Clindamycin/Primaquine Versus Trimethoprim-Sulfamethoxazole as Primary Therapy for Pneumocystis carinii Pneumonia in AIDS: A Randomized, Double-Blind Pilot Trial

Abstract

The aim of this double-blind pilot trial was to compare clindamycin/primaquine with trimethoprim-sulfamethoxazole (TMP-SMZ) as primary treatment for AIDS-related Pneumocystis carinii pneumonia (PCP). The focus was on toxicity and tolerability since comparisons of efficacy were limited by the small sample size. Sixty-five individuals with a first episode of possible PCP were randomly assigned to receive clindamycin/primaquine (34 patients) or TMP-SMZ (31 patients). PCP was subsequently proven microbiologically in 27 and 22 of the patients in these respective groups. Half of the participants had an arterial partial oxygen pressure at enrollment of < or = torr. The incidence and severity of adverse reactions were lower--but not significantly lower (P = .07 and .08, respectively)--with clindamycin/primaquine. The markers of severity improved in a similar manner regardless of which regimen was administered. No significant differences were documented in outcome, duration of survival, length of the PCP-free interval, or rate of relapse. The results of this pilot study show a trend toward less toxicity with clindamycin/primaquine than with TMP-SMZ. This result must be confirmed by larger-scale clinical trials, which are also needed to better compare the efficacy of the two regimens.

Trimethoprim‐Sulfamethoxazole (TMP‐SMZ) Dose Escalation versus Direct Rechallenge forPneumocystis CariniiPneumonia Prophylaxis in Human Immunodeficiency Virus–Infected Patients with Previous Adverse Reaction to TMP‐SMZ

“…In addition to providing effective prophylaxis for PCP, there is evidence that TMP-SMZ is effective as prophylaxis for toxoplasmosis and also may be useful in preventing infections caused by a variety of other organisms [7][8][9][10][11][12].…”

“…In published studies, the rate of adverse reactions requiring discontinuation of TMP-SMZ varied from 9.4% to 54% [2,[8][9][10][13][14][15][16][17][18][19][20][21][22]. Although the rate of drug discontinuation is lower for patients receiving PCP prophylaxis than treatment, patients receiving secondary prophylaxis have developed reactions, despite previously successful acute treatment with TMP-SMZ.…”

Pharmacokinetic Optimisation in the Treatment of Pneumocystis carinii Pneumonia

“…The clinical efficacy, or response rate, in subsequent treatment cycles (table V) performed in patients with PCP of various severity was excellent (78 to 93%) in first-time episodes as well as in patients who failed to respond to prior medications (Black et al 1991;Kay & Dubois 1990;Toma 1991). Comparative trials with cotrimoxazole were carried out retrospectively (Ruf et al 1991) as well as in a double-blind fashion (Toma et al 1992) and the data suggest that the combination of clindamycin and primaquine is equally as effective as treatment with cotrimoxazole (at a dose of 20/100 mg/kg/day), but is less toxic. Larger and multicentre trials are in progress.…”

Antiparasitic Activities and Toxicities of Individual Enantiomers of the 8-Aminoquinoline 8-[(4-Amino-1-Methylbutyl)Amino]-6-Methoxy-4-Methyl-5-[3,4-Dichlorophenoxy]Quinoline Succinate

“…This drug is also reported to be effective against Trypanosoma (28) and Leishmania (39) species and, in combination with clindamycin, for prophylaxis and treatment of Pneumocystis carinii pneumonia (PCP) in animal models (7,33). Several studies have shown that the primaquine-clindamycin combination was extremely effective for prophylaxis (23) and treatment (10,11,20,23,43,44,45) of mild to severe cases of pneumocystis pneumonia in AIDS patients, especially as a salvage therapy in cases where conventional therapy was ineffective or not tolerated. (Note that, in recent years, the nomenclature Pneumocystis jirovecii has been adopted for the human pathogen.)…”