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Pneumocystis carinii infection: current treatment and prevention
R F Miller1, J Le Noury, E L Corbett
1Department of Medicine, University College London Medical School, UK.
Abstract:
Pneumocystis carinii is a common cause of pneumonia in individuals who are immunosuppressed by HIV infection. Use of molecular biological techniques show that P. carinii is a fungus and that infection in man is not a zoonosis. Invasive tests such as sputum induction or bronchoscopy are used to make the diagnosis of P. carinii pneumonia. Life long primary prophylaxis is given to HIV positive individuals with CD4+ lymphocyte counts < 0.20 x 10(9)/L or a CD4: total lymphocyte ratio of < 1.5, constitutional symptoms, or with other AIDS defining diseases. Secondary prophylaxis is given after a first episode to prevent a recurrence. First choice for primary and secondary prophylaxis is oral co-trimoxazole 960 mg od or three times a week. In patients who are intolerant to co-trimoxazole, nebulised pentamidine or dapsone (with or without pyrimethamine) are second and third choices. In a patient with acute PCP disease, severity should be assessed using clinical, radiographic and blood gas criteria as those with moderate or severe disease will benefit from adjuvant glucocorticoids. Co-trimoxazole (120 mg/kg/day in divided doses for 21 days) is first choice therapy for PCP of all degrees of severity. In patients who fail to respond to co-trimoxazole or who are intolerant to it, second line treatment is iv pentamidine in those with severe disease and oral dapsone with trimethoprim, oral clindamycin with primaquine or iv pentamidine in those with mild or moderately severe disease.
Insights
Pneumocystis pneumonia (PCP) is a fungal infection common in HIV-positive individuals. Co-trimoxazole is the primary treatment and prophylaxis, with alternatives available for intolerant patients.
Area of Science:
- Medical Mycology
- Infectious Diseases
- Immunology
Background:
- Pneumocystis carinii pneumonia (PCP) is a significant opportunistic infection in individuals with HIV/AIDS.
- Molecular techniques confirm P. carinii as a fungus, not a zoonotic infection.
- Diagnosis relies on invasive procedures like sputum induction or bronchoscopy.
Purpose of the Study:
- To outline diagnostic and treatment strategies for Pneumocystis pneumonia (PCP) in HIV-infected individuals.
- To detail prophylaxis regimens for preventing PCP in immunocompromised patients.
- To discuss alternative treatments for PCP when co-trimoxazole is not tolerated.
Main Methods:
- Review of diagnostic criteria for PCP, including clinical, radiographic, and blood gas assessments.
- Description of primary and secondary prophylaxis guidelines based on CD4+ counts and clinical status.
- Outline of first-line and second-line therapeutic options for PCP, including co-trimoxazole, pentamidine, dapsone, pyrimethamine, and clindamycin.
Main Results:
- Co-trimoxazole is the preferred agent for both primary and secondary PCP prophylaxis (960 mg daily or thrice weekly).
- Alternative prophylaxis options include nebulized pentamidine or dapsone (with or without pyrimethamine) for co-trimoxazole-intolerant patients.
- Adjuvant glucocorticoids are recommended for moderate to severe PCP cases.
Conclusions:
- PCP management in HIV-infected individuals requires careful assessment of disease severity.
- Co-trimoxazole is the cornerstone of PCP treatment (120 mg/kg/day for 21 days) and prophylaxis.
- Alternative therapies are crucial for patients unable to tolerate co-trimoxazole, with specific regimens tailored to disease severity.