Download is trimephoprim-sulfamethaxozole a real option?

1695. A systematic review of the relative efficacy and toxicity of
treatment regimens for HIV-associated cerebral toxoplasmosis: is
trimephoprim-sulfamethaxozole a real option?
Session: Poster Abstract Session: HIV: Other Opportunistic Infections in HIV
Saturday, October 10, 2015
Room: Poster Hall
Background: Pyrimethamine and sulfadiazine (P-S) combination is effective and considered
the mainstay therapy for cerebral toxoplasmosis (CT). Alternative treatment regimens are
available, but their relative efficacy and tolerability are not well known. Particularly,
trimephoprim-sulfamethaxozole (TMP-SMX) shows potential advantages (i.e., tolerability,
posology, parenteral formulation, cost, and accessibility) but its use is infrequent when P-S is
available.
Methods: We searched PubMed and 4 other databases to identify randomized controlled trials
(RCTs) and cohort studies comparing different regimens for the treatment of HIV-associated
CT. Two independent reviewers searched and identified studies and extracted data. Risk ratios
(RRs) were pooled across studies using random-effects models.
Results: Nine studies were included (5 RCTs, 3 retrospective cohorts, 1 prospective cohort).
Treatment with P-S has the same or better clinical efficacy than P-C or TMP-SMX in terms of
partial or complete response clinical response (P-C vs P-S: RR 0.87, 95%CI 0.70-1.08; TMPSMX vs P-S: RR 0.97, 95%CI 0.78-1.21) and radiological response (P-C vs P-S: RR 0.92,
95%CI 0.82-1.03). Safety profile in terms of skin rash (P-C vs P-S: RR 0.81, 95%CI 0.56-1.17;
TMP-SMX vs P-S: RR 0.17, 95%CI 0.02-1.29), liver impairment (P-C vs P-S: RR 0.48, 95%CI
0.24-0.97) and drug discontinuation due to adverse events (P-C vs P-S: RR 0.32, 95%CI 0.071.47) were worse with P-S regimen.
Conclusion: The available evidence fails to identify any one superior regimen for the
treatment of CT. However, P-S regimen has worse safety profile than P-C or TMP-SMX.
Although current evidence does not allow a definitive recommendation, use of TMP-SMX for
treatment of HIV-associated CT is consistent with the available data. More large studies
comparing alternative therapies are needed.
Priyaleela Thota, MD, Infectious Diseases, Case Western Reserve University, Cleveland,
OH, Abhishek Deshpande, MD, PhD, Infectious Disease, Cleveland Clinic, Cleveland, OH;
Medicine, Cleveland Clinic, Cleveland, OH, Daniela Pellegrino, MD, School of Medicine, University
of Sao Paulo, São Paulo, Brazil, Vinay Pasupuleti, MD, PhD, Medicine, Case Western Reserve
University, Cleveland, OH, Vicente Benites-Zapata, MD, Universidad de San Martin de Porres,
Lima, Peru, José Vidal, MD, PhD, Instituto de Infectologia Emílio Ribas, Sao Paulo, Brazil and
Adrian V. Hernandez, M.D., Ph.D., Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH;
Universidad Peruana de Ciencias Aplicadas, Lima, Peru
Disclosures:
P. Thota, None
A. Deshpande, None
D. Pellegrino, None
V. Pasupuleti, None
V. Benites-Zapata, None
J. Vidal, None
A. V. Hernandez, None