PCP pneumonia is still a serious and present condition, especially for people diagnosed late with HIV. There is limited research on second-line treatments.
AIDSmeds reports on a systematic review of second-line therapy PCP studies:
Better Antibiotics for Second-Line PCP Treatment - AIDSmeds
http://www.aidsmeds.com/articles/aids_pcp_pneumonia_1667_14495.shtmlOriginal abstract in the Journal of Acquired Immune Deficiency Syndromes, May 1 2008 edition:
Second-Line Salvage Treatment of AIDS-Associated Pneumocystis jirovecii Pneumonia: A Case Series and Systematic Review - JAIDS
http://www.jaids.com/pt/re/jaids/abstract.00126334-200805010-00008.htm29 studies, including 82 individual cases, yielded a total of 468 PCP second-line treatment episodes for review.
Response rates to second-line treatment were comparable for trimethoprim-sulfamethoxazole (Septrin, TMP-SMX) at 68%, and clindamycin-primaquine at 73%. Odds ratios for a successful response were: TMP-SMX - 2.1 (95% confidence interval: 1.1 to 3.2), clindamycin-primaquine - 2.7 (95% confidence interval: 1.3 to 4.0). The response rate for intravenous pentamidine was lower at 44%, odds ratio 0.8 (95% confidence interval: 0.6 to 1.0).
The authors conclude: "Clindamycin-primaquine is an alternative to intravenous pentamidine as second-line treatment for PCP in patients who fail treatment with TMP-SMX. TMP-SMX should be used as a second-line treatment for those failing first-line treatments with regimens other than TMP-SMX."
Systematic reviews have limitations (comparing samples, retrospective, non-randomised). This said, the round-up of outcomes from second-line clindamycin-primaquine is useful. The authors' recommendation on TMP-SMX as a second-line agent may be a cause of dismay to people allergic to this drug.
Ref: Benfield, Thomas et al. JAIDS Journal of Acquired Immune Deficiency Syndromes. 48(1):63-67, May 1, 2008.
UKCAB 