Intervention Review

Cotrimoxazole for prophylaxis or treatment of opportunistic infections of HIV/AIDS in patients with previous history of hypersensitivity to cotrimoxazole

  1. Daren Lin2,
  2. Wing-Ki Li3,
  3. Michael J Rieder1,*

Editorial Group: Cochrane HIV/AIDS Group

Published Online: 18 APR 2007

Assessed as up-to-date: 9 FEB 2007

DOI: 10.1002/14651858.CD005646.pub2


How to Cite

Lin D, Li WK, Rieder MJ. Cotrimoxazole for prophylaxis or treatment of opportunistic infections of HIV/AIDS in patients with previous history of hypersensitivity to cotrimoxazole. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005646. DOI: 10.1002/14651858.CD005646.pub2.

Author Information

  1. 1

    Children's Hospital of Western Ontario, Department of Paediatrics, London, Ontario, Canada

  2. 2

    University of Western Ontario, London, ON, Canada

  3. 3

    University of Western Ontario, Department of Paediatrics, London, ON, Canada

*Michael J Rieder, Department of Paediatrics, Children's Hospital of Western Ontario, 800 Commissioner's Rd. E, London, Ontario, N6C 2V5 , Canada. mrieder@uwo.ca.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 APR 2007

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

Background

Opportunistic infections continue to cause a significant amount of morbidity and mortality worldwide in patients infected with HIV. Trimethoprim-sulfamethoxazole (cotrimoxazole) is used in the treatment and prophylaxis of several opportunistic infections. In patients with HIV/AIDS, cotrimoxazole use can cause a higher rate of adverse drug reactions than in the general population. Given the cost-effectiveness of cotrimoxazole, the management of these adverse reactions has included continuing the drug (treating-through) and reintroducing the drug at a later date, either using dose-escalation (desensitization), or rechallenge at full dose. This systematic review is the first to examine the differences in patient outcomes between these strategies.

Objectives

To compare the rate of discontinuation of cotrimoxazole and adverse reactions among the three strategies of treating-through, desensitization, and rechallenge in patients living with HIV who previously had an adverse reaction to cotrimoxazole.

Search methods

We searched MEDLINE, EMBASE, LILACS, The Cochrane Library, Meeting Abstracts, AIDSTRIALS, ACTIS, Current Controlled Trials, The National Institutes of Health Clinical Trials Registry, and CenterWatch (search date May 2006).

Selection criteria

Randomised trials comparing treating-through, rechallenge, or desensitization of cotrimoxazole treatment or prophylaxis in adults (age 18 years or over) and/or children (age 17 years or under).

Data collection and analysis

Two reviewers independently assessed trial eligibility and quality, and extracted data. Where data were incomplete or unclear, a third reviewer resolved conflicts and/or trial authors were contacted for further details.

Main results

Three trials that examined cotrimoxazole prophylaxis and involving 268 adults were included. Meta-analysis of these studies found a beneficial effect of using a desensitization protocol over a rechallenge protocol at six months of follow-up for preventing discontinuation of cotrimoxazole (number needed to treat (NNT) 7.14, 95% confidence interval (CI) 4.0-33.0), and for lower incidence of overall hypersensitivity (NNT 4.55, 95% CI 3.03-9.09). No severe hypersensitivity reactions occurred for either protocol in the three studies.

Authors' conclusions

In the small trials included in this review, when compared to cotrimoxazole rechallenge for prophylaxis of opportunistic infections, cotrimoxazole desensitization resulted in fewer treatment discontinuations and overall adverse reactions in HIV-infected patients with a previous history of mild or moderate hypersensitivity to cotrimoxazole. Paediatric data and trials in resource-poor settings are urgently required. Further randomised controlled trials are also needed for the treatment of opportunistic infections, treating-through, adjunctive medications, and different desensitization-dosing schedules.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

This review examines strategies to enable the continued use of the antibiotic cotrimoxazole in patients with HIV/AIDS to treat or prevent opportunistic infections in patients who previously experienced hypersensitivity to this drug.

