A meta-analysis of salvage therapy for Pneumocystis carinii pneumonia [Smego RA, et al. Arch Intern Med 2001;161:1529]: KThe authors performed a meta-analysis of 27 published clinical trials, case series, and case reports on PCP. There were 497 patients with confirmed PCP who failed initial treatment. Efficacy of salvage regimens in this setting was, as follows: clindamycin-primaquine-42-44/48 (90%), atovaquone-4/5 (80%), TMP-SMX-27/51 (53%), pentamidine-64/164 (39%), and trimetrexate-47/159 (30%). The authors conclude that clindamycin plus primaquine appears to be the most effective alternative treatment for PCP.
Comment: Patients with PCP usually respond within 4-8 days of treatment. Persistence or progression of symptoms after that time is an indication for alternative drugs. In the past, TMP-SMX was generally regarded as the preferred drug for initial therapy (and it continues to be), with pentamidine as the primary alternative, at least for hospitalized patients. A prior study by Klein, et al, showed that survival rates with a switch in either direction for these two drugs was likely to be successful when performed due to toxicity, but was unlikely when the switch was made due to failure [AIDS 1992;6:301]. Clindamycin-primaquine was the most successful regimen in the review by Smego and colleagues, with a response rate of about 90% among patients who failed TMP-SMX, or pentamidine, or both.
posted 7/12/2001

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