trimethoprim--sulfamethoxazole-drug-combination and Tuberculosis--Pulmonary

Tuberculosis (TB) is an important cause of illness and death in HIV-positive children living in areas of high TB prevalence. We know that isoniazid prophylaxis prevents TB in HIV-negative children following TB exposure, but there is uncertainty related to its role in TB preventive treatment in HIV-positive children.. To summarise the effects of TB preventive treatment versus placebo in HIV-positive children with no known TB contact on active TB, death, and reported adverse events.. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, Embase and two trial registers up to February 2017.. We included trials of HIV-positive children with and without known TB exposure, randomized to receive TB preventive treatment or placebo.. Two review authors independently used the study selection criteria, assessed risk of bias, and extracted data. We assessed effects using risk, incidence rate and hazard ratios and assessed the certainty of evidence using GRADE.. We included three trials, involving 991 participants, below the age of 13 years, from South Africa and Botswana. Children were randomized to isoniazid prophylaxis or placebo, given daily or three times weekly. The median length of follow-up ranged from 5.7 to 34 months; some were on antiretroviral therapy (ART).In HIV-positive children not on ART, isoniazid prophylaxis may reduce the risk of active TB (hazard ratio (HR) 0.31, 95% confidence interval (CI) 0.11 to 0.87; 1 trial, 240 participants, low certainty evidence), and death (HR 0.46, 95% CI 0.22 to 0.95; 1 trial, 240 participants, low certainty evidence). One trial (182 participants) reported number of children with laboratory adverse events, which was similar between the isoniazid prophylaxis and placebo groups. No clinical adverse events were reported.In HIV-positive children on ART, we do not know if isoniazid prophylaxis reduces the risk of active TB (risk ratio (RR) 0.76, 95% CI 0.50 to 1.14; 3 trials, 737 participants, very low certainty evidence) or death (RR 1.45, 95% CI 0.78 to 2.72; 3 trials, 737 participants, very low certainty evidence). Two trials (714 participants) reported number of clinical adverse events and three trials (795 participants) reported number of laboratory adverse events; for both categories, the number of adverse events were similar between the isoniazid prophylaxis and placebo groups.. Isoniazid prophylaxis given to all children diagnosed with HIV may reduce the risk of active TB and death in HIV-positive children not on ART in studies from Africa. For children on ART, no clear benefit was detected. .

Topics: AIDS-Related Opportunistic Infections; Anti-HIV Agents; Antitubercular Agents; Child; HIV Infections; Humans; Incidence; Isoniazid; Randomized Controlled Trials as Topic; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Multidrug-Resistant; Tuberculosis, Pulmonary

Antiretroviral therapy (ART) is the main intervention needed to reduce morbidity and mortality and to prevent tuberculosis in adults living with HIV. However, in most resource-limited countries, especially in sub-Saharan Africa, ART is started too late to have an effect with substantial early morbidity and mortality, and in high tuberculosis burden settings ART does not reduce the tuberculosis risk to that reported in individuals not infected with HIV. Co-trimoxazole preventive therapy started before or with ART, irrespective of CD4 cell count, reduces morbidity and mortality with benefits that continue indefinitely. Isoniazid preventive therapy as an adjunct to ART prevents tuberculosis in high-exposure settings, with long-term treatment likely to be needed to sustain this benefit. Unfortunately, both preventive therapies are underused in low-income and high-burden settings. ART development has benefited from patient-centred simplification with several effective regimens now available as a one per day pill. We argue that co-trimoxazole and isoniazid should also be combined into a single fixed-dose pill, along with pyridoxine (vitamin B6), that would be taken once per day to help with individual uptake and national scale-up of therapies.

Topics: Adult; Africa South of the Sahara; Anti-HIV Agents; Antiretroviral Therapy, Highly Active; Antitubercular Agents; Coinfection; Drug Combinations; Female; HIV Infections; HIV-1; Humans; Isoniazid; Male; Mycobacterium tuberculosis; Tablets; Time Factors; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Vitamin B 6

Despite policies, strategies, and guidelines, the epidemic of HIV-associated tuberculosis continues to rage, particularly in southern Africa. We focus our attention on the regions with the greatest burden of disease, especially sub-Saharan Africa, and concentrate on prevention of tuberculosis in people with HIV infection, a challenge that has been greatly neglected. We argue for a much more aggressive approach to early diagnosis and treatment of HIV infection in affected communities, and propose urgent assessment of frequent testing for HIV and early start of antiretroviral treatment (ART). This approach should result in short-term and long-term declines in tuberculosis incidence through individual immune reconstitution and reduced HIV transmission. Implementation of the 3Is policy (intensified tuberculosis case finding, infection control, and isoniazid preventive therapy) for prevention of HIV-associated tuberculosis, combined with earlier start of ART, will reduce the burden of tuberculosis in people with HIV infection and provide a safe clinical environment for delivery of ART. Some progress is being made in provision of HIV care to HIV-infected patients with tuberculosis, but too few receive co-trimoxazole prophylaxis and ART. We make practical recommendations about how to improve this situation. Early HIV diagnosis and treatment, the 3Is, and a comprehensive package of HIV care, in association with directly observed therapy, short-course (DOTS) for tuberculosis, form the basis of prevention and control of HIV-associated tuberculosis. This call to action recommends that both HIV and tuberculosis programmes exhort implementation of strategies that are known to be effective, and test innovative strategies that could work. The continuing HIV-associated tuberculosis epidemic needs bold but responsible action, without which the future will simply mirror the past.