Opportunistic infections are a threat to the lives and health of people living with HIV. Cotrimoxazole, an antibiotic also known as trimethoprim-sulfamethoxazole, is used in the treatment and prevention of several opportunistic infections. In patients with HIV/AIDS, cotrimoxazole can cause more drug-related side effects than in the general population. However, there are not many effective alternatives for this drug, which is also by far the cheapest option available. When a patient with HIV experiences a side effect related to cotrimoxazole, often the drug is continued (treating-through) or reintroduced at a later date, either using increasingly larger doses (desensitization), or immediately starting at the full dose (rechallenge). This systematic review is the first to examine the differences in how patients are able to tolerate these strategies.

Three trials examining the use of cotrimoxazole in preventing opportunistic infections were included in the review. When compared to rechallenge, desensitization appeared to result in fewer treatment stoppages and side effects in HIV-infected adult patients who had a previous mild or moderate reaction to cotrimoxazole. However, more data are needed for these results to be conclusive. It is important to note that reintroduction of cotrimoxazole was usually successful using either desensitization or rechallenge, with 44.4% to 79.4% of patients still on cotrimoxazole after six months in the three studies. Furthermore, in the studies reviewed, no strategy resulted in severe hypersensitivity reactions. Severe limitations of this review included the absence of data in paediatric populations and the minimal data from resource-poor populations.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

Cotrimoxazole(复方新诺明)用于预防和治疗对Cotrimoxazole有过敏病史的HIV/AIDS患者的机会性感染

研究背景

机会性感染一直是造成HIV感染者高患病率和高死亡率的重要原因。Cotrimoxazole用于治疗和预防数种机会性感染。与一般人群相比,Cotrimoxazole可以在HIV/AIDS患者中产生较多的药物不良反应。考虑到Cotrimoxazole具有较好的成本效益比,针对这些不良反应的对策包括: 持续使用这类药物直到治疗完成,以及间隔一段时间后再重新使用此类药物,后者包括逐渐增加使用剂量即脱敏疗法,和直接重新给予全部剂量即重新给药法。这篇系统评价是首次针对上述不同给药方案导致病人预后的差异进行评估。

研究目的

比较采取上述三种策略(使用持续治疗法、脱敏疗法和重新给药法)时,在既往具有Cotrimoxazole不良反应史的HIV感染者中出现中断Cotrimoxazole治疗或产生不良反应的比例。

检索方法

2006年5月,我们检索了MEDLINE, EMBASE, LILACS, The Cochrane Library、Meeting Abstracts、AIDSTRIALS、ACTIS、Current Controlled Trials、National Institutes of Health Clinical Trials Registry、以及CenterWatch 数据库。

纳入标准

纳入的随机试验对Cotrimoxazole的三种用药策略(持续治疗、脱敏法和重新给药)进行了研究,这些试验分别应用于成人(≥18岁)和/或儿童(≤17岁)的治疗或预防。

数据收集与分析

两位评价者独立地评估试验的合格性和质量 ,并提取数据。当资料不完整或不清楚时,由第三方解决分歧和/或联系原始研究作者取得更详细的资料。

主要结果

共纳入了三个评估Cotrimoxazole预防效果的试验,包含268位成人受试者。这些研究的Meta-分析结果发现,在随访六个月时,使用脱敏法对于预防Cotrimoxazole治疗中断的效果优于重新给药法(NNT (需要治疗的人数)7.14, 95% CI:4.0 ∼ 33.0 ),且整体的过敏发生率较低(NNT 4.55, 95% CI 3.03 ∼ 9.09 )。在这三个研究中,均没有发生严重的过敏反应。

作者结论

本系统评价纳入的小样本试验显示,在将Cotrimoxazole应用于那些既往对Cotrimoxazole有轻微至中度过敏反应HIV感染者的机会性感染时,脱敏法较重新给药法更少发生治疗中断和不良反应。目前研究资料缺乏,尤其急需儿科方面的资料和研究实验。仍需要进一步开展有关机会性感染治疗的随机对照试验,评价持续给药法、辅助药物疗法和不同脱敏剂量设置的效果。

