PENTAMIDINE AEROSOL VERSUS TRIMETHOPRIM-SULFAMETHOXAZOLE FOR PNEUMOCYSTIS-CARINII IN ACQUIRED-IMMUNE-DEFICIENCY-SYNDROME

Pneumocystis carinii pneumonia remains one of the most common opportun istic infections in patients with acquired immune deficiency syndrome (AIDS). Treatment with either intravenous pentamidine or trimethoprim- sulfamethoxazole (TMP-SMX) is frequently complicated by serious advers e reactions. This study was a prospective, blinded comparison of 600 m g/d of pentamidine as an aerosol versus 15 mg/kg/d of trimethoprim plu s 75 mg/kg/d of sulfamethoxazole for patients with mild or moderately severe P. carinii pneumonia (alveolar arterial oxygen difference of le ss than 55 mm Hg). Of 367 participants who were randomized to receive study therapies, 287 had proven and 16 had presumed Pneumocystis pneum onia. There were 29 deaths within 35 d of study initiation: 12 in the aerosolized pentamidine group and 17 in the TMP-SMX groups (log rank p = 0.28). The difference in mortality was 3.4% (95% CI = - 3.5, 10.8%) . Ninety-four patients treated with aerosolized pentamidine had to hav e their study therapy changed because of lack of efficacy, compared wi th 22 patients treated with TMP-SMX(p = 0.002). In addition PaO2 impro ved faster in patients treated with TMP-SMX. However, aerosolized pent amidine was discontinued less often than TMP-SMX because of toxicity ( 9.4 versus 40% p < 0.001). Rash (0.6 versus 14.9%), nausea and vomitin g (1.7 versus 12.2%), and abnormalities of liver function tests (1.7 v ersus 12.2%) were the most common adverse effects necessitating treatm ent discontinuation. During 6-mo follow-up there was no difference in mortality. Recurrences of P. carinii pneumonia were more frequent in p atients treated with aerosolized pentamidine. Although aerosolized pen tamidine was better tolerated than TMP-SMX, patients treated with TMP- SMX showed treatment failure, less often showed more rapidly improved oxygenation, and relapsed