Co-trimoxazole (trimethoprim component 21 days 15—20mg/kg per day p.o./i.v. in divided doses). Alternative regimens:
1. Severe disease: 21 days Pentamidine isethionate 4mg/kg per day as slow intravenous infusion
Trimetrexate 45mg/m2 i.v. and folinic 21 days acid 80 mg/m2
2. Mild to moderate disease: 21 days Clindamycin 600mg 6 hourly p.o./i.v.
and primaquine 15 mg daily p.o.
Trimethoprim 20mg per kg/day p.o./i.v. 21 days in 2—3 divided doses and dapsone 100 mg daily p.o.
Atovaquone suspension 750mg 21 days twice daily
Adjuvant high-dose steroids 5 days
(for example, prednisolone 40—60 mg daily p.o.)
Nausea, vomiting, fever, rash, marrow suppression, raised transaminases
Hypotension, hyper- and hypoglycaemia, renal failure, marrow suppression, nausea, vomiting, cardiac arrest Marrow suppression, raised transaminases rash, anaphylaxis Diarrhoea, rash, nausea, vomiting, marrow suppression, methaemoglobinaemia, haemolysis Rash, nausea, methaemoglobinaemia, marrow suppression Rash, raised transaminases and neutropenia tapering over 14-21 days
Intolerance common (25-50% of treated patients)
80% of patients will respond to treatment
Should only be used as third or fourth line treatment
Clostridium difficile toxin associated diarrhoea is a frequent complication of clindamycin therapy
Alternative regimens should be used in patients with G6PD deficiency
Must be taken with food. Consider combination with i.v. pantamidine as resistance reported with monotherapy
Indicated in severe disease. Optimal dose not determined
Although clinical trials have shown greater efficacy for co-trimoxazole compared to other regimens, there is a high rate of discontinuation due to side-effects. Desensitisation regimens are used with the aim of reducing the rate of intolerance but there is uncertainty about their efficacy and which regimen is best.
In patients responding to antiretroviral therapy, primary or secondary prophylaxis can be safely discontinued once the CD4 count has increased to levels persistently above 200 X 106/l.
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