Primary Prophylaxis for Pneumocystis jirovecii Pneumonia in People Living with HIV after Early Initiation of Highly Active Antiretroviral Therapy Era: Does It Still Need?
Pisit Pothong1, Atibordee Meesing2, Wantin Sribenjalux2, Siriluck Anunnatsiri2, Piroon Mootsikapun2, Ploenchan Chetchotisakd2
Affiliation : 1 Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand 2 Division of Infectious Diseases and Tropical Medicines, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Background: Co-trimoxazole is a mainstay for primary Pneumocystis jirovecii pneumonia (PJP) prophylaxis in people living with human immunodeficiency virus (PLWH) whose CD4 count is <200 cells/mm³. However, there is limited evidence of the outcome of co-trimoxazole to prevent PJP after early initiation of highly active antiretroviral therapy era.
Objective: To assess co-trimoxazole’s efficacy and side effects in primary PJP prophylaxis in PLWH.
Materials and Methods: A retrospective study was performed from January 2010 to December 2019 at a single medical university hospital in Thailand. Adults aged 18 or older who received combination antiretroviral therapy (cART), had baseline CD4 <200 cells/mm³, and were not diagnosed with PJP before the cART were enrolled. Patients with a history of sulfa allergy who received co-trimoxazole for treatment of other diseases, received drugs that had a therapeutic effect on Pneumocystis jirovecii, or lost important data were excluded.
Results: A total of 1,249 individuals, 227 patients (126 PLWH received co-trimoxazole and 101 PLWH did not receive co-trimoxazole [control group]) complied with eligibility conditions for analysis. The median (IQR) age was 34.7 (27.8 to 42.7) years. The median (IQR) baseline CD4 count in co-trimoxazole and control group were 52 (26 to 106) and 107 (75 to 151) cells/mm³ (p<0.001), respectively. The prevalence of PJP after cART initiation in co-trimoxazole group and control group were 0.8% and 1.0% (p=1.00), respectively. The all-cause mortality rate in the co-trimoxazole group was 3.2%, while there was no death in the control group.
Conclusion: There is no significant difference between the rate of PJP in PLWH who receive and do not receive co-trimoxazole prophylaxis. Primary PJP prophylaxis in all PLWH whose CD4 count <200 cells/mm³ may not be necessary for the era of highly effective cART, and the guideline recommendation should be reconsidered.
Received 6 March 2024 | Revised 17 April 2024 | Accepted 24 April 2024
DOI: 10.35755/jmedassocthai.2024.S01.S24-S30
Keywords : HIV; Pneumocystis pneumonia; Co-trimoxazole; Primary prophylaxis
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