Topics: Africa South of the Sahara; AIDS-Related Opportunistic Infections; Anti-Infective Agents; Anti-Retroviral Agents; Antitubercular Agents; Disease Outbreaks; Global Health; Government Programs; Health Facilities; Health Services Needs and Demand; HIV Infections; Humans; Infection Control; Isoniazid; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Children with HIV are at increased risk of acquiring tuberculosis (TB), a common cause of acute and chronic respiratory disease and death in HIV-infected children living in areas where prevalence of the disease is high. Children infected with HIV and TB have worse outcomes than HIV-uninfected children who have TB; thus, preventing the infection and disease in HIV-infected children is potentially an important public health intervention. Isoniazid, an anti-tuberculosis medication, has been used effectively to prevent TB in HIV-uninfected children, but currently there are no guidelines on the use of TB preventive therapy in HIV-infected children.. To determine the impact of TB preventive therapy on TB-related incidence and death in HIV-infected children. We searched the Cochrane Controlled Trials Register (CENTRAL/CCTR), Cochrane HIV/AIDS Group Specialized Register, MEDLINE/PubMed, EMBASE, and AIDSearch. In addition, we scanned reference lists, manually searched conference abstracts, and contacted content experts.. We included studies of HIV-infected children randomised to receive TB preventive therapy or placebo, or an alternative TB preventive regimen. Participants could have tuberculin skin test results that were positive or negative.. Two authors independently used the study selection criteria, assessed methodological quality and extracted data. Effects were assessed using hazard ratios.. One trial met the selection criteria for the review. The trial participants were HIV-infected children, most of whom were not taking antiretroviral therapy. Subjects were randomised to isoniazid and cotrimoxazole or placebo and cotrimoxazole, given daily or three times a week. The trial showed a marked reduction in TB incidence and death in the isoniazid group. As yet, however, there are no long-term follow-up data on the durability of the protective effect or on possible long-term adverse events. This trial also was unable to assess the impact of isoniazid prophylaxis on children receiving antiretroviral therapy.. Isoniazid prophylaxis in HIV-infected children has the potential to play a major public health role by reducing TB incidence and death. As yet, however, data are insufficient to guide the duration of prophylaxis and to support its use in children using highly active antiretroviral therapy (HAART) and in those living in areas of low TB prevalence. Further studies are needed to assess whether TB preventive therapy is of benefit in all HIV-infected children, irrespective of use of antiretroviral treatment, the optimal duration of preventive therapy, or long-term adverse events.

Topics: AIDS-Related Opportunistic Infections; Anti-HIV Agents; Antitubercular Agents; Child; HIV Infections; Humans; Incidence; Isoniazid; Randomized Controlled Trials as Topic; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Multidrug-Resistant; Tuberculosis, Pulmonary

Human immunodeficiency virus (HIV)/acquired immunedeficiency syndrome (AIDS) and tuberculosis (TB) cause an immense burden of disease in sub-Saharan Africa. A large amount of knowledge has been gathered in the last 15 years about the negative impact that HIV has on TB control, both at a programme level and at the level of the individual patient. Equally, interventions that are known to benefit patients have been tested and piloted, and these form important components of international TB-HIV guidelines, a TB-HIV strategic framework and an interim policy on TB-HIV coordination. Unfortunately, in sub-Saharan Africa there is little evidence that these interventions are being implemented on the ground, and one of the reasons for this paralysis is that the operational details are not well developed. This paper takes the three important HIV interventions of HIV testing and counselling, cotrimoxazole preventive treatment and antiretroviral treatment, and discusses some of the practical details of on-the-ground implementation. We hope that this will generate discussion, but above all, the impetus to start delivering services to patients.

Topics: Africa South of the Sahara; Antiviral Agents; HIV; HIV Infections; Humans; Infection Control; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Topics: 2-Aminopurine; Acyclovir; AIDS-Related Opportunistic Infections; Anti-Bacterial Agents; Anti-HIV Agents; Antifungal Agents; Antitubercular Agents; Antiviral Agents; Azithromycin; Chickenpox; Clarithromycin; Cytomegalovirus Infections; Drug Therapy, Combination; Famciclovir; Ganciclovir; Herpes Simplex; Humans; Mycobacterium avium-intracellulare Infection; Mycoses; Pneumonia, Pneumocystis; Rifabutin; Toxoplasmosis; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Topics: Acyclovir; AIDS-Related Opportunistic Infections; Anti-HIV Agents; Anti-Infective Agents; Antitubercular Agents; Antiviral Agents; Atovaquone; Azithromycin; Chickenpox; Clarithromycin; Cytomegalovirus Infections; Drug Therapy, Combination; Ganciclovir; Herpes Simplex; Humans; Mycobacterium avium-intracellulare Infection; Naphthoquinones; Pneumonia, Pneumocystis; Rifabutin; Toxoplasmosis; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Valacyclovir; Valine

Topics: 2-Aminopurine; Acyclovir; AIDS-Related Opportunistic Infections; Anti-Infective Agents; Antifungal Agents; Antiprotozoal Agents; Antiretroviral Therapy, Highly Active; Antitubercular Agents; Antiviral Agents; Atovaquone; Azithromycin; Clarithromycin; Cytomegalovirus Infections; Drug Therapy, Combination; Famciclovir; Herpes Simplex; Herpes Zoster; Humans; Mycobacterium avium-intracellulare Infection; Mycoses; Naphthoquinones; Pneumonia, Pneumocystis; Toxoplasmosis; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Valacyclovir; Valine

The burden of human immunodeficiency virus (HIV)-related disease in sub-Saharan Africa continues to increase; providing adequate care for the huge number of people affected is a daunting task, especially given the limited resources available. Recent studies have shown that low-cost regimens can prevent some of the most important causes of HIV-related disease in African countries. Isoniazid preventive therapy can reduce the incidence of tuberculosis; priorities are to seek opportunities for implementation, to assess effectiveness under operational conditions, and to monitor its effect on resistance patterns. Cotrimoxazole was shown to be highly effective in reducing morbidity and mortality among individuals with symptomatic HIV disease in Côte d'Ivoire, and should be implemented where it is likely to be of benefit. Pneumococcal polysaccharide vaccine was disappointingly ineffective among HIV-infected Ugandan adults, but newer conjugate vaccines are becoming available that should be investigated. The benefit of these preventive regimens to the individual may be modest when compared with the effect of antiretroviral therapy. However, simple preventive therapies could reach a much wider population than is immediately feasible for expensive and complex antiretroviral regimens, and thus have the potential for substantial benefit at the population level. The availability of effective and affordable regimens to prevent HIV-related disease may also encourage people to seek HIV testing, combat denial, and help overcome the sense of powerlessness in countries where the HIV epidemic has hit hardest.

Topics: Adult; Africa; AIDS-Related Opportunistic Infections; Anti-Infective Agents; Antitubercular Agents; Humans; Isoniazid; Preventive Health Services; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Pneumocystis carinii pneumonia (PCP) is one of the leading complications among HIV-infected patients. Recent advances in PCP prophylaxis, diagnosis and treatment have caused a decrease in PCP-related morbidity and mortality. Despite these advances, PCP continues to be frequent in patients not known to be HIV-infected and in those patients with poor adherence to prophylactic regimens or severe immunosuppression. In typical cases diagnosis may be suspected by the patient's clinical presentation. Clinicians are frequently faced with the differential diagnosis between PCP, bacterial pneumonia, pulmonary tuberculosis, and other specific respiratory disorders HIV-associated. Definitive diagnosis of PCP requires demonstration of Pneumocystis carinii (PC) in respiratory secretions or lung tissue. Conventional techniques, immunofluorescence using monoclonal antibodies and molecular techniques are highly specific, but sensitivity varies depending on the PC load present in the sample. Best diagnostic yield is obtained analyzing samples obtained by bronchoalveolar lavage. PC diagnosis using highly sensitive PCR in sputum-induced samples might allow noninvasive diagnosis in most HIV-infected patients suffering from PCP but PCR techniques remain to be standardized. Like in PCP prophylaxis, trimethoprim-sulphametoxazole (TS) is the drug of choice for PCP treatment. In severe case, TS is given intravenously. If patient is intolerant to TS, i.v. pentamidine or i.v. trimetrexate with folinic acid can be used. TS has a dose-dependent toxicity. In cases of hypersensitivity to TS, drug-desensitization should be tried. In severe documented PCP adjunctive corticosteroid therapy is effective and safe. In mild to moderate PCP, TS can be given orally. Best alternatives to TS in this situation are dapsone-pyrimethamine or clindamycin-primaquine (CP). Other effective options are oral atovaquone, aerosolize pentamidine and i.v. pentamidine.

