reference librarian comments, March 2000
| On Doctoring MEDLINE searches, with reference librarian comments, March 2000 |
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The question was
Fungal Infection Mangement in Patients with HIV Disease
1 "FUNGAL INFECTIONS".mp. results=2469
2 "HIV DISEASE".mp. results=2360
3 1 and 2 and "3".mp. [mp=title, abstract, registry number results= 0
word, mesh subject heading]
4 Hiv/ or "hiv".mp. results=71772
5 1 and 2 and 4 results= 10
6 "PATIENT MANAGEMENT".mp. results= 3498
7 1 and 2 and 4 and 6 results= 0
8 "HIV AND TREATMENT".mp. results= 123
9 1 and 8 results= 0
10 exp acquired immunodeficiency syndrome/ or exp aids-related results= 100239
opportunistic infections/ or exp hiv infections/ or exp
hiv-1/ or "hiv opportunistic infection".mp.
11 1 and 8 and 10 results= 0
12 *Aids-related opportunistic infections/ results= 6827
13 "TREATMENT".mp. results= 1040795
14 12 and 13 results= 1770
15 1 and 14 results= 25
Reference Librarian comments
You picked two tricky concepts. Fungal diseases is "mycoses" to MEDLINE, and "HIV disease" is acquired immunodeficiency syndrome. But you could also use aids-related opportunistic infections, perhaps.
You were bravely combining sets and learning how MEDLINE works. Congratulations. My advice is to try to put one concept at a time in a set, and then later "combine" sets.
Have a look at my approach, below, which by no means is the 'best' way -- just another strategy, and one which might behave a little better in Ovid. When I got so many in set #4, I decided to try the "EBM" (Evidence-based medicine) trick, to see if there were some structured reviews from Cochrane or ACP out there...)
Medline 1991 to January 2000#
Search History
Results
1
exp *Acquired immunodeficiency syndrome/pc,dh,dt,rt,su,th [Prevention & Control, Diet Therapy, Drug
Therapy, Radiotherapy, Surgery, Therapy]
4190
2
exp *Aids-related opportunistic infections/pc,dt,rt,su,th [Prevention & Control, Drug Therapy,
Radiotherapy, Surgery, Therapy]
1810
3
exp *Mycoses/pc,dt,rt,su,th [Prevention & Control, Drug Therapy, Radiotherapy, Surgery, Therapy]
4336
4
(1 or 2) and 3
528
5
limit 4 to ebm reviews
7
6
from 5 keep 1-7
7
<1>
AN 96135999
AU Ioannidis JP. Cappelleri JC. Skolnik PR. Lau J. Sacks HS.
IN Division of Geographic Medicine and Infectious Diseases, New England Medical
Center Hospitals, Boston, Mass, USA.
TI A meta-analysis of the relative efficacy and toxicity of Pneumocystis
carinii prophylactic regimens [see comments].
CM Comment in: ACP J Club 1996 Jul-Aug;125(1):12
SO Archives of Internal Medicine. 156(2):177-88, 1996 Jan 22.
LM Dana (complete) and MFHSL (incomplete, check catalog).
AB BACKGROUND: Finding the optimal strategy for Pneumocystis carinii
prophylaxis in patients with human immunodeficiency virus
infection can be problematic. Several prophylactic regimens are available,
but their relative efficacy and tolerance are not well understood. METHODS: A
meta-analysis overviewed 35 randomized trials comparing different regimens
for P carinii prophylaxis directly or with placebo. Analyses were based on
intention-to-treat. On-treatment data were also analyzed when available.
RESULTS: Regardless of dose, sulfamethoxazole-trimethoprim was almost
universally effective for patients who tolerated it. The risk of
discontinuing sulfamethoxazole-trimethoprim because of side effects decreased
by 43% (95% confidence interval, 30% to 54%) if one double-strength tablet
was given three times a week instead of daily. For dapsone, among 100
patients given 100 mg daily instead of twice a week for 1 year (primary
prophylaxis), seven fewer patients would develop P carinii pneumonia, but 17
more would have significant toxic reactions. Aerosolized pentamidine was well
tolerated regardless of the dose used. Prophylaxis failures might be halved
if the dose of aerosolized pentamidine were doubled. Compared with
aerosolized pentamidine, oral regimens prevented 73% (95% confidence
interval, 57% to 82%) of toxoplasmosis events by on-treatment analysis, but
only 33% (95% confidence interval, 12% to 50%) by intention-to-treat. No
significant difference in mortality was demonstrated between different
regimens. CONCLUSIONS: Sulfamethoxazole-trimethoprim is the superior regimen,
and low doses could improve tolerance without losing effectiveness for
primary prophylaxis. Low doses of dapsone reduce toxic effects, but at the
expense of some loss of efficacy. There are few data on the use of low-dose
regimens for secondary prophylaxis. High doses of aerosolized pentamidine may
improve the efficacy of this regimen. Aerosolized pentamidine is inadequate
for prevention of toxoplasmosis, and strategies that improve the tolerance of
oral regimens may increase effectiveness in preventing toxoplasmosis.
<2>
AN 95233645
AU Podzamczer D. Salazar A. Jimenez J. Consiglio E. Santin M. Casanova A.
Rufi G. Gudiol F.
IN Infectious Disease Service, Ciutat Sanitaria de Bellvitge, Barcelona, Spain.
TI Intermittent trimethoprim-sulfamethoxazole compared with
dapsone-pyrimethamine for the simultaneous primary prophylaxis of
Pneumocystis pneumonia and toxoplasmosis in patients infected with HIV [see
comments].
CM Comment in: ACP J Club 1995 Sep-Oct;123(2):40-1, Comment in: Ann Intern Med
1996 Jun 15;124(12):1096
SO Annals of Internal Medicine. 122(10):755-61, 1995 May 15.
LM Dana(complete) &MFHSL(1990-date);also Web,check catalog .
AB OBJECTIVE: To evaluate the efficacy and safety of two oral, intermittent
drug regimens for the simultaneous primary prophylaxis of Pneumocystis
carinii pneumonia and toxoplasmosis in patients with HIV infection. DESIGN:
Nonblinded randomized study: Patients received either 1)
trimethoprim-sulfamethoxazole (160 mg-800 mg orally twice a day on a thrice
weekly regimen) or 2) 100 mg of dapsone plus 50 mg of pyrimethamine orally
twice weekly. SETTING: University teaching hospital in Barcelona. PATIENTS:
230 patients infected with HIV who had CD4 cell counts of less than 200 x
10(6)/L and who had not previously had P. carinii pneumonia or toxoplasmosis.
MEASUREMENTS: Clinical and biological evaluations; adverse reactions; and end
points of P. carinii pneumonia, toxoplasmosis, and death. RESULTS: After a
median follow-up of 430 days, 6 (6.3%) of 96 evaluable patients receiving
dapsone-pyrimethamine and 0 of 104 evaluable patients receiving
trimethoprim-sulfamethoxazole developed P. carinii pneumonia (P < 0.0001).
The cumulative rates of P. carinii pneumonia at 12 and 24 months were 0% and
0% for patients receiving trimethoprim-sulfamethoxazole and 4% and 11% for
patients receiving dapsone-pyrimethamine (Mantel-Cox, P = 0.014). However,
only one episode of P. carinii pneumonia developed while patients were taking
these drugs. No differences were observed for toxoplasmosis (one episode in
the trimethoprim-sulfamethoxazole arm and two in the dapsone-pyrimethamine
arm), with cumulative rates at 12 and 24 months of 0% and 4% for the
trimethoprim-sulfamethoxazole arm and 2% and 7% for the dapsone-pyrimethamine
arm (P = 0.65). Similar mortality rates were observed during follow-up (P =
0.85). Nineteen patients (9.5%) discontinued therapy with the drugs because
of adverse effects: Ten were in the trimethoprim-sulfamethoxazole arm and 9
were in the dapsone-pyrimethamine arm (P = 0.95). CONCLUSIONS: Thrice-weekly
trimethoprim-sulfamethoxazole is an effective and well-tolerated regimen for
the simultaneous primary prophylaxis of P. carinii pneumonia and
toxoplasmosis in patients infected with HIV. Twice-weekly
dapsone-pyrimethamine appears to be a safe and effective alternative.
<3>
AN 95157588
AU Powderly WG. Finkelstein D. Feinberg J. Frame P. He W. van der Horst C.
Koletar SL. Eyster ME. Carey J. Waskin H. et al.
IN Washington University School of Medicine, St. Louis.
TI A randomized trial comparing fluconazole with clotrimazole troches for the
prevention of fungal infections in patients with advanced
human immunodeficiency virus infection. NIAID AIDS Clinical
Trials Group [see comments].