 

概要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

Cotrimoxazole(复方新诺明)用于预防和治疗对Cotrimoxazole有过敏病史的HIV/AIDS患者的机会性感染

在对Cotrimoxazole有过敏史的HIV感染者/AIDS患者中,评估使他们能持续使用Cotrimoxazole治疗或预防机会性感染的几种策略。

机会性感染对于HIV感染者的生命健康一直是个威胁。Cotrimoxazole是一种抗生素,也称为甲氧芐啶/磺胺甲恶唑(trimethoprim-sulfamethoxazole),用来治疗和预防数种机会性感染。比起一般人群,Cotrimoxazole在HIV感染者/AIDS患者中,可以引起更多的药物副作用。然而,目前并没有很多有效的替代药物,Cotrimoxazole仍是可使用药物中最便宜的选择。当HIV患者发生过Cotrimoxazole 引起的副作用时,通常会选择持续用药(持续给药法 )或在一段时间后再重新给予此药,后者包括慢慢增加剂量(脱敏法 )或立即开始完全剂量(重新给药法)。这篇系统评价首次评估了病人在上述治疗策略下的不同耐受性。

本研究纳入了三个关于评估Cotrimoxazole用于预防机会性感染的试验。在既往对Cotrimoxazole有轻微至中度过敏反应的HIV 成年感染者中,比起重新给药法,脱敏法似乎较少发生治疗中断和药物副作用。但是仍需要更多的数据支持该结论。值得注意的是,在这三个研究中,重新给予Cotrimoxazole(不论是脱敏法或重新给药法)通常可以成功地使44.4%至79.4%的病人在六个月后仍坚持Cotrimoxazole治疗。此外,纳入的这几个研究显示,这些策略都不会导致严重的过敏反应。这篇综述的主要局限性在于缺乏儿科资料和来自资源贫乏地区人口的资料很少。

翻译注解

本摘要由重庆医科大学中国循证卫生保健协作网(China Effective Health Care Network)翻译。

翻译注解":本摘要由重庆医科大学中国循证卫生保健协作网(China Effective Health Care Network)翻译。: China Effective Health Care Network

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

背景

複方新諾明用於預防和治療之前對複方新諾明有過敏病史的人類免疫缺乏病毒感染者/後天免疫力缺乏症候群患者的伺機性感染

對於全世界HIV感染者,伺機性感染一直是造成罹病率和死亡率的重要原因。Trimethoprimsulfamethoxazole(cotrimoxazole)用於治療和預防數種伺機性感染。相較於一般人,cotrimoxazole在HIV/後天免疫缺乏症候群(AIDS)患者會有較多的副作用。考慮到cotrimoxazole的成本及有效性,處理這些副作用的方法包括:持續使用這類藥物(持續治療完成, treatingthrough)及稍後再重新使用此類藥物,不管是逐漸增加使用劑量(減敏法, desensitization)或直接重新給予全部劑量(rechallenge)。這篇系統性的回顧,是第一次針對上述不同用藥策略對於病人預後的差異進行檢驗。 ◆ 人類免疫病毒缺感染者的伺機性感染持續在全世界引起大量的罹病率和死亡率。甲氧芐啶/磺胺甲噁唑 (複方新諾明)被用於治療和預防數種伺機性感染。複方新諾明的使用相較於一般人,在後天免疫力缺乏症候群/人類免疫病毒缺感染者會引起較高比例的副作用。以複方新諾明成本效益來看,處理這些副作用的方法包括持續使用這類藥物(持續治療);較久時間之後再重新使用此類藥物,其中包括使用劑量逐步升高(減敏法)或重新給予完全劑量。這篇系統性的回顧文章,是第一篇文章分析上述不同方法對於病人預後差異。