Topics: AIDS-Related Opportunistic Infections; Anti-Infective Agents; Bronchoalveolar Lavage Fluid; Diagnosis, Differential; DNA, Bacterial; Humans; Pneumocystis; Pneumonia, Bacterial; Pneumonia, Pneumocystis; Polymerase Chain Reaction; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Thanks to a simplification of surgical techniques, single or double lung transplants have expanded significantly in latter years. Infection remains an important cause for morbidity and mortality, more so in early rather than late stages. Bacterial infections cause approximately fifty per cent of all infections. They can be prevented in part by prophylaxis. Infections to CMV have become less frequent thanks to adequate prophylaxis with ganciclovir. Herpetic infections are prevented by acyclovir or ganciclovir. A better control of immunosuppression seems to be associated with fewer lymphoproliferative disorders secondary to the Epstein-Barr virus. Respiratory viruses remain a serious threat for these patients, although infections due to respiratory syncitial virus may be attenuated by ribavirine. Fungal infections are dangerous but prophylactic prescription of azole derivatives have reduced the incidence and severity. Prophylaxis of infections to Pneumocystis carinii is essential, the use of sulfamethoxazole trimethoprim is efficacious against this as well as nocardiosis. Infections to Mycobacterium tuberculosis are often atypical and should be looked for and anticipated whenever possible.

Topics: Acyclovir; Antibiotic Prophylaxis; Antifungal Agents; Antiviral Agents; Bacterial Infections; Chemoprevention; Cytomegalovirus Infections; Ganciclovir; Graft Survival; Heart-Lung Transplantation; Herpesviridae Infections; Herpesvirus 4, Human; Humans; Immunosuppression Therapy; Lung Transplantation; Lymphoproliferative Disorders; Mycobacterium Infections, Nontuberculous; Nocardia Infections; Pneumonia, Pneumocystis; Respiratory Syncytial Virus Infections; Ribavirin; Survival Rate; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Tumor Virus Infections; Virus Diseases

A large number and variety of organisms can infect the lungs of persons with AIDS. An abnormal chest X-ray associated with pulmonary symptoms should trigger a vigorous search for an infectious agent. In many cases, if the patient is ambulatory, the workup can proceed on an outpatient basis. Pneumocystis carinii pneumonia is the most common infection and also one of the most readily treatable illnesses that these patients encounter. A careful and considered diagnostic approach is necessary to conserve the time and resources of both patients and healthcare providers.

Topics: Acquired Immunodeficiency Syndrome; Ambulatory Care; Cytomegalovirus Infections; Humans; Mycobacterium avium-intracellulare Infection; Mycoses; Opportunistic Infections; Pentamidine; Pneumonia; Pneumonia, Pneumocystis; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa.. The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices.. Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$ 265 (95%CI 254-275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up.

Topics: Adult; Anti-HIV Agents; Antiretroviral Therapy, Highly Active; CD4 Lymphocyte Count; Delivery of Health Care; Disease Progression; Female; Health Care Costs; Health Resources; HIV Infections; Humans; Male; Meningitis, Cryptococcal; Public Health Systems Research; Tanzania; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Zambia

To assess the impact of prophylactic oral co-trimoxazole in reducing mortality in HIV positive Zambian adults being treated for pulmonary tuberculosis.. Double blind placebo controlled randomised clinical trial.. Two groups of antiretroviral treatment naive adults with HIV infection: patients newly diagnosed as having tuberculosis and receiving tuberculosis treatment either for the first time or for retreatment after relapse; previously treated patients not receiving treatment.. Oral co-trimoxazole or matching placebo daily. Primary outcome measures Time to death and occurrence of serious adverse events related to study drug.. 1003 patients were randomised: 835 (416 co-trimoxazole, 419 placebo) were receiving treatment for tuberculosis, 762 (376 co-trimoxazole, 386 placebo) of them newly diagnosed previously untreated patients and 73 (40 co-trimoxazole, 33 placebo) receiving a retreatment regimen; 168 (84 co-trimoxazole, 84 placebo) were not on treatment but had received treatment in the past. Of 835 participants receiving tuberculosis treatment, follow-up information was available for 757, with a total of 1012.6 person years of follow-up. A total of 310 (147 co-trimoxazole, 163 placebo) participants died, corresponding to death rates of 27.3 and 34.4 per 100 person years. In the Cox regression analysis, the hazard ratio for death (co-trimoxazole:placebo) was 0.79 (95% confidence interval 0.63 to 0.99). The effect of co-trimoxazole waned with time, possibly owing to falling adherence levels; in a per protocol analysis based on patients who spent at least 90% of their time at risk supplied with study drug, the hazard ratio was 0.65 (0.45 to 0.93).. Prophylaxis with co-trimoxazole reduces mortality in HIV infected adults with pulmonary tuberculosis. Co-trimoxazole was generally safe and well tolerated.. Current Controlled Trials ISRCTN15281875.

Topics: Administration, Oral; Adolescent; Adult; Aged; Anti-Infective Agents; Double-Blind Method; Epidemiologic Methods; Female; HIV Infections; Humans; Male; Middle Aged; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

The proportion of patients with antituberculosis drug-induced hepatotoxicity (ATDH) was unexpectedly low during a trial on cotrimoxazole prophylaxis in Malawian HIV-positive pulmonary tuberculosis patients. About 2% of the patients developed grade 2 or 3 hepatotoxicity during tuberculosis (TB) treatment, according to WHO definitions. Data on ATDH in sub-Saharan Africa are limited. Although the numbers are not very strong, our trial and other papers suggest that ATDH is uncommon in this region. These findings are encouraging in that hepatotoxicity may cause less problem than expected, especially in the light of combined HIV/TB treatment, where drug toxicity is a major cause of treatment interruption.

