title: Impact of an intravenous trimethoprim/sulfamethoxazole shortage on treatment outcomes among HIV-infected patients with Pneumocystis jirovecii pneumonia.
abstract: BACKGROUND
  Trimethoprim/sulfamethoxazole (TMP/SMX) is the recommended first-line treatment for human immunodeficiency virus (HIV)-infected patients with Pneumocystis jirovecii pneumonia (PJP).However, in June 2010, the lone manufacturer of intravenous (IV) TMP/SMX in the United States stopped production of this medication.
  
  
  OBJECTIVE
  To (a) evaluate the impact of the national IV TMP/SMX shortage on PJP treatment outcomes between 2 groups of HIV-infected patients-those treated before the shortage and those after the shortage-and (b) compare the length of hospital stay (LOS) and PJP treatment used before and after the shortage.
  
  
  METHODS
  A retrospective, quasi-experimental study examining 2 groups of HIV-infected adult patients with PJP was performed at an academic medical center from September 1, 2008, to June 30, 2012. Patients treated when IV TMP/SMX was available, or preshortage (PRE), were compared with patients treated when IV TMP/SMX was not available, or postshortage (POST).PRE included patients treated between September 1, 2008, and May 30, 2010, and POST included patients treated between June 1, 2010, and June 30, 2012.
  
  
  RESULTS
  Thirty-six patients were included in the study, 18 in each group. Treatment failure, the primary outcome, included mortality or worsening clinical status (WCS) after at least 5 days of therapy. Three patients in PRE (16.7%) and 6 patients in POST (33.3%) experienced treatment failure (P = 0.248). No patients in PRE and 3 patients in POST (16.7%) experienced WCS (P = 0.035). Three patients in each group expired.In POST, 5 of the 6 treatment failures (83.3%) occurred during the first 6 months of the shortage. Median (interquartile range) LOS was 11 days (7-17) in PRE and 14 days (5-22) in POST (P = 0.800).In PRE, 7 patients (38.9%) were initiated on oral PJP treatment compared with 13 (72.2%) in POST (P = 0.042).
  
  
  CONCLUSIONS
  The national shortage of IV TMP/SMX may have led to an immediate but temporary negative impact on treatment outcomes among HIV-infected patients with PJP at an academic medical center.Pharmacist collaboration with physicians may have helped mitigate the impact of this drug shortage on patient outcomes.
authors.affiliation: University of New Mexico College of Pharmacy, 2502 Marble N.E., MSC 09 5360, Albuquerque, NM 87131-0001. rmercier@unm.edu.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Dilworth
authors.forename: Omar M
authors.initials: OM
authors.lastname: Ibrahim
authors.forename: Renée-Claude
authors.initials: RC
authors.lastname: Mercier
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy*; D000328:Adult; D000890:Anti-Infective Agents / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D005260:Female; D015658:HIV Infections; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008499:Medical Records; D045363:Pneumocystis carinii; D011020:Pneumonia, Pneumocystis / Q000188:drug therapy*; D012189:Retrospective Studies; D016896:Treatment Outcome; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000008:administration & dosage*; D014481:United States
chemical_list: D000890:Anti-Infective Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination