Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei.
Department of Internal Medicine, Changhua Christian Hospital, Changhua County.
AIDS. 2019 Jul 1;33(8):1345-1351. doi: 10.1097/QAD.0000000000002207.
Treatment with trimethoprim-sulfamethoxazole for Pneumocystis pneumonia (PCP) is often associated with adverse effects. Echinocandins, by inhibiting the cyst form of Pneumocystis jirovecii, may be an alternative therapy for PCP. However, clinical experience with echinocandins in the treatment of PCP remains limited among HIV-infected patients.
From August 2013 to April 2018, data of HIV-infected patients with confirmed PCP who received echinocandins as alternative treatment because of intolerance or unresponsiveness to trimethoprim-sulfamethoxazole were retrospectively reviewed to assess the effectiveness and safety of echinocandins alone or in combination with other agents.
In total, 34 patients were included, with a median CD4 count of 27 cells/μl [interquartile range (IQR), 20-93). Twenty-four patients (70.6%) presented with moderate-to-severe PCP. The most common adverse effects leading to withdrawal of trimethoprim-sulfamethoxazole were hepatotoxicity (29.4%), gastrointestinal upset (23.5%), and rash (17.6%). Nine patients (26.5%) were switched to echinocandins after failure of trimethoprim-sulfamethoxazole. The median interval before switch from trimethoprim-sulfamethoxazole to echinocandins was 9.0 days (IQR 5.0-14.0). The all-cause and PCP-related in-hospital mortality rate of patients receiving echinocandins as alternative therapy was 20.6% (7/34) and 14.7% (5/34), respectively. The all-cause in-hospital mortality was 0% in mild PCP cases and 29% (7/24) in moderate-to-severe PCP cases. Patients who had failed to respond to first-line trimethoprim-sulfamethoxazole treatment tended to have a higher in-hospital mortality rate than those without first-line trimethoprim-sulfamethoxazole failure (44.4% versus 12.0%, P = 0.06).
Echinocandin therapy might serve as an alternative option for HIV-infected patients with PCP who are intolerable to trimethoprim-sulfamethoxazole.
治疗肺孢子菌肺炎（PCP）时使用甲氧苄啶-磺胺甲噁唑常伴有不良反应。棘白菌素类药物通过抑制肺孢子菌的囊型，可能成为 PCP 的另一种治疗选择。然而，棘白菌素类药物在 HIV 感染患者中的治疗 PCP 的临床经验仍然有限。
2013 年 8 月至 2018 年 4 月，回顾性分析了因不耐受或对甲氧苄啶-磺胺甲噁唑无反应而接受棘白菌素类药物作为替代治疗的确诊为 PCP 的 HIV 感染患者的数据，以评估棘白菌素类药物单独或联合其他药物的有效性和安全性。
共纳入 34 例患者，中位 CD4 计数为 27 个/μl[四分位距（IQR）：20-93]。24 例（70.6%）患者表现为中重度 PCP。导致停用甲氧苄啶-磺胺甲噁唑的最常见不良反应是肝毒性（29.4%）、胃肠道不适（23.5%）和皮疹（17.6%）。29.4%（9/31）的患者因不耐受而停用甲氧苄啶-磺胺甲噁唑，9 例（26.5%）患者在失败后改用棘白菌素类药物。从甲氧苄啶-磺胺甲噁唑转为棘白菌素类药物的中位间隔时间为 9.0 天（IQR：5.0-14.0）。接受棘白菌素类药物替代治疗的患者的全因和 PCP 相关院内死亡率分别为 20.6%（7/34）和 14.7%（5/34）。轻度 PCP 病例的全因院内死亡率为 0%，中重度 PCP 病例为 29%（7/24）。对一线治疗甲氧苄啶-磺胺甲噁唑无反应的患者的院内死亡率高于对一线治疗甲氧苄啶-磺胺甲噁唑无反应的患者（44.4%比 12.0%，P=0.06）。
棘白菌素类药物治疗可能是不耐受甲氧苄啶-磺胺甲噁唑的 HIV 感染患者治疗 PCP 的另一种选择。