Topics: Adolescent; Adult; Age Distribution; Anti-Infective Agents; Antitubercular Agents; Chemical and Drug Induced Liver Injury; Drug Administration Schedule; Female; HIV Infections; Humans; Liver Diseases; Malawi; Male; Middle Aged; Sex Distribution; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

To assess the efficacy and safety of two different dosages of cotrimoxazole (CTX) in prophylaxis in HIV-positive new smear-positive pulmonary tuberculosis (TB) patients in Blantyre, Malawi.. Randomized, double-blind trial using 480 and 960 mg of CTX given to new TB patients, who were followed up until the end of the tuberculosis treatment. The primary outcome was survival. The outcome in the two groups was also compared with an unselected cohort of similar patients registered in Zomba, Malawi in 1995 and new smear-positive patients registered in the National Tuberculosis Programme in 1999. The secondary outcome was the occurrence of (opportunistic) events, especially bacterial pneumonia.. There were no statistically significant differences in mortality and bacterial pneumonia between the groups receiving the two different dosages. The case fatality rate at the end of the tuberculosis treatment was 15.4% in the 480 mg group and 14.0% in the 960 mg group. This was lower than the case fatality rate in the Zomba cohort (19.2%, P = 0.10) and lower than the case fatality rate in the national programme (21.0%, P < 0.001). CTX was well tolerated. Compliance was fair.. CTX prophylaxis may have a beneficial effect on mortality and morbidity in HIV-infected smear-positive tuberculosis patients in Malawi. The efficacy of both dosages is not significantly different. The intervention is cheap and easy to implement. These results would support implementation of CTX in this patient group until better strategies are available or evidence is convincingly presented to suggest that its benefit is marginal.

Topics: Adolescent; Adult; Antitubercular Agents; Double-Blind Method; Drug Administration Schedule; Female; HIV Infections; Humans; Malawi; Male; Middle Aged; Patient Compliance; Pneumonia; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Topics: Aged; Anti-Bacterial Agents; Antitubercular Agents; Coinfection; Culture Techniques; Diabetes Mellitus, Type 2; Humans; Immunocompetence; India; Male; Nocardia; Nocardia Infections; Sputum; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

 The World Health Organization aims to reduce tuberculosis (TB) mortality rate from 15% in 2015 to 6.5% by 2025..  This study determined the profile of TB and human immunodeficiency virus (HIV) co-infected patients who died in Mahalapye District, Botswana, while on anti-TB medication and the factors that contributed to such outcome..  The study was conducted in the Mahalapye Health District in Botswana..  This was a cross-sectional study that reviewed patient records from the Mahalapye District Health Management Team Electronic Tuberculosis Register from January 2013 to December 2015..  The majority of the TB and HIV co-infected patients were on antiretroviral therapy (ART) (486 [81.63%]) or were initiated cotrimoxazole preventive therapy (CPT) (518 [87.2%]) while taking anti-TB treatment. Seventy-three (13.6%) TB and HIV co-infected patients died before completing anti-TB treatment. Three-quarters (54 [74.4%]) of patients who died before completing anti-TB treatment were on ART, among them two patients who were on ART at least 3 months prior to commencing anti-TB. Also, the majority (64 [87.7%]) of TB and HIV co-infected patients were commenced on CPT prior to death. There was a bimodal density curve of death occurrence in those who did not commence ART and in those who did not commence CPT..  This study established that TB and HIV co-infected patients had a TB mortality of 13.6%. A high mortality rate was observed during the first 3 months in those who did not take ART and during the second and the fifth month in those who did not commence CPT. Further study is needed to clarify this matter.

Topics: Adolescent; Adult; Aged; Anti-HIV Agents; Antitubercular Agents; Botswana; Coinfection; Cross-Sectional Studies; Female; HIV Infections; Humans; Male; Middle Aged; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Young Adult

To identify the incidence of and predictors for tuberculosis in children living with HIV in Northern Ethiopia.. Observational, retrospective follow-up study.. A total of 645 HIV-infected children were observed between September 2009 and September 2014. Cox regression analysis was used to identify predictors for developing TB.. The incidence rate of tuberculosis was 4.2 per 100 child-years. Incidence of tuberculosis was higher for subjects who were not on cotrimoxazole preventive therapy, were not on isoniazid preventive therapy, had delayed motor development, had a CD4 cell count below the threshold, had hemoglobin level less than 10 mg/dl and were assessed as World Health Organization (WHO) clinical stage III or IV.. Incidence of TB in children living with HIV was high. This study reaffirmed that isoniazid preventive therapy is one of the best strategy to reduce incidence of TB in children living with HIV. All children living with HIV should be screened for TB but for children with delayed motor development, advanced WHO clinical stage, anemia or immune suppression, intensified screening is highly recommended.

Topics: Adolescent; AIDS-Related Opportunistic Infections; Antitubercular Agents; Child; Child, Preschool; Ethiopia; Female; Follow-Up Studies; Humans; Incidence; Isoniazid; Kaplan-Meier Estimate; Male; Proportional Hazards Models; Retrospective Studies; Risk Factors; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Nocardia, a branching, filamentous bacteria, is widely distributed in the environment and can cause human infection in immune-compromised hosts. Inhalation of Nocardia leads to pulmonary disease. Microbiology laboratory processed the clinical samples from patients with respiratory infections. Smears were prepared from the samples and were stained and cultured. Five cases were positive for Nocardia. They were treated with the trimethoprim-sulfamethoxazole combination. The disease was cured in three patients, and two died due to other comorbid conditions leading to complications. Nocardiosis is encountered in parts of the world even where it is not endemic due to increased world travel. So physicians and laboratory staff should be aware of this and try to diagnose it. Early detection can lead to the prompt initiation of treatment and reduced mortality in these patients. Patients with disseminated or severe nocardiosis should be treated with combination therapy with two or more active agents.

Topics: Adult; Aged; Amikacin; Anti-Bacterial Agents; Cough; Diabetes Mellitus; Dyspnea; Female; Humans; Imipenem; Immunocompromised Host; India; Male; Meropenem; Middle Aged; Nocardia Infections; Pneumonia, Bacterial; Pulmonary Disease, Chronic Obstructive; Thienamycins; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Co-trimoxazole use is the standard of care for preventing Pneumocystis jirovecii pneumonia in sub-Saharan Africa but implementation remains slow. Co-trimoxazole is self- administered with uncertain adherence. Knowledge of co-trimoxazole use among HIV infected persons is unknown.. To assess knowledge, attitudes and practices of co-trimoxazole use among HIV infected adults evaluated for recurrent PTB in Kampala, Uganda.. A qualitative study utilizing 5 focus group discussions among 30 HIV infected PTB suspects at the national referral tuberculosis treatment centre in Kampala.. Males and females had similar median ages. 80% were currently on co-trimoxazole and 50% of participants were on HAART. Majority of participants defined co-trimoxazole as an analgesic. Few noted co-trimoxazole was a drug to treat cough and chest pain. However, few responses revealed that co-trimoxazole prevents opportunistic diseases among PLHIV. Most of participants believed HAART and anti-TB drugs work as co-trimoxazole thus it should not be taken together with them. This belief may lead to increased risk of opportunistic infections, morbidity and mortality.. We revealed gaps in understanding of co-trimoxazole use among study participants. We therefore recommend that more facts about co-trimoxazle as prophylaxis against P. jirovecii, bacterial and diarrheal pathogens should be incorporated in VCT fact sheets.

