静脉注射磺胺甲恶唑/甲氧苄啶短缺对 HIV 感染合并肺孢子菌肺炎患者治疗结局的影响。
Impact of an intravenous trimethoprim/sulfamethoxazole shortage on treatment outcomes among HIV-infected patients with Pneumocystis jirovecii pneumonia.
机构信息
University of New Mexico College of Pharmacy, 2502 Marble N.E., MSC 09 5360, Albuquerque, NM 87131-0001.
出版信息
J Manag Care Spec Pharm. 2014 Dec;20(12):1246-54. doi: 10.18553/jmcp.2014.20.12.1246.
BACKGROUND
Trimethoprim/sulfamethoxazole (TMP/SMX) is the recommended first-line treatment for human immunodeficiency virus (HIV)-infected patients with Pneumocystis jirovecii pneumonia (PJP).However, in June 2010, the lone manufacturer of intravenous (IV) TMP/SMX in the United States stopped production of this medication.
OBJECTIVES
To (a) evaluate the impact of the national IV TMP/SMX shortage on PJP treatment outcomes between 2 groups of HIV-infected patients-those treated before the shortage and those after the shortage-and (b) compare the length of hospital stay (LOS) and PJP treatment used before and after the shortage.
METHODS
A retrospective, quasi-experimental study examining 2 groups of HIV-infected adult patients with PJP was performed at an academic medical center from September 1, 2008, to June 30, 2012. Patients treated when IV TMP/SMX was available, or preshortage (PRE), were compared with patients treated when IV TMP/SMX was not available, or postshortage (POST).PRE included patients treated between September 1, 2008, and May 30, 2010, and POST included patients treated between June 1, 2010, and June 30, 2012.
RESULTS
Thirty-six patients were included in the study, 18 in each group. Treatment failure, the primary outcome, included mortality or worsening clinical status (WCS) after at least 5 days of therapy. Three patients in PRE (16.7%) and 6 patients in POST (33.3%) experienced treatment failure (P = 0.248). No patients in PRE and 3 patients in POST (16.7%) experienced WCS (P = 0.035). Three patients in each group expired.In POST, 5 of the 6 treatment failures (83.3%) occurred during the first 6 months of the shortage. Median (interquartile range) LOS was 11 days (7-17) in PRE and 14 days (5-22) in POST (P = 0.800).In PRE, 7 patients (38.9%) were initiated on oral PJP treatment compared with 13 (72.2%) in POST (P = 0.042).
CONCLUSIONS
The national shortage of IV TMP/SMX may have led to an immediate but temporary negative impact on treatment outcomes among HIV-infected patients with PJP at an academic medical center.Pharmacist collaboration with physicians may have helped mitigate the impact of this drug shortage on patient outcomes.
背景
复方磺胺甲噁唑（TMP/SMX）是治疗人类免疫缺陷病毒（HIV）感染合并卡氏肺孢子菌肺炎（PJP）患者的一线推荐用药。然而，2010 年 6 月，美国唯一的静脉用（IV）TMP/SMX 生产商停止了这种药物的生产。
目的
（a）评估全国范围内 IV TMP/SMX 短缺对两组 HIV 感染患者 PJP 治疗结果的影响——一组在短缺前接受治疗，一组在短缺后接受治疗；（b）比较短缺前后住院时间（LOS）和 PJP 治疗的差异。
方法
回顾性、准实验研究，在一所学术医疗中心对 2008 年 9 月 1 日至 2012 年 6 月 30 日期间的两组 HIV 感染成人 PJP 患者进行研究。当 IV TMP/SMX 可用时（即预短缺期，PRE）接受治疗的患者与 IV TMP/SMX 不可用时（即短缺后期，POST）接受治疗的患者进行比较。PRE 组包括 2008 年 9 月 1 日至 2010 年 5 月 30 日期间接受治疗的患者，POST 组包括 2010 年 6 月 1 日至 2012 年 6 月 30 日期间接受治疗的患者。
结果
本研究共纳入 36 例患者，每组 18 例。主要结局为治疗失败，包括治疗至少 5 天后的死亡率或临床恶化（WCS）。PRE 组有 3 例（16.7%）和 POST 组有 6 例（33.3%）患者治疗失败（P=0.248）。PRE 组无一例患者出现 WCS，而 POST 组有 3 例（16.7%）患者出现 WCS（P=0.035）。两组各有 3 例患者死亡。在 POST 组，6 例治疗失败患者中有 5 例（83.3%）发生在短缺的前 6 个月。PRE 组的中位（四分位间距）LOS 为 11 天（7-17），POST 组为 14 天（5-22）（P=0.800）。在 PRE 组，7 例（38.9%）患者开始口服 PJP 治疗，而 POST 组有 13 例（72.2%）患者开始口服 PJP 治疗（P=0.042）。
结论
在一所学术医疗中心，全国范围内 IV TMP/SMX 短缺可能对 HIV 感染合并 PJP 患者的治疗结果产生了立即但暂时的负面影响。药剂师与医生的合作可能有助于减轻药物短缺对患者结局的影响。
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