Ineffectiveness of Trimethoprim‐Sulfamethoxazole Prophylaxis and the Importance of Bacterial and Viral Coinfections in African Children withPneumocystis cariniiPneumonia

Abstract

African human immunodeficiency virus type 1 (HIV-1)-infected children were evaluated to define the burden of Pneumocystis carinii pneumonia (PCP) and its interaction with bacterial and viral pathogens. P. carinii was identified in 101 (43.7%) of 231 episodes of pneumonia among 185 HIV-1-infected children (median age, 4.5 months; range, 1.7-27.3 months). Receipt of trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis was not associated with a significant reduction (36%; 95% confidence interval [CI], -15.4% to 64.5%) in isolation of P. carinii among children considered to have received adequate prophylaxis (37.7% of children) compared with children who had never received any prophylaxis (48.5% of children). However, deaths among children with PCP who had been taking TMP-SMX prophylaxis were markedly reduced (98.6%; 95% CI, 89.1%-99.8%) compared with children who were not taking prophylaxis. Concurrent P. carinii infection was observed in 6 of 18, 11 of 26, and 4 of 6 HIV-1-infected children who had bacteremia, a respiratory virus isolated, or Mycobacterium species isolated, respectively.

Antibiotic and systemic therapies for pneumonia in human immunodeficiency virus (HIV)-infected and HIV-exposed children

“…Additionally, no information was provided on CPT among the children who developed PCP, which was first recommended in early 1991 [43], i.e., prior to when the historical control group were identified and during the period when the intervention group were recruited. This would be important as a history of CPT was found to be associated with substantial reduction in mortality risk among HIVinfected children with CAP in whom P. jirovecii was identified [15]. Despite the strong association (RR > 5), the lack of control for potential confounding factors and possibility of publication bias due to favourable results render this study low quality as scientific evidence.…”

“…Pneumocystis jirovecii is a significant cause of pneumonia (PCP) in HIV-infected children, especially in the absence of antiretroviral (ARV) therapy or prophylactic treatment (CPT), with high (28-63%) mortality rates [9][10][11][12][13][14][15]. The estimated risk of PCP among perinatally HIV-infected children during the first year of life ranges from 7% to 20% [16][17][18][19].…”

“…The estimated risk of PCP among perinatally HIV-infected children during the first year of life ranges from 7% to 20% [16][17][18][19]. Younger age (< 1 year) is associated with increased risk of PCP, especially during the first six months of life [10,[15][16][17][18][20][21][22][23][24]. Studies from Africa reported PCP prevalence rates from 10% to 48.5% among HIV-infected children hospitalized with severe pneumonia [10][11][12]14,15].…”

“…Younger age (< 1 year) is associated with increased risk of PCP, especially during the first six months of life [10,[15][16][17][18][20][21][22][23][24]. Studies from Africa reported PCP prevalence rates from 10% to 48.5% among HIV-infected children hospitalized with severe pneumonia [10][11][12]14,15]. Postmortem studies have shown that the prevalence of PCP among HIV-related deaths in children ranged from 11.5% to 52% [18,[25][26][27][28][29].…”

Cytokine profile and clinical correlates in HIV-exposed infants with severe (hypoxic) pneumonia

“…[6,7] The case fatality rate from PCP is 100% if not treated with trimethoprim-sulphamethoxazole (TMP-SMX). [8] However, where TMP-SMX prophylaxis is employed alone, mortality is not significantly reduced. [9] Because the disease often causes severe hypoxia, these children would benefit from paediatric intensive care admission.…”