Topics: Adolescent; Adult; AIDS-Related Opportunistic Infections; Ambulatory Care Facilities; Anti-Infective Agents; Antiretroviral Therapy, Highly Active; Cross-Sectional Studies; Female; Health Knowledge, Attitudes, Practice; HIV Infections; Hospitals, Teaching; Humans; Male; Qualitative Research; Recurrence; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Uganda

Pseudoclavibacter has rarely been documented as an etiologic agent of infection in humans. We presented the first case report of Pseudoclavibacter otitis media in a boy with pulmonary and spinal tuberculosis.A 3-year-old boy was referred to our hospital due to prolonged fever and progressive paraplegia for 3 months. He had yellowish discharge from both ear canals. The pleural fluid culture was positive for Mycobacterium tuberculosis. The discharge from both ears culture yielded yellow colonies of gram-positive bacilli with branching. This organism was positive for modified acid-fast bacilli stain but negative for acid-fast bacilli stain. Biochemical characteristics of this isolate were positive for catalase test but negative for oxidase, nitrate, esculin, and sugar utilization tests. The organism was further subjected to be identified by 16S ribosomal deoxyribonucleic acid gene sequencing. The result yielded Pseudoclavibacter species (99.4% identical), which could be most likely a potential pathogen in immunocompromised host like this patient. He responded well with intravenous trimetroprim-sulfamethoxazole for 6 weeks.This is the first case report of Pseudoclavibacter otitis media in children, and this case could emphasize Pseudoclavibacter species as a potential pathogen in immunocompromised host.

Topics: Actinomycetales; Actinomycetales Infections; Child, Preschool; Humans; Male; Mycobacterium tuberculosis; Otitis Media; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Tuberculosis, Spinal

Additional drugs are needed for the treatment of multidrug-resistant tuberculosis (TB). Sulfamethoxazole has been shown to have in vitro activity against Mycobacterium tuberculosis; however, there is concern about resistance given the widespread use of trimethoprim-sulfamethoxazole prophylaxis among HIV-infected patients in sub-Saharan Africa. Thirty-eight of 40 Mycobacterium tuberculosis isolates (95%) from pretreatment sputum samples from Ugandan adults with pulmonary TB, including HIV-infected patients taking trimethoprim-sulfamethoxazole prophylaxis, were susceptible with MICs of ≤38.4 μg/ml.

Topics: Adult; Antitubercular Agents; Drug Resistance, Multiple, Bacterial; Female; HIV Infections; Humans; Male; Mycobacterium tuberculosis; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Multidrug-Resistant; Tuberculosis, Pulmonary; Young Adult

Pulmonary alveolar proteinosis (PAP) is a rare disease with worldwide distribution and an estimated incidence of 0.36 cases per million. We report a case of a PAP coexisting with Pneumocystis jiroveci pneumonia and Mycobacterium tuberculosis infection. The patient was treated with serial lobar lung lavages, GM-CSF, cotrimoxazole, and antituberculosis drugs. His PaO2 on room air improved from 45.7 to 63.8 torr and pulmonary functions normalized (FVC 81.2%, FEV1 95.3%, FEV1/FVC 91.8). A high-resolution computed tomography scan of the thorax showed clearing of both lower lobes. Whole-lung lavage is used in the treatment of PAP, but it may worsen the hypoxemia and lead to hemodynamic instability during the procedure. To the best of our knowledge, there are no reports of bronchoscopic serial lobar lung lavages in cases of PAP performed in India. This method can be performed in bronchoscopic suites having general anesthesia facilities without the requirement of special gadgets.

Topics: Adult; Anti-Infective Agents; Bronchoalveolar Lavage; Bronchoscopy; Granulocyte-Macrophage Colony-Stimulating Factor; Humans; Hypoxia; India; Male; Oxygen; Periodic Acid-Schiff Reaction; Pneumonia, Pneumocystis; Pulmonary Alveolar Proteinosis; Respiration, Artificial; Respiratory Function Tests; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

In the April 2010 issue of this journal, Date et al. expressed concern over the slow scale-up in low-income settings of two therapies for the prevention of opportunistic infections in people living with the human immunodeficiency virus: co-trimoxazole prophylaxis and isoniazid preventive therapy. This short paper discusses the important ways in which policy analysis can be of use in understanding and explaining how and why certain evidence makes its way into policy and practice and what local factors influence this process. Key lessons about policy development are drawn from the research evidence on co-trimoxazole prophylaxis, as such lessons may prove helpful to those who seek to influence the development of national policy on isoniazid preventive therapy and other treatments. Researchers are encouraged to disseminate their findings in a manner that is clear, but they must also pay attention to how structural, institutional and political factors shape policy development and implementation. Doing so will help them to understand and address the concerns raised by Date et al. and other experts. Mainstreaming policy analysis approaches that explain how local factors shape the uptake of research evidence can provide an additional tool for researchers who feel frustrated because their research findings have not made their way into policy and practice.

Topics: AIDS-Related Opportunistic Infections; Anti-Infective Agents; Developing Countries; Evidence-Based Medicine; Health Resources; HIV Infections; Humans; Malawi; Poverty; Primary Prevention; Socioeconomic Factors; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Uganda; Zambia

The purpose of this report is to describe four cases of nocardiosis observed over an eight-year period in medical units of Principal Hospital in Dakar, Senegal. It is a rare infection occurring mainly in people with weakened immune systems. Pulmonary forms are predominate and clinical and laboratory presentation can mimic pulmonary tuberculosis. Diagnosis should be suspected in patients presenting pulmonary infections and negative sputum bacilloscopy. Nocardia bacteria should be identified before starting antibiotic treatment. Patients require long-term antibiotic treatment with third generation cephalosporins or sulfamethoxazole-trimethoprim.

