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HIV+ patients still need PCP prophylaxis
By Carol Kemper, MD, FACP
Dr. Kemper reports no financial relationships relevant to this field of study. This article originally appeared in the April 2005 issue of Infectious Disease Alert. It was peer reviewed by Connie Price, MD and edited by Stan Deresinski, MD. Infectious Disease Alert's Physician Editor, Stan Deresinski, MD, FACP, serves on the speaker's bureau of Merck, Pharmacia, GlaxoSmithKline, Pfizer, Bayer, and Wyeth, and does research for Merck. Peer reviewer Connie Price, MD, reports no consultant, stockholder, speaker's bureau, research, or other financial relationship with any company related to this field of study.
Source: Teshale EH, et al. Reasons for lack of appropriate receipt of primary Pneumocystis jiroveci pneumonia prophylaxis among HIV-infected persons receiving treatment in the United States: 1994-2003, Clin Infect Dis. 2007; 44:879-883.
Prophylaxis against pcp remains the single most cost-effective intervention in HIV+ patients at risk. But treatment has, in some ways, become a moving target in some patients, as their CD4 count rises and falls with newer HIV therapies, medication side effects, and variable compliance. Despite the increased use of highly active antiretroviral therapy, this Atlanta-based clinic reported an unusually high number of PCP cases. During a 4-year period from 1999-2003, 483 cases of PCP were diagnosed during 7315 person years. The incidence in persons receiving both HAART and PCP prophylaxis was low (5.2 episodes per 100 person years). However, the rates of PCP in persons who had an initially favorable CD4 response but later dropped their CD4 below 200 cells/mm3, those that stopped prophylaxis while their CD4 count was < 200 cells/mm3, or those that never started below 200 cells/mm3 were 6.3, 11.3 and 19.2 episodes per person per year, respectively. Rates for persons with CD4 < 100 were greater.
Women, Latinos, injection drug users, those new to treatment, and those with fewer clinic visits were significantly less likely to receive PCP prophylaxis. Physicians need to be aware of the potential "gap" in PCP prophylaxis for these at-risk subjects. Additional research is needed to determine if there is benefit in maintaining or starting at-risk subjects on PCP prophylaxis at higher CD4 counts, eg, 250 cells/mm3, recognizing the benefits may outweigh the risks. In addition to decreasing the risk of PCP, prophylaxis with trimethoprim-sulfame-thoxazole has been found to decrease the risk of bronchitis and sinus infection, and recent data found that HIV+ patients maintained on trimethoprim-sulfamethoxazole were at lower risk for infection with MRSA.