Larsen
Jannik
J
D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy*; D002981:Clindamycin / Q000008:administration & dosage / Q000627:therapeutic use*; D015331:Cohort Studies; D006801:Humans; D010419:Pentamidine / Q000627:therapeutic use*; D045363:Pneumocystis carinii / Q000302:isolation & purification*; D011020:Pneumonia, Pneumocystis / Q000188:drug therapy* / Q000382:microbiology; D011319:Primaquine / Q000008:administration & dosage / Q000627:therapeutic use*; D016879:Salvage Therapy; D016896:Treatment Outcome; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use*
D002981:Clindamycin; D010419:Pentamidine; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D011319:Primaquine