Topics: Adult; AIDS-Related Opportunistic Infections; Anti-Bacterial Agents; Diagnosis, Differential; Female; HIV Infections; HIV-1; Humans; Immunocompromised Host; Male; Middle Aged; Nocardia Infections; Radiography, Thoracic; Senegal; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Topics: Antitubercular Agents; Humans; In Vitro Techniques; Microbial Sensitivity Tests; Mycobacterium tuberculosis; Sulfamethoxazole; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

New diagnoses of tuberculosis (TB) present important opportunities to detect and treat HIV. Rates of HIV and TB in Indonesia's easternmost Papua Province exceed national figures, but data on co-infection rates and outcomes are lacking. We aimed to measure TB-HIV co-infection rates, examine longitudinal trends, compare management with World Health Organisation (WHO) recommendations, and document progress and outcome.. Adults with newly-diagnosed smear-positive pulmonary TB managed at the Timika TB clinic, Papua Province, were offered voluntary counselling and testing for HIV in accordance with Indonesian National Guidelines, using a point-of-care antibody test. Positive tests were confirmed with 2 further rapid tests. Study participants were assessed using clinical, bacteriological, functional and radiological measures and followed up for 6 months.. Of 162 participants, HIV status was determined in 138 (85.2%), of whom 18 (13.0%) were HIV+. Indigenous Papuans were significantly more likely to be HIV+ than Non-Papuans (Odds Ratio [OR] 4.42, 95% confidence interval [CI] 1.38-14.23). HIV prevalence among people with TB was significantly higher than during a 2003-4 survey at the same TB clinic, and substantially higher than the Indonesian national estimate of 3%. Compared with HIV- study participants, those with TB-HIV co-infection had significantly lower exercise tolerance (median difference in 6-minute walk test: 25 m, p = 0.04), haemoglobin (mean difference: 1.3 g/dL, p = 0.002), and likelihood of cavitary disease (OR 0.35, 95% CI 0.12-1.01), and increased occurrence of pleural effusion (OR 3.60, 95% CI 1.70-7.58), higher rates of hospitalisation or death (OR 11.80, 95% CI 1.82-76.43), but no difference in the likelihood of successful 6-month treatment outcome. Adherence to WHO guidelines was limited by the absence of integration of TB and HIV services, specifically, with no on-site ART prescriber available. Only six people had CD4+ T-cell counts recorded, 11 were prescribed co-trimoxazole and 4 received ART before, during or after TB treatment, despite ART being indicated in 14 according to 2006 WHO guidelines.. TB-HIV co-infection in southern Papua, Indonesia, is a serious emerging problem especially among the Indigenous population, and has risen rapidly in the last 5 years. Major efforts are required to incorporate new WHO recommendations on TB-HIV management into national guidelines, and support their implementation in community settings.

Topics: Adult; Anti-Retroviral Agents; Antitubercular Agents; CD4 Lymphocyte Count; Coinfection; Female; HIV Infections; Humans; Indonesia; Male; Models, Biological; Prevalence; Prospective Studies; Regression Analysis; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Nocardia infections are rare among normal individuals. Mostly they occur in immuno-compromised individuals. Here, we report a case of pulmonary nocardiosis in a person who was diagnosed as having pulmonary tuberculosis and was treated with anti-tuberculous treatment for 6 months. But the sputum smear was positive even after a complete course of treatment. The patient was seropositive to HIV-1 antibodies.

Topics: Adult; AIDS-Related Opportunistic Infections; Anti-Bacterial Agents; Antitubercular Agents; Coinfection; HIV-1; Humans; Male; Nocardia asteroides; Nocardia Infections; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Pneumocystis jivorecii (formerly known as carinii) pneumonia (PCP) is potentially a life-threatening opportunistic infection after organ transplantation, occurring most frequently in the first 12 months, where the incidence rate is several-fold higher than in later years. PCP typically presents with fever, cough, dyspnoea and hypoxia. In organ transplant recipients, the onset of symptoms is generally more fulminant compared to patients infected with the human immunodeficiency virus. We present a patient who developed PCP five years after a renal transplantation. His presentation was characterised by atypical symptoms and an indolent onset. Previous acute vascular rejection, ongoing maintenance prednisolone usage, cytomegalovirus seropositivity and past tuberculous infection may have predisposed this patient to PCP.

Topics: Anti-Infective Agents; Bronchoscopy; Cytomegalovirus Infections; Graft Rejection; Humans; Immunosuppressive Agents; Kidney Transplantation; Male; Middle Aged; Pleural Effusion; Pneumonia, Pneumocystis; Prednisolone; Radiography, Thoracic; Risk Factors; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Temozolomide (TMZ) is a cytotoxic agent of the imidazotetrazine class, chemically related to dacarbazine. Its use poses higher risks of lymphopenia and opportunistic infections. Prophylaxis for Pneumocystis jiroveci must be considered up to 12 months after treatment discontinuation. The due literature (MEDLINE) makes no mention of a possible connection between the use of TMZ and tuberculosis (TB). A female patient, aged 59, featuring glioblastoma multiforme and having undergone solely a brain biopsy, was submitted to TMZ along with radiotherapy. After the first TMZ maintenance cycle, the referred patient was admitted displaying a background of a 40-day afternoon fever and productive coughing. She was thus submitted to a bronchoscopy and LBA, which resulted BAAR 1+/4+. TMZ was then suspended, and rifampicin, isoniazid, and pyrazinamide introduced. Considerations on prophylaxis with isoniazide in cancer patients are long-lived and scarce. Some subgroups are likely to benefit from the prophylactic administration of isoniazide during TMZ treatment, such as those patients under high doses of corticoids, patients with past medical history of TB, the malnourished, patients from endemic regions, and patients with highly reactive tuberculinic tests. That, nevertheless, must not restrict the administration of TMZ, but, rather, stand for a warning about its possible toxicity, and thus mitigate complications.

