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Intervention Review

Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection

  1. Matthias Briel1,*,
  2. Heiner Bucher2,
  3. Remy Boscacci3,
  4. Hansjakob Furrer3

Editorial Group: Cochrane HIV/AIDS Group

Published Online: 19 JUL 2006

Assessed as up-to-date: 23 MAY 2006

DOI: 10.1002/14651858.CD006150


How to Cite

Briel M, Bucher H, Boscacci R, Furrer H. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006150. DOI: 10.1002/14651858.CD006150.

Author Information

  1. 1

    University Hospital Basel (USB), Basel Institute for Clinical Epidemiology, Internal Medicine, Basel, Switzerland

  2. 2

    University Hospital Basel (USB), Basel Institute for Clinical Epidemiology, Basel, Switzerland

  3. 3

    Inselspital Bern, Infectious Diseases, Bern, Switzerland

*Matthias Briel, Basel Institute for Clinical Epidemiology, Internal Medicine, University Hospital Basel (USB), Hebelstrasse 10, Basel, 4031, Switzerland. brielm@uhbs.ch.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 19 JUL 2006

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This is not the most recent version of the article. View current version (02 APR 2015)

 

Abstract

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

Background

Pneumocystis jiroveci pneumonia (PCP) remains the most common opportunistic infection in patients infected with the human immunodeficiency virus (HIV). Among patients with HIV infection and PCP the mortality rate is 10 to 20% during the initial infection and increases substantially with the need for mechanical ventilation. It was suggested that in these patients corticosteroids adjunctive to standard treatment for PCP could prevent the need for mechanical ventilation and decrease mortality.

Objectives

To assess the effects of adjunctive corticosteroids on overall mortality and the need for mechanical ventilation in HIV-infected patients with PCP and substantial hypoxemia (arterial oxygen partial pressure <70 mmHg or alveolar-arterial gradient >35 mmHg on room air).

Search methods

We searched Medline (January 1980-December 2004), EMBASE (January 1985-December 2004) and The Cochrane Library (Issue 4, 2004) without language restrictions to identify randomised controlled trials that compared adjunctive corticosteroids to control in HIV-infected patients with PCP. We further reviewed the reference lists from previously published overviews, we searched UptoDate version 2005 and Clinical Evidence Concise (Issue 12, 2004), contacted experts of the field, and searched reference lists of identified publications for citations of additional relevant articles.

Selection criteria

Trials were considered eligible for this review if they compared corticosteroids to placebo or usual care in HIV-infected patients with PCP in addition to baseline treatment with trimethoprim-sulfamethoxazole, pentamidine or dapsone-trimethoprim, used random allocation, and reported mortality data. We excluded trials in patients with no or mild hypoxemia (arterial oxygen partial pressure >70 mmHg or an alveolar-arterial gradient <35 mmHg on room air) and trials with a follow-up of less than 30 days.

Data collection and analysis

Two teams of reviewers independently evaluated the methodology and extracted data from each primary study. We pooled treatment effects across studies and calculated a weighted average risk ratio of overall mortality in the treatment and control groups by using a random effects model.

Main results

Six studies were included in the review and meta-analysis. Risk ratios for overall mortality for adjunctive corticosteroids were 0.56 (95% confidence interval [CI], 0.32-0.98) at 1 month and 0.68 (95% CI, 0.50-0.94) at 3-4 months of follow-up. To prevent 1 death, numbers needed to treat are 9 patients in a setting without highly active antiretroviral therapy (HAART) available, and 23 patients with HAART available. Only the 3 largest trials provided data on the need for mechanical ventilation with a risk ratio of 0.38 (95% CI, 0.20-0.73) in favour of adjunctive corticosteroids.

Authors' conclusions

The number and size of trials investigating adjunctive corticosteroids for HIV-infected patients with PCP is small, but evidence from this review suggests a beneficial effect for patients with substantial hypoxemia.

 

Plain language summary

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

Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection

Pneumocystis jiroveci pneumonia (PCP), formerly called Pneumocystis carinii pneumonia, is the most common opportunistic infection among patients infected with HIV. In 1990, based on evidence from five randomized control trials, an expert panel recommended the use of corticosteroids for HIV-infected patients with PCP and substantial hypoxemia (low levels of oxygen in the blood). The objective of this systematic review was to assess the effects of adjunctive corticosteroids on mortality, and the need for mechanical ventilation in patients co-infected with HIV and PCP. Six studies were included in this review and meta-analysis. While the number and size of the trials investigating adjunctive corticosteroids for HIV-infected patients co-infected with PCP is small, evidence from this review suggests a beneficial effect for patients with substantial hypoxemia.

