A meta-analysis of salvage therapy for Pneumocystis carinii pneumonia

Objective: To determine the relative efficacies of alternative antipneumocy stis agents in human immunodeficiency virus (HIV)-infected patients with Pn eumocystis carinii pneumonia unresponsive to primary drug treatment with a combination product of trimethoprim and sulfamethoxazole or parenteral pent amidine. Methods: Meta-analysis of 27 published clinical drug trials, case series, a nd case reports involving P carinii pneumonia. Data extracted included unde rlying disease, primary antipneumocystis treatment, days of failed primary treatment, salvage regimen, use of systemic corticosteroids and antiretrovi ral drugs, and clinical outcome. Results: In 497 patients with microbiologically confirmed P carinii pneumon ia (456 with HIV or acquired immunodeficiency syndrome), initial antipneumo cystis treatment failed and they therefore required alternative drug therap y. Failed regimens included trimethoprim-sulfamethoxazole (160 patients), i ntravenous pentamidine (63 patients), trimethoprim-sulfamethoxazole and/or pentamidine (258 patients), aerosolized pentamidine (6 patients), atovaquon e (3 patients), dapsone (3 patients), a combination product of trimethoprim and dapsone (2 patients), and trimethoprim-sulfamethoxazole followed by a combination of clindamycin and primaquine phosphate (2 patients). Efficacie s of salvage regimens were as follows: clindamycin-primaquine (42 to 44 [88 %-92%] of 48 patients; P < 10(-8)), atovaquone (4 [80%] of 5), eflornithine hydrochloride (40 [57%] of 70; P < .01), trimethoprim-sulfamethoxazole (27 [53%] of 51; P < .08), pentamidine (64 [39%] of 164), and trimetrexate (47 [30%]of 159). Conclusion: The combination of clindamycin plus primaquine appears to be th e most effective alternative treatment for patients with P carinii pneumoni a who are unresponsive to conventional antipneumocystis agents.