Topics: Anti-Infective Agents; Anti-Inflammatory Agents; Anti-Ulcer Agents; Antibiotics, Antitubercular; Anticholesteremic Agents; Anticonvulsants; Antineoplastic Agents, Alkylating; Atorvastatin; Brain Neoplasms; Combined Modality Therapy; Cyclosporine; Dacarbazine; Dexamethasone; Female; Fluoxetine; Glioblastoma; Heptanoic Acids; Humans; Immunosuppressive Agents; Isoniazid; Middle Aged; Omeprazole; Phenobarbital; Prednisone; Pyrazinamide; Pyrroles; Radiotherapy; Red-Cell Aplasia, Pure; Rifampin; Temozolomide; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

We conducted a prospective, multicenter observational cohort study in Thailand to characterize the epidemiology of extrapulmonary tuberculosis (TB) in HIV-infected persons and to identify risk factors for death.. From May 2005 to September 2006, we enrolled, interviewed, examined, and performed laboratory tests on HIV-infected adult TB patients and followed them from TB treatment initiation until the end of TB treatment. We conducted multivariate proportional hazards analysis to identify factors associated with death.. Of the 769 patients, pulmonary TB only was diagnosed in 461 (60%), both pulmonary and extrapulmonary TB in 78 (10%), extrapulmonary TB at one site in 223 (29%), and extrapulmonary TB at more than one site in seven (1%) patients. Death during TB treatment occurred in 59 of 308 patients (19%) with any extrapulmonary involvement. In a proportional hazards model, patients with extrapulmonary TB had an increased risk of death if they had meningitis, and a CD4+ T-lymphocyte count <200 cells/microl. Patients who received co-trimoxazole, fluconazole, and antiretroviral therapy during TB treatment had a lower risk of death.. Among HIV-infected patients with TB, extrapulmonary disease occurred in 40% of the patients, particularly in those with advanced immune suppression. Death during TB treatment was common, but the risk of death was reduced in patients who took co-trimoxazole, fluconazole, and antiretroviral therapy.

Topics: Adult; AIDS-Related Opportunistic Infections; Anti-HIV Agents; Anti-Infective Agents; Cohort Studies; Female; Fluconazole; HIV Infections; Humans; Male; Risk Factors; Survival Analysis; Survival Rate; Thailand; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis; Tuberculosis, Pulmonary; Young Adult

Topics: Adult; Africa; Anti-Infective Agents; HIV Infections; Humans; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Human immunodeficiency virus (HIV) infected children are at risk of a range of lung diseases related to HIV infection, including tuberculosis (TB). As in non-HIV-infected children, the presence of three or more of the following four features strongly suggests the diagnosis of TB: 1) chronic symptoms suggestive of TB; 2) physical changes highly suggestive of TB; 3) a positive tuberculin skin test; 4) a chest radiograph suggestive of TB. Every effort must be made to expedite the process of making the diagnosis, as TB may be rapidly progressive in HIV-infected children. As many children who present with chronic symptoms suggestive of TB may not have been tested for HIV infection, in high HIV prevalence settings (and in all settings where HIV is suspected in a child) children and their families should be offered HIV counselling and testing as part of a full TB work-up. Most current international guidelines recommend that TB in HIV-infected children, as in non-HIV-infected children, should be treated with a 6-month regimen containing rifampicin throughout. All HIV-infected children with advanced immunosuppression, including many with TB, should receive cotrimoxazole prophylaxis. Although the optimal timing for the initiation of antiretroviral treatment (ART) during TB treatment is not known, the decision to initiate ART should take into consideration the degree of immune suppression and the child's progress during TB treatment.

Topics: Anti-Infective Agents; Antibiotics, Antitubercular; Antiviral Agents; Child; Drug Therapy, Combination; HIV Infections; Humans; Rifampin; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Topics: Adult; Asthma; Biopsy; Diagnosis, Differential; Erythema Nodosum; Exanthema; Female; Humans; Irritable Bowel Syndrome; Leg; Lymphatic Diseases; Mycobacterium tuberculosis; Pain; Radiography; Sarcoidosis; Skin; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculin Test; Tuberculosis, Pulmonary

In countries with high HIV rates, diagnosis of lower respiratory disease etiology is both challenging and clinically important.. To determine the etiology of lower respiratory tract disease among persons with suspected tuberculosis (TB) and abnormal chest X-rays in a setting with very high HIV seroprevalence.. Cross-sectional prevalence data from a prospective cohort of predominantly hospitalized adults with suspected TB in Botswana, January-December 1997.. Of 229 patients, 86% were HIV-positive and 71% had a pathogen identified. TB was confirmed in 52%, 17% had acute mycoplasma pneumonia, 3% had Pneumocystis carinii, 27% grew a bacterial pathogen from sputum and 8% from blood. Ninety-four per cent of TB diagnoses were made through expectorated sputum and only 5% of TB cases were diagnosed by sputum induction alone. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis had positive and negative predictive values of 94% and 59%, respectively. Male sex, cough < 2 weeks, and tuberculin skin test > or = 5 mm were independently associated with culture-positive TB among persons with negative acid-fast bacilli smears. Co-infection with two or more pathogens occurred in 25%.. Mycoplasma pneumoniae infection was quite common despite clinical suspicion of TB, and sputum induction and PCR did not significantly improve our ability to diagnose TB, although clinical presentation had some predictive value.

Topics: Adult; Antibiotics, Antitubercular; Botswana; Cross-Sectional Studies; Female; HIV Infections; HIV-1; Humans; Male; Mycobacterium tuberculosis; Pneumonia, Mycoplasma; Polymerase Chain Reaction; Prevalence; Sputum; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

To investigate the influence of empiric treatments prior to fiberoptic bronchoscopy (FOB) on the diagnostic yield of BAL in HIV-positive patients with respiratory symptoms.. We studied 123 consecutive FOBs with BAL in HIV-positive patients; 101 of these patients (82%) had received previous antimicrobial treatment from 1 to 60 days. Diagnostic yield of BAL for Pneumocystis carinii, Mycobacterium tuberculosis, and bacterial pneumonia was compared between patients with and without previous empiric treatments.. A diagnosis was obtained in 85 patients (69%), of whom 17 (20%) had multiple infections. Diagnostic yield was higher in patients without previous treatment, 91% (20/22) compared with 64% (65/101), p < 0.03. Diagnostic yield was also higher for bacterial pneumonia: seven isolations from 22 patients not receiving previous empiric treatment (32%), compared with 11 of those who had (11%; p < 0.02). The duration of empiric treatment against P carinii in patients in whom it was isolated was significantly shorter than in those in whom P carinii was not detected (3.5 +/- 1.8 days compared with 5.2 +/- 2.4 days; p = 0.003). FOB permitted a change in treatment in 62% of patients with a final diagnosis.. This study demonstrates that empiric treatments prior to FOB significantly impair the diagnostic yield of BAL in detecting common pathogens in HIV-infected patients with respiratory symptoms.

Topics: Adult; AIDS-Related Opportunistic Infections; Anti-Bacterial Agents; Anti-Infective Agents; Antifungal Agents; Antitubercular Agents; Bacteria; Bronchoalveolar Lavage; Bronchoalveolar Lavage Fluid; Bronchoscopy; Cytomegalovirus; Cytomegalovirus Infections; Female; Fiber Optic Technology; Herpes Simplex; Humans; Length of Stay; Lung Diseases; Male; Middle Aged; Mycobacterium tuberculosis; Pentamidine; Pneumocystis; Pneumonia, Bacterial; Pneumonia, Pneumocystis; Simplexvirus; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

To evaluate the risk of developing tuberculosis or other AIDS-related diseases (ARD) in HIV-infected patients treated with corticosteroids as adjunctive therapy for Pneumocystis carinii pneumonia (PCP).. Retrospective study.. Infectious Disease Service of a 1000-bed university teaching hospital in Barcelona, Spain.. HIV-infected patients diagnosed with PCP from 1985 to 1992. Patients were classified into two groups: steroid (group A) and non-steroid (group B) adjunctive therapy. Baseline characteristics, antibiotherapy, dose and duration of steroidal treatment were analysed. Endpoints were either the development of tuberculosis or other ARD or death.. From the 129 patients included in this study 72 were in group A and 57 in group B. No differences between groups were observed in baseline characteristics or mean follow-up period (15 versus 14 months, respectively). The mean total dose of steroids was 420 mg (range, 160-1260 mg) methylprednisolone or its equivalent in dexamethasone, with a mean treatment duration of 12 days (range, 4-33 days). No differences were found in the occurrence of tuberculosis or other endpoints in the first 6 months of follow-up. In addition, the cumulative rate of developing tuberculosis was 7% in group A and 12% in group B at 12 months of follow-up, and 13 versus 12% at 24 months (P = 0.622, Mantel-Cox): 4 versus 4% at 12 months and 27 versus 24% at 24 months (P = 0.873) for non-tuberculosis mycobacterial infection, and 40 versus 42% at 12 months, and 88 versus 66% at 24 months (P = 0.330) for non-mycobacterial ARD. The cumulative survival rate was 79 versus 71% and 46 versus 34% at 12 and 24 months, respectively (P = 0.526).. Our data suggest that the use of corticosteroids during PCP in HIV-infected patients at the doses and for the duration used in our patients did not enhance the risk of developing or relapsing tuberculosis or other ARD.

Topics: Adrenal Cortex Hormones; Adult; AIDS-Related Opportunistic Infections; Dexamethasone; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Male; Methylprednisolone; Middle Aged; Pentamidine; Pneumonia, Pneumocystis; Retrospective Studies; Risk Factors; Survival Rate; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Tuberculosis is a common cause of cavitating pneumonia in Singapore. In patients with the human immunodeficiency virus (HIV), cavitary pneumonias mimicking tuberculosis can mislead the clinician, delaying diagnosis, resulting in increased morbidity. We describe a HIV seropositive patient with cavitating pneumonia in whom the diagnosis of Pneumocystis carinii pneumonia (PCP) was ultimately established only on bronchoscopy.. In February 1991, a 30-year old single, Chinese male, who had not has sexual intercourse with another man but did have it with a woman while in another country 12 months earlier, sought medical care at Tan Tock Seng Hospital in Singapore. He had a productive cough for 3 months, lost 5 kg over 4 months, and had been gasping for breath for 3 days. Upon admission, he had a low grade fever and breathed very rapidly while resting. The apical segment of the right lower lobe of the lung had a 3 x 2 cm cavity which was filling with exudate. A sputum smear did not indicate acid fast bacilli in 2 of 3 samples and blood cultures did not yield aerobic or anaerobic bacteria. The Western blot test revealed HIV antibodies. The absolute CD4 lymphocyte count stood at 80/cu mm compared with more than 500/cm mm in healthy individuals. Physicians used a bronchoscope to do bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB), both of which disclosed cysts of Pneumocystis carinii. Treatment first consisted of trimethoprim/sulfamethoxazole for 7 days and antituberculosis chemotherapy for 2 weeks until the physicians realized he had Pneumocystis carinii. They switched the treatment to iv pentamidine isethionate because he still had a fever after 7 days. This treatment was successful. Physicians then administered Zidovudine (AZT) and aerosolized pentamidine each month. As of mid-1992 he was still healthy. In addition to the BAL/TBLB results indicating Pneumocystis carinii and excluding tuberculosis, other features excluding tuberculosis were a Mantoux reading of O, absence of hilar and/or mediastinal lymphadenopathy, response to pentamidine isethionate, and sputum and blood cultures that did not indicate Mycobacterium species.

Topics: Adult; AIDS-Related Opportunistic Infections; Biopsy; Diagnosis, Differential; Humans; Lung; Male; Pneumonia, Pneumocystis; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Zidovudine

A case of Pneumocystis carinii pneumonia and the acquired immunodeficiency syndrome presented radiographically with upper lobe cavitation and association pleural thickening, mimicking granulomatous lung disease. The patient was diagnosed in our institution with transbronchial biopsies which showed P carinii organisms and foamy eosinophilic debris in the alveolar spaces. Clinical and radiographic resolution occurred with trimethoprim sulfamethoxazole therapy. This particular radiographic pattern has not been previously reported in the literature.

Topics: Acquired Immunodeficiency Syndrome; Adult; Diagnosis, Differential; Granuloma; Humans; Lung Diseases; Male; Pneumonia, Pneumocystis; Radiography; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

1. Patients (n = 15) who were admitted with complications of tuberculosis, were given antitubercular therapy (ATT) with rifampicin (RIF), for a minimum period of 15 d, and cotrimoxazole (CTZ), concurrently, for 5-10 d. 2. The serum RIF levels were measured before the start of CTZ treatment and at the end of its administration. 3. The plasma half-life (t1/2) of RIF increased significantly from 1.92 +/- 0.57 h to 2.31 +/- 0.134 h after CTZ treatment. 4. The mean serum levels of RIF increased significantly at 4 and 6 h after CTZ administration.

Topics: Adolescent; Adult; Anti-Infective Agents, Urinary; Drug Interactions; Female; Humans; Male; Middle Aged; Rifampin; Time Factors; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Topics: Adult; Drug Therapy, Combination; Enoxacin; Humans; Male; Mycobacterium Infections, Nontuberculous; Pneumonia; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Mycobacterium fortuitum rarely causes lung disease despite its sporadic isolation as a saprophytic colonizer from sputum or saliva. If pulmonary disease occurs, it is usually indolent in nature. The case presented appears to be the first reported case of a M. fortuitum lung abscess that was successfully treated with a prolonged course of trimethoprim/sulfamethoxazole. The patient remains well without evidence of recurrence nearly 2 yr after the cessation of therapy.

Topics: Adult; Humans; Lung Abscess; Male; Mycobacterium Infections; Mycobacterium Infections, Nontuberculous; Nontuberculous Mycobacteria; Time Factors; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

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

Topics: Acquired Immunodeficiency Syndrome; Drug Combinations; Female; Humans; Lung Diseases; Lung Diseases, Fungal; Lymphatic Diseases; Male; Mycobacterium Infections, Nontuberculous; Pentamidine; Pneumonia, Pneumocystis; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary