Tidings from the Citadel: Restarting ART in Patients with OIs

Concern over overlapping toxicities, pill burden, and drug interactions led some clinicians to delay ART initiation in patients with AIDS-related OI. This study demonstrates that initiating early ART is beneficial.

282 patients with CD4 <200 and AIDs-related OI or severe bacterial infection randomized to early ART within 14 days or deferred ART that started after 4 weeks. Improved AIDs illnesses or deaths. The study population consisted predominantly of patients with Pneumocystis pneumonia (63%), cryptococcal meningitis (12%), and AIDS-associated bacterial infections (12%).

The actual timing of when ARTs were started was 12 vs 45 days, which argues for starting ARTs within 2 weeks and not immediately.

No difference in the occurrence of IRIS (6 vs 9%).

Keywords:

#Early #HIV #Opportunistic infections #Retroviral Therapy #ART #pneumocystis #OI #HAART #Mortality

Reference:

Early Antiretroviral Therapy Reduces AIDS Progression/ Death in Individuals with Acute Opportunistic Infections: A Multicenter Randomized Strategy Trial – Zolopa AR, Andersen J, Komarow L, Sanne I, Sanchez A, et al. PLoS ONE 2009 4(5): e5575.

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Flea Bytes: Fungitell (B,D Glucans) for Diagnosis of Pneumocystis Pneumonia

The gold standard for diagnosing pneumocystis jirovecii pneumonia is by isolating the bug itself either by DFA or culture. This task is much harder in non-HIV patients as the organism load is much lower. This meta-analysis examined 14 studies, most were retrospective. 2 only included patients with HIV, 8 with both HIV and non-HIV patients with other types of immunosuppression, and 2 with non-HIV immunosuppressed patients.

Using this pool of studies, the authors found that Fungitell had excellent sensitivity 95%, very good specificity  86%, and AUC of 97%.

+ LR 6.9 (5.1–9.3)

–  LR 0.06 (0.03–0.11)

The p-value for heterogeneity was 0.31. Two studies lie clearly out of the 95% ellipse.

In cases where obtaining microbiologic samples is impossible, dangerous, or even too difficult – BD glucans may be a way to empirically treat patients with some confidence.