 

摘要

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

背景

感染人類後天免疫不全病毒的病患,使用輔助性類固醇治療肺囊蟲肺炎

在人類後天免疫不全病毒感染病人身上,最常見的伺機性感染依然是肺囊蟲肺炎。同時有人類免疫不全病毒與肺囊蟲肺炎感染的病人,其感染肺囊蟲肺炎後之死亡率為10% – 20%,並且隨著呼吸器情形需要增加。曾經有人建議,在這些病人的標準肺囊蟲肺炎治療處置上,加上輔助性類固醇可以預防需要使用到呼吸器的狀況以及降低死亡率。

目標

評估輔助性類固醇,用在感染人類後天免疫不全病毒與肺囊蟲肺炎並且有嚴重缺氧(動脈血氧壓力<70mmHg,或肺泡動脈氧壓力差在正常氧分壓上>35mmhg)的病人,其整體死亡率以及對於呼吸器的需求量的效果。

搜尋策略

我們蒐尋了Medline(1980年1月∼2004年12月)以及Cochrane Library (2004年,第四期),不考慮語言之限制,尋找並比較關於輔助性類固醇,治療並控制有肺囊蟲肺炎感染的人類後天免疫不全病毒感染病人的隨機對照試驗。我們更進一步回顧了那些發表在之前文章中的參考文獻,我們蒐尋了2005年版Uptodate以及Clinical Evidence Concise(2004年第12期),接洽在這一方面的專家們,並尋找其他之前發表相關研究的參考文獻。

選擇標準

若是一個試驗除了用基本的trimethoprimsulfamethoxazole、pentamidine、dapsonetrimethoprim之外,還比較了類固醇與安慰劑或一般照顧用於感染人類後天免疫不全病毒的肺囊蟲肺炎病人,並使用隨機分配且呈現死亡率數據則此一試驗我們認為是適合收錄進我們的分析研究。對於試驗當中,病人若是沒有缺氧或是只有輕微缺氧(動脈氧分壓>70mmHg,或是在大氣氧分壓下,肺泡動脈氧壓差<35mmHg)以及追蹤治療成效短於30天,則我們予以排除在分析研究之外。

資料收集與分析

兩個回顧團隊獨立地評估每一個研究試驗的方法及資料。我們把各研究的治療作用蒐集起來,並運用隨機效果模式,計算治療組與對照組整體死亡率平均加權風險率。

主要結論

蒐集了六個研究並進行綜合分析。使用輔助性類固醇的整體死亡率的風險比率為第1個月為0.56(95% CI 為0.32∼0.98),第3到4個月之追蹤為百分之0.68(95% CI 0.50∼0.94)。為了預防一個死亡病例,在沒有高活性抗反轉錄病毒治療的情況下,益一需治數第9個,有高活性抗反轉錄病毒治療的情況下,接受治療的數目至少為23個病人。只有前3大規模的試驗有提供需要呼吸器治療的資料,其風險比率為0.38(95% CI 為0.20∼0.73),傾向於使用輔助性類固醇。

作者結論

人類後天免疫不全缺陷病毒感染並有肺囊蟲肺炎感染的病人,治療感染的試驗並不多且量不大,但由本回顧而來的證據顯示,它對於有嚴重缺氧的病人是有幫助的。

翻譯人

本摘要由臺北榮民總醫院楊宗霖翻譯。

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

總結

在感染人類後天免疫不全病毒的病人,肺囊蟲肺炎是最常見的伺機性感染。在90年代,根據五個隨機對照的試驗,專家建議,在感染人類後天免疫不全病毒以及肺囊蟲肺炎並且有嚴重缺氧(低血氧)的病人,使用類固醇。此系統性回顧的目的,是評估輔助性類固醇的作用,如何影響同時感染人類免疫缺陷病毒及肺囊蟲肺炎病人的死亡率及其呼吸器需求度。6個研究被收錄進來比較與綜合分析。雖然研究輔助性類固醇在同時感染人類後天後天免疫不全病毒與肺囊蟲肺炎病人的數目很少且規模不大,但由本回顧所得的證據顯示,對於有嚴重缺氧的病人,它是有益的。