目標

比較對複方新諾明之前有過敏病反應的人類免疫缺乏病毒感染者,若採取上述三種策略包括使用持續治療法、減敏法和重新給藥法後停用複方新諾明和其所引起副作用的比例。

搜尋策略

我們搜尋的資料庫包括MEDLINE, EMBASE, LILACS, 考科藍圖書館(The Cochrane Library)、會議摘要(Meeting Abstracts)、愛滋病臨床試驗(AIDSTRIALS)、ACTIS、當今隨機對照臨床試驗註冊資料庫(Current Controlled Trials)、國家衛生研究院臨床試驗註冊資料庫(National Institutes of Health Clinical Trials Registry)、以及CenterWatch等(搜尋日期西元2006年5月)

選擇標準

於成人(大於等於18歲)和/或兒童(小於等於17歲),比較治療或預防性使用cotrimoxazole時三種用藥策略(持續治療、減敏法和重新給藥)的隨機試驗。

資料收集與分析

兩位系統回顧者獨立地評估研究實驗是否合實驗適、品質和所得到的資料。當資料不完全或不清楚,由第三位系統回顧者解決衝突和/或去聯絡研究實驗的作者取得更詳細的資料。。

主要結論

我們收錄了三個研究複方新諾明預防效果的實驗,其中包含268位成人受試者。這些研究的統合分析發現在預防停用複方新諾明方面,追蹤六個月後,使用減敏法會優於重新給樂法(需要治療的數目(NNT)7.14, 95%信賴區間(CI):4.0 – 33.0),且有較低的整體過敏發生率(NNT 4.55, 95% CI 3.03 – 9.09)。在這三個研究實驗中並沒有任何一個發生嚴重的過敏反應。

作者結論

在這篇回顧文章的小型研究實驗中,對於預防伺機性感染方面,比起重新給藥法,減敏法在之前有對複方新諾明有輕微至中度過敏反應的人類免疫缺乏病毒感染者有較少的停藥機率和副作用反應。目前仍急需要關於兒科方面的資料和研究實驗。更進一步的針對治療伺機性感染、持續給藥法、加入輔助藥物和不同劑量的減敏法相關的隨機控制試驗也是需要的。

翻譯人

本摘要由臺北榮民總醫院歐朔銘翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

這篇回顧文章分析了之前對複方新諾明有過敏病經驗的的人類免疫缺乏病毒感染者/後天免疫力缺乏症候群患者,能否持續使用複方新諾明治療或預防伺機性感染。伺機性感染對於人類免疫缺乏病毒感染者的生命和健康一直是個威脅。複方新諾明屬於抗生素藥物,也稱為甲氧芐啶/磺胺甲噁唑,用來治療和預防數種伺機性感染。比起一般人,複方新諾明在人類免疫缺乏病毒感染者/後天免疫力缺乏症候群患者中可以引起更多的藥物副作用。然而目前並沒有很多有效的替代藥物,複方新諾明仍是可使用藥物中最便宜的選擇。當愛滋病患者發生過複方新諾明的副作用時,常會選擇持續使用(持續給藥法)或在較久時間後在從新給予此藥,其中包括慢慢增加劑量(減敏法)或立即開始完全劑量(重新給樂法)。這篇系統回顧文章,是第一篇文章針對病人在上述治療策略的不同忍受性。有三個研究實驗是關於的檢驗使用複方新諾明來預防伺機性感染都被包含在這篇回顧文章中。比起重新給藥法,在之前複方新諾明有輕微至中度對產生過敏反應的人類免疫缺乏病毒感染者減敏法似乎會有較少的治療停頓和藥物副作用。但是仍需要更多的資料來支持才能下這樣的結論。在這三個研究顯示,重新給複方新諾明(不論是減敏法或重新給藥法)在六個月後追蹤分別有44.4% 到79.4%仍可以繼續使用複方新諾明。除此之外,回顧這些研究這些策略都不會導致嚴重的過敏反應。這篇回顧性文章嚴重受限於仍缺乏兒科資料和只有少數來自於資源貧乏地區人口的資料。