CM Comment in: N Engl J Med 1995 Mar 16;332(11):739-40, Comment in: ACP J Club
1995 Sep-Oct;123(2):43
SO New England Journal of Medicine. 332(11):700-5, 1995 Mar 16.
LM Dana(complete) &MFHSL(1990-date);also Web,check catalog .
AB BACKGROUND. Cryptococcal meningitis and other serious fungal
infections are common complications in patients infected
with the human immunodeficiency virus (HIV). Fluconazole is
effective for long-term suppression of many fungal
infections, but its effectiveness as primary prophylaxis had
not been adequately evaluated. METHODS. We conducted a prospective,
randomized trial that compared fluconazole (200 mg per day) with clotrimazole
troches (10 mg taken five times daily) in patients who were also
participating in a randomized trial of primary prophylaxis for Pneumocystis
carinii pneumonia. RESULTS. After a median follow-up of 35 months, invasive
fungal infections had developed in 4.1 percent of the
patients in the fluconazole group (9 of 217) and in 10.9 percent of those in
the clotrimazole group (23 of 211; relative hazard, as adjusted for the CD4+
count, 3.3; 95 percent confidence interval, 1.5 to 7.6). Of the 32 invasive
fungal infections, 17 were cryptococcosis (2 in the
fluconazole group and 15 in the clotrimazole group; adjusted relative hazard,
8.5; 95 percent confidence interval, 1.9 to 37.6). The benefit of fluconazole
was greater for the patients with 50 or fewer CD4+ cells per cubic millimeter
than for the patients with higher counts. Fluconazole was also effective in
preventing esophageal candidiasis (adjusted relative hazard, 5.8; 95 percent
confidence interval, 1.7 to 20.0; P = 0.004) and confirmed and presumed
oropharyngeal candidiasis (5.7 and 38.1 cases per 100 years of follow-up in
the fluconazole and clotrimazole groups, respectively; P < 0.001). Survival
was similar in the two groups. CONCLUSIONS. Fluconazole taken
prophylactically reduces the frequency of cryptococcosis, esophageal
candidiasis, and superficial fungal infections in
HIV-infected patients, especially those with 50 or fewer CD4+ lymphocytes per
cubic millimeter, but the drug does not reduce overall mortality.
<4>
AN 95157587
AU Bozzette SA. Finkelstein DM. Spector SA. Frame P. Powderly WG. He W.
Phillips L. Craven D. van der Horst C. Feinberg J.
IN University of California, San Diego, La Jolla.
TI A randomized trial of three antipneumocystis agents in patients with
advanced human immunodeficiency virus infection. NIAID AIDS
Clinical Trials Group [see comments].
CM Comment in: N Engl J Med 1995 Mar 16;332(11):739-40, Comment in: ACP J Club
1995 Sep-Oct;123(2):40-1
SO New England Journal of Medicine. 332(11):693-9, 1995 Mar 16.
LM Dana(complete) &MFHSL(1990-date);also Web,check catalog .
AB BACKGROUND. We evaluated the effectiveness of three treatment strategies for
the prevention of a first episode of Pneumocystis carinii pneumonia in
patients infected with the human immunodeficiency virus
(HIV). METHODS. In an open-label trial, 843 patients with HIV infection and
fewer than 200 CD4+ cells per cubic millimeter received zidovudine plus one
of three randomly assigned prophylactic agents, beginning with
trimethoprim-sulfamethoxazole, dapsone, or aerosolized pentamidine and
followed by a defined sequence of other drugs to be used in cases of
intolerance. RESULTS. The estimated 36-month cumulative risks of P. carinii
pneumonia were 18 percent, 17 percent, and 21 percent in the
trimethoprim-sulfamethoxazole, dapsone, and aerosolized-pentamidine groups,
respectively (P = 0.22). The difference in risk among treatment strategies
was negligible in patients entering the study with 100 or more CD4+
lymphocytes per cubic millimeter. In those entering with fewer than 100 CD4+
cells per cubic millimeter, the risk was 33 percent with aerosolized
pentamidine, as compared with 19 percent with trimethoprim-sulfamethoxazole
and 22 percent with dapsone (P = 0.04). The lowest failure rates occurred in
patients receiving trimethoprim-sulfamethoxazole, and failures were more
common with 50 mg of dapsone than with 100 mg. Toxoplasmosis developed in
less than 3 percent of patients. Of the patients assigned to the two systemic
therapies, only 23 percent were receiving their assigned drug and dose when
they completed the study. The median survival was approximately 39 months in
all three groups, and the mortality attributable to P. carinii pneumonia was
only 1 percent. CONCLUSIONS. In patients with advanced HIV infection, the
three treatment strategies we examined have similar effectiveness in
preventing P. carinii pneumonia. Strategies that start with
trimethoprim-sulfamethoxazole or with high-dose dapsone, rather than
aerosolized pentamidine, are superior in patients with fewer than 100 CD4+
lymphocytes per cubic millimeter.
<5>
AN 94082600
AU Torres RA. Barr M. Thorn M. Gregory G. Kiely S. Chanin E. Carlo C.
Martin M. Thornton J.
IN Department of Medicine St. Vincent's Hospital, New York, New York 10011.
TI Randomized trial of dapsone and aerosolized pentamidine for the prophylaxis
of Pneumocystis carinii pneumonia and toxoplasmic encephalitis [see
comments].
CM Comment in: ACP J Club 1994 May-Jun;120 Suppl 3:69
SO American Journal of Medicine. 95(6):573-83, 1993 Dec.
LM Pre-1993 Dana; 1993-dateMFHSL;for Web access-check catalog
AB PURPOSE: Pneumocystis carinii pneumonia (PCP) and toxoplasmic encephalitis
are the most frequent pulmonary and central nervous system
opportunistic infections associated with
human immunodeficiency virus (HIV) infection. We designed a
prospective study to compare the effects of aerosolized pentamidine and
dapsone in the prophylaxis of these infections in
HIV-infected persons with CD4+ lymphocyte counts less than 250/mm3. PATIENTS
AND METHODS: Two hundred seventy-eight patients seropositive for HIV who had
acquired immunodeficiency
syndrome (AIDS) or advanced AIDS-related
complex were randomly assigned to receive intermittent dapsone (100 mg twice
weekly) or aerosolized pentamidine (100 mg every 2 weeks). The proportion of
patients remaining free of PCP or toxoplasmosis was analyzed with the
log-rank test as a function of time, as were the effects of zidovudine or
prophylaxis on survival. RESULTS: Dapsone and aerosolized pentamidine
demonstrated similar efficacy in the primary and secondary prophylaxis of
PCP, with 15 (18%) failures among patients receiving dapsone compared to 15
(14%) among those receiving aerosolized pentamidine (p = 0.4), after a mean
length of follow-up of 42 and 44 weeks, respectively. Dapsone was more
effective in the primary prophylaxis of toxoplasmic encephalitis, with six
toxoplasmic encephalitis events occurring among those receiving aerosolized
pentamidine, compared to none among those taking dapsone (p = 0.01). Primary
prophylaxis for PCP was more effective than secondary prophylaxis with either
therapy. Zidovudine therapy did not prevent PCP yet prolonged the PCP-free
interval for those in whom either prophylactic therapy failed. Kaplan-Meier
estimates did not show a difference in survival between the patients
receiving either therapy, yet zidovudine use was associated with improved
survival, independent of race and risk factor (Cox proportional hazards
model, p = 0.001). The 1-month survival for patients developing PCP despite
prophylaxis was better with those in whom dapsone failed than it was for
those in whom aerosolized pentamidine failed (p = 0.08). CONCLUSION: Dapsone
is as effective as aerosolized pentamidine in preventing PCP and has the
advantage of a lower cost, easier administration, and possibly an additional
preventive effect against toxoplasmosis. Zidovudine prolongs the PCP-free
interval for patients receiving prophylaxis, regardless of which prophylactic
agent is used.
<6>
AN 93078812
AU Schneider MM. Hoepelman AI. Eeftinck Schattenkerk JK. Nielsen TL. van
der Graaf Y. Frissen JP. van der Ende IM. Kolsters AF. Borleffs JC.
IN Department of Internal Medicine, University Hospital Utrecht, The
Netherlands.
TI A controlled trial of aerosolized pentamidine or
trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis
carinii pneumonia in patients with human immunodeficiency
virus infection. The Dutch AIDS Treatment Group [see comments].
CM Comment in: N Engl J Med 1993 May 20;328(20):1499
SO New England Journal of Medicine. 327(26):1836-41, 1992 Dec 24.
LM Dana(complete) &MFHSL(1990-date);also Web,check catalog .
AB BACKGROUND. Primary prophylaxis against Pneumocystis carinii pneumonia (PCP)
is recommended for patients with human immunodeficiency
virus (HIV) infection if their CD4 cell counts are below 200 per cubic
millimeter (0.2 x 10(9) per liter). Either aerosolized pentamidine or
trimethoprim-sulfamethoxazole (co-trimoxazole) is commonly prescribed for
prophylaxis, but the relative efficacy and toxicity of these agents are
unknown. METHODS. We conducted a multicenter trial involving 215 HIV-infected
patients with no history of PCP but with CD4 cell counts below 200 per cubic
millimeter. The patients were randomly assigned to one of three regimens:
aerosolized pentamidine once a month, 480 mg of trimethoprim-sulfamethoxazole
once a day (80 mg of trimethoprim and 400 mg of sulfamethoxazole), or 960 mg
of trimethoprim-sulfamethoxazole once a day (160 mg and 800 mg,
respectively). The cumulative incidence of PCP was estimated by Kaplan-Meier
survival analysis. RESULTS. After a mean follow-up of 264 days, 6 of the 71
patients in the pentamidine group had a confirmed first episode of PCP (11
percent), whereas none of the 142 patients in the two
trimethoprim-sulfamethoxazole groups had PCP (P = 0.002). However, adverse
events that required discontinuation of the medication were much more
frequent in the trimethoprim-sulfamethoxazole groups (17 and 18 patients)
than in the pentamidine group (2 patients). The adverse reactions occurred
significantly sooner in the group given 960 mg of
trimethoprim-sulfamethoxazole than in the group given 480 mg (mean time, 16
vs. 57 days; P = 0.02). CONCLUSIONS. For patients with HIV infection,
trimethoprim-sulfamethoxazole taken once a day is more effective as primary
prophylaxis against PCP than aerosolized pentamidine administered once a
month, although adverse drug reactions are more frequent with
trimethoprim-sulfamethoxazole.
<7>
AN 93078813
AU Hardy WD. Feinberg J. Finkelstein DM. Power ME. He W. Kaczka C. Frame
PT. Holmes M. Waskin H. Fass RJ. et al.
IN Department of Medicine, University of California, Los Angeles.
TI A controlled trial of trimethoprim-sulfamethoxazole or aerosolized
pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in
patients with the acquired immunodeficiency
syndrome. AIDS Clinical Trials Group Protocol 021.
SO New England Journal of Medicine. 327(26):1842-8, 1992 Dec 24.
LM Dana(complete) &MFHSL(1990-date);also Web,check catalog .
AB BACKGROUND. Pneumocystis carinii pneumonia (PCP) continues to be the most
common index diagnosis in the acquired
immunodeficiency syndrome (AIDS), but it is
not clear which of several available agents is the most effective in
preventing a recurrence of PCP. METHODS. We conducted a comparative,
open-label trial in 310 adults with AIDS who had recently recovered from an
initial episode of PCP and had no treatment-limiting toxic effects of
trimethoprim-sulfamethoxazole or pentamidine. All the patients were treated
with zidovudine and were randomly assigned to receive either 800 mg of
sulfamethoxazole and 160 mg of trimethoprim once daily or 300 mg of
aerosolized pentamidine administered every four weeks by jet nebulizer. The
participants were followed for a median of 17.4 months. RESULTS. In the
trimethoprim-sulfamethoxazole group (n = 154) there were 14 recurrences of
PCP, as compared with 36 recurrences (including 1 extrapulmonary recurrence)
in the aerosolized-pentamidine group (n = 156). The estimated recurrence
rates at 18 months were 11.4 percent with trimethoprim-sulfamethoxazole and
27.6 percent with pentamidine (P < 0.001). The risk of a recurrence (adjusted
for initial CD4 cell count) was 3.25 times higher in the pentamidine group (P
< 0.001, 95 percent confidence interval, 1.72 to 6.16). There were no
significant differences between the groups in survival or in hematologic or
hepatic toxicity. Crossovers from trimethoprim-sulfamethoxazole to
aerosolized pentamidine were more common than the reverse (27 vs. 4 percent),
partly because of the study protocols for the management of leukopenia. There
were 19 serious bacterial infections in the
trimethoprim-sulfamethoxazole group and 38 in the pentamidine group. The time
to a first bacterial infection was significantly greater for those assigned
to trimethoprim-sulfamethoxazole (P = 0.017). CONCLUSIONS. In patients with
AIDS who are receiving zidovudine, trimethoprim-sulfamethoxazole is more
effective than aerosolized pentamidine in conventional doses for the
prevention of recurrent pneumocystis infection.