trimethoprim--sulfamethoxazole-drug-combination and Respiratory-Insufficiency

Pneumonia caused by Pneumocystis carinii is the most frequent indication for admission of AIDS patients to intensive care units. In this article, an approach to the diagnosis and management of this condition will be presented along with prognostic information. Differential diagnosis will be discussed, and characteristic responses to current standard and alternative chemotherapeutic agents and modes of ventilatory support will be reviewed.

Topics: Adrenal Cortex Hormones; AIDS-Related Opportunistic Infections; Diagnosis, Differential; Health Personnel; Humans; Infection Control; Intensive Care Units; Pentamidine; Pneumonia, Pneumocystis; Prognosis; Respiration, Artificial; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination

Preliminary reports suggest that patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia may benefit from the addition of corticosteroid treatment to antibiotic therapy.. We conducted a double-blind, placebo-controlled trial to assess the efficacy of adjunctive corticosteroids in patients with AIDS and severe P. carinii pneumonia. Patients with marked abnormalities in gas exchange who had been treated with antibiotics for less than 72 hours were randomly assigned to receive either methylprednisolone (40 mg) or placebo every 6 hours for 7 days, in addition to treatment for 21 days with trimethoprim-sulfamethoxazole. The primary outcome measures were survival until hospital discharge and the development of respiratory failure.. Twenty-three patients were enrolled in the study; there were no significant differences in base-line clinical or laboratory measures between the two treatment groups. Of 12 patients treated with corticosteroids, 9 (75 percent) survived until hospital discharge, as compared with only 2 of 11 placebo recipients (18 percent) (P less than 0.008). Respiratory failure developed in nine placebo recipients, as compared with only three patients treated with corticosteroids (P less than 0.008). No patient required the interruption or discontinuation of corticosteroid or antibiotic treatment because of toxicity or a complicating event. Because of the marked difference in survival, it was deemed unethical to continue the trial, and the study was terminated.. Early adjunctive corticosteroid therapy can improve survival and decrease the occurrence of respiratory failure in patients with AIDS and severe P. carinii pneumonia.

Topics: Acquired Immunodeficiency Syndrome; Adrenal Cortex Hormones; Adult; Aged; Double-Blind Method; Female; Follow-Up Studies; Humans; Male; Methylprednisolone; Middle Aged; Pneumonia, Pneumocystis; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination

We have identified an underrecognized severe adverse drug reaction (ADR) of trimethoprim-sulfamethoxazole (TMP-SMX) associated respiratory failure in previously healthy children and young adults. We investigated potential genetic risk factors associated with TMP-SMX induced respiratory failure in a cohort of seven patients. We explored whole genome sequence among seven patients representing nearly half of all reported cases worldwide and 63 unrelated control individuals in two stages: (1) human leukocyte antigen (HLA) locus variation as several other ADRs have been associated HLA genetic variants and (2) coding variation to catalog and explore potential rare variants contributing to this devastating reaction. All cases were either heterozygous (carriers) or homozygous for the common HLA-B*07:02-HLA-C*07:02 haplotype. Despite the small sample size, this observation is statistically significant both in conservative comparison to maximum reported population frequencies (binomial P = 0.00017 for HLA-B and P = 0.00028 for HLA-C) and to our control population assessed by same HLA genotyping approach (binomial P = 0.000001 for HLA-B and P = 0.000018 for HLA-C). No gene elsewhere in the genome harnessed shared rare case enriched coding variation. Our results suggests that HLA-B*07:02 and HLA-C*07:02 are necessary for a patient to develop respiratory failure due to TMP-SMX.

Topics: Child; HLA-B Antigens; HLA-B7 Antigen; HLA-C Antigens; Humans; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination

Anti-melanoma differentiation-associated gene 5 juvenile dermatomyositis (anti-MDA5 JDM) is associated with high risk of developing rapidly progressive interstitial lung disease (RP-ILD). Here we report an 11-year-old girl with anti-MDA5 JDM and RP-ILD which led to a fatal outcome, further aggravated by SARS-CoV-2 infection. She was referred to our hospital after being diagnosed with anti-MDA5 JDM and respiratory failure due to RP-ILD. On admission, fibrobronchoscopy with bronchoalveolar lavage (BAL) revealed

Topics: Adenosine Monophosphate; Alanine; Anti-Bacterial Agents; Antibodies, Monoclonal, Humanized; Antiviral Agents; Autoantibodies; Bronchoscopy; Child; COVID-19; COVID-19 Nucleic Acid Testing; Cyclophosphamide; Dermatomyositis; Disease Progression; Fatal Outcome; Female; Humans; Hydroxychloroquine; Immunocompromised Host; Immunoglobulins, Intravenous; Immunologic Factors; Immunosuppressive Agents; Interferon-Induced Helicase, IFIH1; Lung; Lung Diseases, Interstitial; Lymphohistiocytosis, Hemophagocytic; Mediastinal Emphysema; Methylprednisolone; Piperidines; Pneumonia, Pneumocystis; Pneumothorax; Pyrimidines; Respiratory Insufficiency; Shock, Septic; Subcutaneous Emphysema; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adolescent; Adult; Anti-Bacterial Agents; Bacterial Infections; Child; Female; Humans; Male; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination; Young Adult

The prevalence of pneumocystis pneumonia (PCP) and associated hypoxic respiratory failure is increasing in human immunodeficiency virus (HIV)-negative patients. However, no prior studies have evaluated the effect of early anti-PCP treatment on clinical outcomes in HIV-negative patient with severe PCP. Therefore, this study investigated the association between the time to anti-PCP treatment and the clinical outcomes in HIV-negative patients with PCP who presented with hypoxemic respiratory failure.. A retrospective observational study was performed involving 51 HIV-negative patients with PCP who presented in respiratory failure and were admitted to the intensive care unit between October 2005 and July 2018. A logistic regression model was used to adjust for potential confounding factors in the association between the time to anti-PCP treatment and in-hospital mortality.. All patients were treated with appropriate anti-PCP treatment, primarily involving trimethoprim/sulfamethoxazole. The median time to anti-PCP treatment was 58.0 (28.0-97.8) hours. Thirty-one (60.8%) patients were treated empirically prior to confirmation of the microbiological diagnosis. However, the hospital mortality rates were not associated with increasing quartiles of time until anti-PCP treatment (P = 0.818, test for trend). In addition, hospital mortality of patients received early empiric treatment was not better than those of patients received definitive treatment after microbiologic diagnosis (48.4% vs. 40.0%, P = 0.765). In a multiple logistic regression model, the time to anti-PCP treatment was not associated with increased mortality. However, age (adjusted OR 1.07, 95% CI 1.01-1.14) and failure to initial treatment (adjusted OR 13.03, 95% CI 2.34-72.65) were independently associated with increased mortality.. There was no association between the time to anti-PCP treatment and treatment outcomes in HIV-negative patients with PCP who presented in hypoxemic respiratory failure.

Topics: Adult; Age Factors; Aged; Anti-Bacterial Agents; Critical Care; Female; HIV Seronegativity; Hospital Mortality; Humans; Male; Middle Aged; Pneumonia, Pneumocystis; Respiratory Insufficiency; Retrospective Studies; Time-to-Treatment; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Pulmonary toxicity induced by trimethoprim-sulfamethoxazole (TMP-SMX) has been described, although the disease process is poorly understood. We report 5 previously healthy adolescent patients who developed acute respiratory failure while taking TMP-SMX. Four of the 5 adolescents required extracorporeal membrane oxygenation support, and 2 of the teenagers died. All children required a tracheostomy, and all cases were complicated by pneumothoraces and pneumomediastinum. The majority of children were prescribed TMP-SMX for the treatment of acne vulgaris.

Topics: Acute Disease; Adolescent; Anti-Bacterial Agents; Female; Humans; Male; Respiratory Insufficiency; Severity of Illness Index; Trimethoprim, Sulfamethoxazole Drug Combination

Pneumonia caused by Pneumocystis jirovecii is an uncommon infection in kidney transplant patients that can have an acute and rapid progression to respiratory failure and death. The period of greatest risk occurs in the first six months after the transplant, and it relates to the high doses of immunosuppression drugs required by patients. However, it may occur late, associated with the suspension of prophylaxis with trimethoprim-sulfamethoxazole.We present two cases of renal transplant patients who had severe hypoxemic respiratory failure due to P. jirovecii six years after transplantation. In addition to steroids, they received treatment with trimethoprim-sulfamethoxazole. One patient died, while the other had clinical recovery, with preservation of the renal graft function.

