Letters to the Editor- October 15, 2000 - American Family Physician

Letters to the Editor

Pneumocystis carinii Pneumonia in HIV-Infected Patients

TO THE EDITOR: In their excellent review¹ of Pneumocystis carinii pneumonia (PCP) in patients infected with human immunodeficiency virus (HIV), Drs. Wilkin and Feinberg refer to the latest Public Health Service guidelines which "recommend discontinuation of primary PCP prophylaxis in patients whose CD4⁺ cell counts are sustained above 200 per mm³ for at least six months and who have well-controlled HIV viral loads."² This new recommendation is based on study results suggesting that patients who respond well to potent combination antiretroviral therapy have protection against PCP and other opportunistic infections.^3-6

Our experience at the Family Practice Inpatient Service, San Francisco General Hospital, is consistent with this observation. Despite increasing numbers of total admissions to our service in recent years, the number of patients admitted with acquired immunodeficiency syndrome (AIDS), including those with PCP, have dropped dramatically since the emergence of potent antiretroviral therapy (see the accompanying figure).

Patients with PCP and AIDS admitted to the Family Practice Inpatient Service at San Francisco General Hospital.

Indeed, most patients admitted with acute PCP over the past few years have not been taking antiretroviral agents consistently. For the family physician caring for HIV-infected patients who are responders to potent combination antiretroviral therapy, omitting primary PCP prophylaxis while carefully monitoring for any signs of disease progression is a reasonable management strategy.

TODD A. MAY, M.D.
CRISTINA I. GRUTA, PHARM.D.
RONALD H. GOLDSCHMIDT, M.D.
UCSF Family Practice Residency Program
San Francisco General Hospital
San Francisco, CA 94110

REFERENCES

Wilkin A, Feinberg J. Pneumocystis carinii pneumonia: a clinical review. Am Fam Physician 1999;60: 1699-708,1713-14.

1999 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with the human immunodeficiency virus. U.S. Public Health Service (USPHS) and Infectious Diseases Society of American (IDSA) MMWR Morb Mortal Wkly Rep 1999;48:1-59,61-6.

Ledergerber B, Egger M, Erard V, Weber R, Hirschel B, Furrer H, et al. AIDS-related opportunistic illnesses occurring after initiation of potent antiretroviral therapy: the Swiss HIV Cohort Study. JAMA 1999;282:2220-6.

Furrer H, Egger M, Opravil M, Bernasconi E, Hirschel B, Battegay M, et al. Discontinuation of primary prophylaxis against Pneumocystis carinii pneumonia in HIV-1-infected adults treated with combination antiretroviral therapy. N Eng J Med 1999;340:1301-6.

Weverling GJ, Mocroft A, Ledergerber B, Kirk O, Gonzales-Lahoz J, Monforte A, et al. Discontinuation of Pneumocystis carinii pneumonia prophylaxis after start of highly active antiretroviral therapy in HIV-1 infection. EuroSIDA Study Group. Lancet 1999;353:1293-8.

Schneider MM, Borleffs JC, Stolk RP, Jaspers CA, Hoepelman AI. Discontinuation of prophylaxis for Pneumocystis carinii pneumonia in HIV-1-infected patients treated with highly active antiretroviral therapy. Lancet 1999;353:201-3.

EDITOR'S NOTE: This letter was sent to the authors of "Pneumocystis carinii Pneumonia: A Clinical Review," who did not reply.

Corrections

The article "Lichen Planus" (June 1, 2000, page 3319) contained an incorrect trade name. On page 3322, in the final paragraph of the right-hand column, the trade name for cyclosporine should be Sandimmune. Seromycin, the trade name given, is the trade name for the antibiotic cycloserine.

The article "Uterine Fibroid Embolization" (June 15, 2000, page 3601) contained an error in the discussion of patient selection for the procedure. The second sentence of the third paragraph should read as follows: "Although there is no fixed size limitation, patients with pedunculated subserosal fibroids are not considered ideal candidates."

The "Diary from a Week in Practice" in the July 1, 2000, issue (page 88) contained an error in the Monday entry. The correct meaning of the acronym BATHE is as follows: B stands for background; A stands for affect (the feeling state); T stands for trouble; H stands for handling; E stands for empathy.

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