Cotrimoxazole prophylaxis for opportunistic infections in children with HIV infection

  • Review
  • Intervention

Authors


Abstract

Background

The majority of children with HIV infection live in low-income countries without access to antiretroviral drugs. The prevention and early treatment of opportunistic infections are the mainstay of their medical management. Cotrimoxazole is cheap and effective against a wide range of organisms, including Pneumocystis jiroveci pneumonia (PCP), which is an important cause of death and illness in the first year of life. It is safe with relatively few side effects. Diagnosis of HIV in children is complicated by the presence of maternal antibodies in early life. Providing prophylaxis based initially on maternal status is one possible solution. However, routine prophylactic treatment is difficult to deliver in low-resource settings, and could also lead to increased resistance to the drug.

Objectives

To assess the effects of routinely administered cotrimoxazole on death and illness episodes in children with HIV infection, and in infants of HIV-infected mothers.

Search methods

We searched the Cochrane HIV/AIDS registry, MEDLINE, the Cochrane Controlled Trials Register, LILACS, AIDSLINE, AIDSTRIALS and AIDSDRUGS databases, and proceedings and abstracts from AIDS and TB conferences (search date Feb 2005). We checked reference lists of pertinent articles, and contacted pharmaceutical companies and experts in the field.

Selection criteria

Randomised or quasi-randomised trials comparing routinely administered cotrimoxazole versus placebo or no treatment in children (age less than 15 years) with HIV infection, or children less than 18 months with HIV infected mothers.

Data collection and analysis

Two reviewers independently assessed trial eligibility and quality. Where data were incomplete or unclear trial authors were contacted for further details.

Main results

One study was identified that fulfilled the inclusion criteria. It studied 534 children with HIV infection in Lusaka, Zambia. The study was conducted in an area of high bacterial resistance to cotrimoxazole (60-80%). A reduction in mortality of 33% was seen in the cotrimoxazole group as compared to placebo, relative risk 0.67 (95% CI 0.53 - 0.85). There was also a beneficial effect on hospitalisation, relative risk 0.77 (95% CI 0.62 - 0.96). There was no difference in adverse events between groups, and the beneficial effect was seen across all ages and CD4%.

Authors' conclusions

A single trial has shown a beneficial effect from the use of cotrimoxazole prophylaxis in HIV infected children in Zambia. It must be decided whether this can be extrapolated to other resource-poor settings.

摘要

對於人類免疫缺乏病毒感染的幼童,投與Cotrimoxazole作為伺機性感染的預防性治療

研究背景

大部分住在低收入國家的人類免疫缺乏病毒感染的幼童沒有接受反轉錄病毒的藥物治療。 預防及早期治療伺機性感染是他們的醫療處置主要方式。COTRIMOXAZOLE便宜且可有效對抗廣泛的微生物,包括肺囊蟲肺炎,一種造成一歲以下嬰兒生病及死亡的主要原因。它很安全的與相對較少的副作用,由於出生的這段期間會出現母源抗體,使得兒童HIV診斷變得複雜。根據母親的情形提供預防是一個可行的辦法。不過,例行的預防性治療很難在低資源的環境提供,也可能導致增加藥物抗藥性。

研究目的

在人類免疫缺乏病毒感染的幼童與人類免疫缺乏病毒感染的母親所產下的嬰兒,評估常規使用cotrimoxazole對於死亡和疾病發作的影響。

检索策略

我們搜索考科藍愛人類免疫缺乏病毒/愛滋病的註冊表,MEDLINE,文獻對照試驗登記, LILACS,AIDSLINE,AODSTRIALS和AIDSDRUGS資料庫,與愛滋病和結核病會議的摘要(搜索日期2005年2月)。我們檢查了出處名單,相關文章,並且接觸,製藥公司和該領域的專家。

标准/纳入排除标准

隨機或半隨機試驗的比較常規使用cotrimoxazole比較安慰劑或無治療的人類免疫缺乏病毒感染的兒童(年齡小於15歲)或人類免疫缺乏病毒感染的母親生下的兒童(年齡小於18個月)。

数据收集与分析

二個評審個各自評估試驗的納入與否與品質。如果資料不完整或不清楚,則會聯絡試驗的作者以了解進一步的細節。

主要结果

在尚比亞首者盧薩卡所進行的一個研究符合納入的標準。它探討534名人類免疫缺乏病毒感染的兒童。該項研究在一個cotrimoxazole高抗藥性的地區(60–80 %)進行。在cotrimoxazole的這組和安慰劑相比有減少死亡率33%,相對危險度0.67(95 %信賴區間為0.53–0.85)。對於住院率也有益處,相對危險度0.77 ( 95 %信賴區間為0.62–0.96)。在組別之間的不良事件沒有差別,對於所有年齡和CD4%皆有益處。

作者结论

一個單一的試驗發現在贊比亞使用cotrimoxazole預防人類免疫缺乏病毒感染的兒童有益處。這必須決定是否此方式可以比照其他資源貧乏的情形。

Plain language summary

The majority of children with HIV infection live in low-income countries without access to antiretroviral drugs. The prevention and early treatment of opportunistic infections are the mainstay of their medical management. Cotrimoxazole is cheap and effective against a wide range of organisms, including Pneumocystis jiroveci pneumonia (PCP), which is an important cause of death and illness in the first year of life. It is safe with relatively few side effects.

One study fulfilled the inclusion criteria for this review. This was a well-conducted trial of good methodological quality. It shows a significant reduction in mortality in children between the ages of 1 and 15 years, taking cotrimoxazole in comparison to placebo. Using cotrimoxazole in HIV-infected children waiting for antiretroviral treatment, or not yet requiring it, may increase survival and reduce the number of days spent in hospital.

概要

大多數愛滋病毒感染的兒童生活在低收入國家而無法獲得反轉錄病毒藥物。預防和早期治療伺機性感染是醫療管理的主要方式。COTRIMOXAZOLE便宜且可有效對抗廣泛的微生物,包括肺囊蟲肺炎,它是造成一歲以下嬰兒生病及死亡的主要原因。它安全且很少副作用。一項研究確定符合納入的標準而進行這項檢查。它在方法學上有很好的品質與良好的設計。它顯示相較於安慰劑以cotrimoxazole預防可顯著降低在年齡介於1至15歲的兒童死亡率。無論等待反轉錄病毒藥物治療與否在愛滋病毒感染的兒童使用cotrimoxazole,可能會增加生存率和減少在醫院接受治療的天數。

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