Topics: Humans; Kidney Transplantation; Pneumocystis carinii; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination

We present a case of a 57-year-old woman who contracted

Topics: Anti-Bacterial Agents; Arthritis, Rheumatoid; Diagnosis, Differential; Drug Combinations; Etanercept; Female; Humans; Immunosuppressive Agents; Injections, Subcutaneous; Intensive Care Units; Methotrexate; Middle Aged; Pneumocystis carinii; Pneumonia, Pneumocystis; Radiography, Thoracic; Respiration, Artificial; Respiratory Insufficiency; Sputum; Steroids; Tomography, X-Ray Computed; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Some IPF patients show a rapid progression of respiratory failure. Most patients are treated with high-dose corticosteroids. However, no large clinical studies have investigated the prognosis or efficacy of combined treatments including high-dose corticosteroids in IPF patients with a rapid progression of respiratory failure.. We enrolled IPF patients who received mechanical ventilation and high-dose corticosteroids between April 2010 and March 2013. Records were extracted from a Japanese nationwide inpatient database. We conducted a retrospective epidemiologic and prognostic analysis.. Two hundred nine patients receiving an average of 12.8 days of ventilatory support were enrolled. There were 138 (66 %) fatal cases; the median survival was 21 days. The short-term (within 30 days) and long-term (within 90 days) survival rates were 44.6 and 24.6 %, respectively. The average monthly admission rate among the IPF patients with the rapid progression of respiratory failure in the winter was significantly higher than that in spring (p = 0.018). Survival did not differ to a statistically significant extent in the different geographic areas of Japan. Survivors were significantly younger (p = 0.002) with higher rates of mild dyspnea on admission (p = 0.012), they more frequently underwent bronchoscopy (p < 0.001), and received anticoagulants (p = 0.027), co-trimoxazole (p < 0.001) and macrolide (p = 0.02) more frequently than non-survivors. A multivariate logistic analysis demonstrated that two factors were significantly associated with a poor prognosis: >80 years of age (OR = 2.94, 95 % Cl 1.044-8.303; p = 0.041) and the intravenous administration of high-dose cyclophosphamide (OR = 3.17, 95 % Cl 1.101-9.148; p = 0.033). Undergoing bronchoscopy during intubation (OR = 0.25, 95 % Cl 0.079-0.798; p = 0.019) and the administration of co-trimoxazole (OR = 0.28, 95 % Cl 0.132-0.607; p = 0.001) and macrolides (OR = 0.37, 95 % Cl 0.155-0.867; p = 0.033) were significantly associated with a good prognosis. The dosage of co-trimoxazole significantly correlated with survival.. Co-trimoxazole and macrolides may be a good addition to high-dose corticosteroids in the treatment of IPF patients with a rapid progression of respiratory failure.

Topics: Adrenal Cortex Hormones; Aged; Aged, 80 and over; Bronchoscopy; Databases, Factual; Disease Progression; Female; Humans; Idiopathic Pulmonary Fibrosis; Intensive Care Units; Japan; Kaplan-Meier Estimate; Logistic Models; Macrolides; Male; Middle Aged; Multivariate Analysis; Prognosis; Respiration, Artificial; Respiratory Insufficiency; Retrospective Studies; Survival Rate; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

A 76-year-old female with advanced renal cell carcinoma had been treated with everolimus for 3 months. She visited our hospital because of a cough and fever lasting a few days. Chest X-rays showed bilateral infiltrative shadows, and a chest computed tomography scan showed homogeneous ground-glass opacities with mosaic patterns, especially in the apical region. The laboratory results revealed a decreased white blood cell count with lymphocytopenia and high levels of lactate dehydrogenase, C-reactive protein and KL-6. Pneumonitis was suspected and, therefore, everolimus therapy was interrupted. At that time, the pneumonitis was thought to be drug-induced interstitial lung disease. However, it was not possible to rule out pneumocystis pneumonia, because the patient was immunocompromised and the computed tomography findings suggested the possibility of pneumocystis pneumonia. The pneumonitis progressed rapidly and the patient developed respiratory failure, so we performed bronchoalveolar lavage to make a definitive diagnosis, and simultaneously started treatment with prednisolone and trimethoprim-sulfamethoxazole to cover both interstitial lung disease and pneumocystis pneumonia. A polymerase chain reaction assay of the bronchoalveolar lavage fluid was positive for Pneumocystis carinii DNA, and the serum level of β-d-glucan was significantly elevated. Thus, the patient was diagnosed with pneumocystis pneumonia, which was cured by the treatment. Interstitial lung disease is a major adverse drug reaction associated with everolimus, and interstitial lung disease is the first condition suspected when a patient presents with pneumonitis during everolimus therapy. Pneumocystis pneumonia associated with everolimus therapy is rare, but our experience suggests that pneumocystis pneumonia should be considered as a differential diagnosis when pneumonitis is encountered in patients receiving everolimus therapy.

Topics: Aged; Anti-Infective Agents; Antineoplastic Agents; Bronchoalveolar Lavage; Carcinoma, Renal Cell; Diagnosis, Differential; Drug Administration Schedule; Everolimus; Female; Humans; Immunocompromised Host; Immunosuppressive Agents; Kidney Neoplasms; Lung Diseases, Interstitial; Pneumocystis carinii; Pneumonia, Pneumocystis; Polymerase Chain Reaction; Respiratory Insufficiency; Sirolimus; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Nocardia concava was identified as a new species in 2005; however, the clinical manifestations of Nocardia concava infection have yet to be clarified. We herein present the case of an immunosuppressed patient who developed disseminated nocardiosis caused by N. concava with multiple abscesses in the lungs, cutis, subcutaneous tissue, skeletal muscles and kidneys accompanied by central nervous system involvement, including meningitis and ventriculitis. The patient was cured with appropriate treatment including linezolid after testing for susceptibility. Linezolid should be considered as an alternative agent for treating disseminated nocardiosis because of its effective distribution to multiple sites.

Topics: Acetamides; Acute Disease; Aged; Anti-Bacterial Agents; Central Nervous System Diseases; Humans; Immunocompromised Host; Linezolid; Male; Microbial Sensitivity Tests; Minocycline; Nocardia; Nocardia Infections; Oxazolidinones; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination

A 22-year-old man was admitted to our hospital with fever, cough and dyspnea. His chest radiograph showed diffuse ground-glass attenuation in both lung fields. Arterial blood gas analysis showed hypoxemia (PaO2 28.7 Torr breathing room air) and he required mechanical ventilation within 6 hours after admission. Gomori methenamine silver (GMS) stain of the bronchoalveolar lavage (BAL) fluid smear showed round and indented organisms, and polymerase chain reaction revealed pneumocystis jirovecii in the BAL fluid. The HIV antibody was positive and peripheral blood CD4-positive lymphocytes decreased to 4.0%. Pneumocystis pneumonia complicated with acquired immunodeficiency syndrome (AIDS) was diagnosed. There was no four-fold rise in screen viral titers. We treated him with antibiotics, trimethoprim-sulfamethoxazole, ganciclovir, fos-fluconazole, steroid pulse therapy and sivelestat sodium hydrate. Respiratory failure was relieved within 5 days following treatment. The percentage of neutrophils in the BAL fluid was elevated (44.6%). Neutrophil elastase on admission was increased and improved to the normal range after treatment. Sivelestat sodium hydrate is an anti-neutrophil elastase inhibitor and may be one of the treatment options for acute respiratory failure due to pneumocystis pneumonia in AIDS patients.

Topics: Acquired Immunodeficiency Syndrome; Acute Disease; Adult; Drug Therapy, Combination; Ganciclovir; Glycine; Humans; Male; Methylprednisolone; Pneumonia, Pneumocystis; Proteinase Inhibitory Proteins, Secretory; Pulse Therapy, Drug; Respiratory Insufficiency; Severity of Illness Index; Sulfonamides; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adult; Anti-Infective Agents; Chorionic Gonadotropin, beta Subunit, Human; Female; Humans; Hydatidiform Mole, Invasive; Immunosuppressive Agents; Methotrexate; Opportunistic Infections; Pneumocystis carinii; Pneumonia, Pneumocystis; Pregnancy; Respiratory Insufficiency; Retreatment; Trimethoprim, Sulfamethoxazole Drug Combination; Uterine Neoplasms; Vacuum Extraction, Obstetrical

We report a case of acute respiratory failure due to Toxoplasma gondii mimicking pneumocystosis in an AIDS patient. Empirical antibiotic therapy with cotrimoxazole is discussed. Active research and identification of pathogens with adapted laboratory tests is mandatory.

Topics: Acute Disease; Adult; AIDS-Related Opportunistic Infections; Anti-Infective Agents; Anti-Inflammatory Agents; Diagnosis, Differential; Humans; Lung Diseases, Parasitic; Male; Methylprednisolone; Respiratory Insufficiency; Toxoplasmosis; Trimethoprim, Sulfamethoxazole Drug Combination

Pneumocystis carinii (P. carinii) is one of the major opportunistic pathogens responsible for hematopoietic stem cell transplantation (HSCT)-related pneumonias. Although trimethoprim-sulfamethoxazol (TMP/SMX) prophylaxis has been shown to prevent almost all P. carinii infections, 1%-2% of patients may still experience this complication. P. carinii pneumonia (PCP) is usually a late complication in patients receiving TMP/SMX prophylaxis, with most cases occurring later than 2 months post-transplant. We report a patient who developed early onset PCP after allogeneic peripheral blood stem cell transplantation (PBSCT) from an HLA-identical sibling donor. On day 12, the patient complained of dyspnea and cough. A chest X ray showed infiltrates in right upper lobe with bilateral pleural effusion. By the findings of Grocott stain on bronchoalveolar lavage fluid obtained on day 14, he was diagnosed as having PCP. Intravenous TMP/SMX failed to improve the lesion. This is the earliest onset PCP in the literature after HSCT despite the prophylactic administration of TMP/SMX before transplant.

Topics: Antibiotic Prophylaxis; Antineoplastic Combined Chemotherapy Protocols; Asparaginase; Combined Modality Therapy; Cytarabine; Daunorubicin; Etoposide; Fatal Outcome; Hematopoietic Stem Cell Transplantation; Humans; Immune System; Immunocompromised Host; Male; Methotrexate; Middle Aged; Opportunistic Infections; Pneumonia, Pneumocystis; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Prednisolone; Respiratory Insufficiency; Transplantation Conditioning; Transplantation, Autologous; Trimethoprim, Sulfamethoxazole Drug Combination; Vincristine; Whole-Body Irradiation

Topics: Adolescent; Anti-Bacterial Agents; Ehrlichia chaffeensis; Ehrlichiosis; Humans; Male; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Bordetella pertussis; Cough; Diagnosis, Differential; Disease Progression; Erythromycin; Humans; Infant; Lymphocytosis; Male; Microbial Sensitivity Tests; Nasopharynx; Respiratory Insufficiency; Respiratory Tract Infections; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination; Whooping Cough

To determine whether foals with pneumonia that were treated with erythromycin, alone or in combination with rifampin or gentamicin, had a higher risk of developing adverse effects, compared with foals treated with trimethoprim-sulfamethoxazole (TMS), penicillin G procaine (PGP), or a combination of TMS and PGP (control foals).. Retrospective study.. 143 foals < 240 days old.. Information on age, sex, breed, primary drug treatment, total days of treatment with the primary drug, and whether the foal developed diarrhea, hyperthermia, or respiratory distress was obtained from the medical records. Relative risk (RR) and attributable risk (AR) were calculated to compare risk of adverse reactions between foals treated with erythromycin and control foals.. Only 3 (4.3%) control foals developed diarrhea; none developed hyperthermia or respiratory distress. Foals treated with erythromycin had an 8-fold risk (RR, 8.3) of developing diarrhea, compared with control foals, and increased risks of hyperthermia (AR, 25%) and respiratory distress (AR, 15%).. Results suggest that use of erythromycin to treat foals with pneumonia was associated with an increased risk of diarrhea, hyperthermia, and respiratory distress, compared with use of TMS or PGP.

Topics: Animals; Animals, Newborn; Anti-Bacterial Agents; Anti-Infective Agents; Antibiotics, Antitubercular; Diarrhea; Drug Therapy, Combination; Erythromycin; Female; Fever; Gentamicins; Horse Diseases; Horses; Male; Penicillin G Procaine; Penicillins; Pneumonia; Respiratory Insufficiency; Retrospective Studies; Rifampin; Risk Factors; Trimethoprim, Sulfamethoxazole Drug Combination

To characterize clinical, diagnostic and course features of pneumonia caused by Pneumocystis carinii (PC) in hematologic inpatients.. 27 patients with blood diseases were studied. 22 of them had acute respiratory insufficiency and 5 had unclear lung affection. The data from bronchoalveolar lavage (BAL), lung biopsy, serum tests for IgG, IgM anti-PC-antibodies were used for diagnosis of PC-pneumonia.. PC-pneumonia was diagnosed in 8 of 27 patients. Clinical manifestations characteristic for PC-pneumonia were not found. In 5 patients the diagnosis was made on the evidence provided by BAL. Lymphocyte count in BAL was elevated to 27.7 +/- 8.7%. Open biopsy of the lung and transbronchial biopsy diagnosed PC-pneumonia in 2 and 1 patients, respectively. Previous BAL examinations failed to detect PC-pneumonia in 2 of them. In all the patients PC-pneumonia was associated with another infection (bacterial, cytomegaloviral). Histologically, the picture of the disease was determined by the severity of the lung affection or its complications. 5 of 8 patients failed treatment with trimethoprim-sulphamethoxazole and died. Marked respiratory insufficiency was registered at PC-pneumonia diagnosis in all the lethal cases.. Clinical and x-ray pictures of PC-pneumonia in hemoblastosis patients are not specific. All such patients with symptoms of lung infection resistant to antibacterial and antifungal therapy should be examined for PC-pneumonia.

Topics: Acute Disease; Adolescent; Adult; Aged; Anemia, Aplastic; Anemia, Refractory, with Excess of Blasts; Anti-Infective Agents; Biopsy; Bronchoalveolar Lavage Fluid; Female; Hematologic Diseases; Humans; Leukemia, Myelogenous, Chronic, BCR-ABL Positive; Leukemia, Myeloid; Lung; Lymphoproliferative Disorders; Male; Middle Aged; Multiple Myeloma; Pneumonia, Pneumocystis; Radiography, Thoracic; Respiratory Insufficiency; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination

To evaluate CD4 counts as a predictor of mortality in AIDS patients with respiratory failure due to Pneumocystis carinii pneumonia (PCP).. Retrospective chart review.. Urban university medical center.. Forty-eight patients admitted to the medical ICU from January 1993 to August 1996 with diagnosis of HIV/AIDS, PCP, CD4 count <200 cells per cubic millimeter, who required mechanical ventilation for respiratory failure.. Medical records were reviewed and age, CD4 count, lactate dehydrogenase, room air (RA) PaO2, coinfections, and day of admission to day of intubation (DOA-DOI) data were recorded.. All 48 patients (12 women and 36 men) were treated with corticosteroids and IV trimethoprim-sulfamethoxazole. Age ranged from 21 to 65 years; CD4, 1 to 180, RA PaO2, 27 to 93 mm Hg; and DOA-DOI, 0 to 20 days. Mortality varied significantly depending on CD4 counts: CD4 0 to 10 (100%); CD4 11 to 50 (88%); CD4 51 to 100 (50%); and CD4 >100 (25%). There were no significant difference in mortality between the groups with DOA-DOI <5 days (82%) vs >5 days (80%) or between the groups with PaO2 <60 mm Hg (85%) vs PaO2 >60 mm Hg (73%).. Even though overall mortality was 81%, the mortality rate was significantly different among the four groups. Most striking was the progressive increase in mortality as CD4 cells decreased from >100 (25% mortality) to <10 (100% mortality). Survivors had significantly higher CD4 cell counts than those who died. The CD4 cell count within 2 weeks of admission has significant prognostic value and may be helpful when counseling patients, families, and healthcare surrogates in end-of-life decision making.

Topics: Acquired Immunodeficiency Syndrome; Adrenal Cortex Hormones; Adult; Age Factors; Aged; Anti-Infective Agents; CD4 Lymphocyte Count; Comorbidity; Counseling; Decision Making; Evaluation Studies as Topic; Female; Florida; Forecasting; HIV Infections; Humans; L-Lactate Dehydrogenase; Male; Middle Aged; Oxygen; Patient Admission; Pneumonia, Pneumocystis; Prognosis; Respiration, Artificial; Respiratory Insufficiency; Retrospective Studies; Time Factors; Trimethoprim, Sulfamethoxazole Drug Combination

To examine the use of adjunctive corticosteroids in cases of severe Pneumocystis carinii pneumonia (PCP) in non-HIV-infected adult patients.. Retrospective review of medical records.. Tertiary care urban teaching hospital.. Review identified 31 consecutive histologically confirmed primary cases of adult non-HIV-related PCP. Complete records were available for 30 patients, including 20 male and 10 female patients with a mean age of 58.3+/-15 years (+/-SD). Underlying conditions included organ transplantation (n=13), long-term immunosuppressive therapy (n=9), and chemotherapy for malignancy (n=8). All patients had documented PO2 <65 mm Hg or arterial oxygen saturation <90% on room air.. Following the identification of P carinii, in addition to trimethoprim-sulfamethoxazole or pentamidine therapy, 16 patients received increased steroids (> or =60 mg prednisone daily equivalent; increased high-dose steroid group), whereas 14 patients were maintained on a regimen of low doses (< or =30 mg prednisone equivalent daily) or had steroid therapy tapered (low-dose steroid group).. The increased high-dose steroid group demonstrated a shorter required duration for mechanical ventilation (6.3+/-6 days vs 18.0+/-21 days; p=0.047), a shorter duration of ICU admission (8.5+/-7 days vs 15.8+/-8 days; p=0.025), and a shorter duration of supplemental oxygen use (10.0+/-4 vs 32.2+/-33; p=0.05). The hospital duration to discharge for the nine survivors in each group favored the use of corticosteroids (15.4+/-5 days vs 36.3+/-33 days; p=0.077). Similar rates were observed for intubation (75% vs 57%; p=0.442) and in-hospital mortality (44% vs 36%; p=0.722).. These preliminary data suggest that high-dose adjunctive corticosteroids may accelerate recovery in cases of severe adult non-HIV PCP.

Topics: Anti-Infective Agents; Antifungal Agents; Drug Therapy, Combination; Female; Glucocorticoids; HIV Infections; Humans; Intubation, Intratracheal; Male; Middle Aged; Opportunistic Infections; Pentamidine; Pneumonia, Pneumocystis; Prednisone; Respiration, Artificial; Respiratory Insufficiency; Retrospective Studies; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adrenal Cortex Hormones; Adult; Humans; Male; Methylprednisolone; Pneumonia, Mycoplasma; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Drug Hypersensitivity; Fever; Heart Arrest; HIV Infections; Humans; Hypotension; Infant; Male; Respiratory Insufficiency; Tachycardia; Trimethoprim, Sulfamethoxazole Drug Combination

Seven cases of single lung transplantation are reported. The recipients were all below 60 years of age and severely disabled with end-stage lung disease. Transplantation was performed according to ABO blood group compatibility and negative lymphocytotoxic cross-match between donor and recipient irrespective of HLA mismatch. Recipients' diagnoses were sarcoidosis (3), alfa-1 antitrypsin deficiency (3), and idiopathic emphysema (1). Mean recipient age was 48 +/- 2.4 years (range 45-52). Donor age was 29.7 +/- 5.6 years (range 16-49). The immunosuppressive regimen included cyclosporin A, azathioprine, steroids and rabbit antithymocyte globulin. Excellent graft function was achieved. Six patients survived the postoperative period and are alive 4-18 months posttransplant. One patient died after the operation due to pneumonia with respiratory distress syndrome. Graft function was also monitored by transbronchial biopsy, and 57 biopsy procedures were performed without fatal complications. Acute cellular rejection was seen in 16 biopsy specimens from 5 recipients (grade 1 and 2 rejection in 14, grade 3 rejection in 2). Neither severe rejection with septal necrosis (grade 4) nor obliterative bronchiolitis was seen. The rejection rate was 0.03 episodes per patient/month. In contrast to other reports, episodes of cellular rejection occurred throughout the observation period, and were not mainly limited to the first 4 months posttransplant. Graft vascular occlusive disease or chronic vascular rejection was found in 6 biopsy specimens from one recipient. Five patients experienced 7 episodes of cytomegalovirus infection. The cytomegalovirus infection rate was 0.01 episodes per patient/month. The incidence of infection was significantly lower compared to previous studies of rejection in other lung graft combinations. Both infections and rejection episodes may contribute to the development of obliterative bronchiolitis. Almost one third of the specimens (30%) showed lymphocytic bronchitis without perivascular inflammation. The absence of perivascular infiltrates and exclusion of infectious agents leaves in question the aetiology of this inflammation. The lymphocytic bronchitis could be ischaemic, related to aspiration, or represent recurrent sarcoidosis, or, in fact, express bronchial rejection. All biopsy specimens regarded as rejection with cellular infiltrates in the lung parenchyma also showed a lymphocytic bronchitis. The impact of HLA mismatch on cellular and vascu

Topics: Adult; alpha 1-Antitrypsin Deficiency; Biopsy, Needle; Bronchiolitis; Cytomegalovirus Infections; Emphysema; Female; Ganciclovir; Graft Rejection; Humans; Immunosuppression Therapy; Lung; Lung Diseases, Fungal; Lung Transplantation; Male; Middle Aged; Pneumonia, Pneumocystis; Respiratory Insufficiency; Sarcoidosis; Trimethoprim, Sulfamethoxazole Drug Combination

Corticosteroids have proven effective as adjunctive therapy for the treatment of PCP in patients with AIDS, when begun within 72 h of conventional anti-Pneumocystis therapy. Their efficacy as rescue (or salvage) therapy in patients who have failed conventional therapy, however, remains unproven. Ths report presents our experience with 16 patients admitted to our MICU for acute respiratory failure (PaO2/FIO2 ratio less than or equal to 150) due to PCP. Five of six patients (83 percent) who received "primary" CS rescue (initial CS use prompted by acute respiratory failure after 72 h of conventional anti-Pneumocystis therapy) survived hospitalization. Our experience suggests that CSs may be effective even when started after 72 h of conventional therapy. Additional studies are needed to clarify the role of CS rescue therapy.

Topics: Acquired Immunodeficiency Syndrome; Adult; Critical Care; Humans; Methylprednisolone; Pentamidine; Pneumonia, Pneumocystis; Prednisone; Respiratory Insufficiency; Salvage Therapy; Time Factors; Trimethoprim, Sulfamethoxazole Drug Combination

Patients with acquired immunodeficiency syndrome who have Pneumocystis carinii pneumonia (PCP) and respiratory failure have a high mortality. Previous reports have suggested that corticosteroids administered in conjunction with antibiotics improve the outcome in these patients. We reviewed our experience with adjunctive corticosteroids in 20 patients with acquired immunodeficiency syndrome and respiratory failure due to PCP to determine if this was the case. Fourteen patients responded to therapy with initial reversal of their respiratory failure. However, nine of these relapsed with recurrence of respiratory failure after steroid therapy was withdrawn. Eight (40%) of the patients remained alive and well 3 months or more following treatment. When the analysis was restricted to patients requiring intubation, only 25% were alive 3 months later. Despite good initial response to steroids in PCP and respiratory failure, survival remains limited. Controlled trials are needed to define better the role of steroid treatment in these patients.

Topics: Acquired Immunodeficiency Syndrome; Drug Therapy, Combination; Female; Humans; Male; Methylprednisolone; Methylprednisolone Hemisuccinate; Pentamidine; Pneumonia, Pneumocystis; Recurrence; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Antifungal Agents; Drug Combinations; Glucuronates; Humans; Immunologic Deficiency Syndromes; Infant; Infusions, Intravenous; Leucovorin; Male; Pentamidine; Pneumonia, Pneumocystis; Quinazolines; Respiratory Insufficiency; Trimethoprim, Sulfamethoxazole Drug Combination; Trimetrexate

Pulmonary infection is a frequent cause of morbidity and mortality in patients with acquired immunodeficiency syndrome (AIDS), and Pneumocystis carinii pneumonia (PCP) is the predominant infection in these patients. In those patients who experience progression to respiratory failure from PCP, the reported mortality rate has been between 87% to 100%. This, in addition to the ultimately fatal outcome of patients with AIDS, has led many physicians to question the advisability of instituting mechanical support for respiratory failure in the setting of PCP. It had been our impression that the outcome of patients on our service was not as poor as was generally reported. We therefore undertook a retrospective analysis of our clinical experience.. We reviewed the clinical course of patients admitted to our service between December 1984 and June 1988 who required intubation and mechanical ventilation for PCP or presumed PCP.. Thirty-three cases were identified with 18 survivors (54.5%) and 15 non-survivors (45.5%). Twenty-five of the 33 patients were intubated for their first episode of PCP, with 16 survivors (64%), whereas the remaining eight patients were intubated for their second episode of PCP, with two survivors (25%). We were not able to identify any parameters that predicted survival, although the serum lactate dehydrogenase level was useful in following the response to treatment.. It is our belief that there is a reasonable chance of survival for patients requiring mechanical ventilation for PCP. We question the wisdom of avoiding intubation and mechanical ventilation altogether in patients with PCP due to the presumption of fatality in this clinical situation.

Topics: Acquired Immunodeficiency Syndrome; Adult; Anti-Infective Agents; Bronchoscopy; Female; Humans; Intubation, Intratracheal; L-Lactate Dehydrogenase; Male; Pneumonia, Pneumocystis; Prognosis; Respiration, Artificial; Respiratory Insufficiency; Retrospective Studies; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Acquired Immunodeficiency Syndrome; Biopsy; Bronchoscopy; Cytomegalovirus Infections; Drug Combinations; Drug Therapy, Combination; Humans; Lung Diseases; Mycobacterium Infections, Nontuberculous; Pentamidine; Pneumonia, Pneumocystis; Radiography, Thoracic; Respiratory Insufficiency; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary