[Study on the changes of soluble intercellular adhesion molecule-1 level in sera of rats infected with Pneumocystis carinii]

OBJECTIVES

To examine sICAM-1 in Pneumocystis carinii pneumonia (PCP) and the effect of TMP-SMZ therapy on its level and on pathological and immunological changes in rats.

METHODS

50 female Wistar rats were randomly divided into normal group (N group), PCP model group (PCP group) and TMP-SMZ therapy group (SMZ group). 1 mg of dexamethasone was injected intramuscularly twice a week for rats in PCP and SMZ groups to induce PCP. Normal saline was injected for N group in the same way. When the infection was confirmed, TMP-SMZ was given to rats in SMZ group by 25 mg/(kg.d) for 5 days for 3 courses with an interval of 2 weeks. sICAM-1 in serum was detected by ELISA, and the pathological changes in lungs and liver and the Pc in alveoli of lungs were observed.

RESULTS

The level of sICAM-1 in PCP and SMZ groups at the 3rd week [(1.847+/-0.50) ng/ml, (1.787+/-0.59) ng/ml] was lower notably than that at 0 week [(2.407+/-0.81) ng/ml, [(2.478+/-0.59) ng/ml respectively] (P<0.05), and then increased gradually. It was significantly higher in PCP group at 9th week [(3.233+/-0.83) ng/ml] and at 12th week [(3.984+/-0.87) ng/ml] than that of 0 week (P<0.05). Its level in SMZ group at 12th week [(3.621+/-l.62) ng/ml] was also higher than that in 0 week [(2.478+/-0.59) ng/ml] (P<0.05). sICAM-1 level in both PCP and SMZ groups at 9th week and 12th week was higher than that of N group (P<0.05, P<0.01). There was no significant difference between SMZ and PCP groups at 9th week and 12th week (P>0.05).

CONCLUSION

The sICAM-1 level in rats was low but significantly increases after the induction of PCP.

Inhibitory Effect of Umbelliferone Aminoalkyl Derivatives on Oxidosqualene Cyclases fromS. cerevisiae,T. cruzi,P. carinii,H. sapiens, andA. thaliana: a Structure–Activity Study

Eighteen coumarin derivatives were tested as inhibitors of oxidosqualene cyclases (OSCs) from Saccharomyces cerevisiae, Trypanosoma cruzi, Pneumocystis carinii, Homo sapiens, and Arabidopsis thaliana, all expressed in an OSC-defective strain of S. cerevisiae.35 All the compounds have an aminoalkyl chain bound to an aromatic nucleus; unconventional synthetic procedures (microwave- and ultrasound-promoted reactions) were successfully used to prepare some of them. The most interesting structure-dependent difference in inhibitory activities was observed with an N-oxide group replacement of the tertiary amino group at the end of the side chain. An interesting species specificity also emerged: T. cruzi OSC was the least sensitive enzyme; P. carinii and A. thaliana OSCs were the most sensitive. The remarkable activities of three compounds on the T. cruzi enzyme and of five of them on the P. carinii enzyme suggest the present series as a promising compound family for the development of novel antiparasitic agents.

An Official ATS Workshop Summary: Recent advances and future directions in pneumocystis pneumonia (PCP)

Pneumocystis pneumonia (PCP) is a major cause of morbidity and mortality among immunocompromised persons, and it remains a leading acquired immune deficiency syndrome (AIDS)-defining opportunistic infection in human immunodeficiency virus (HIV)-infected individuals throughout the world. Pneumocystis has proven difficult to study, in part due to the lack of a reliable culture system for the organism. With the development of molecular techniques, significant advances in our understanding of the organism and the disease have been made over the past several years. These advances include an improved understanding of host-organism interactions and host defense, the development of noninvasive polymerase chain reaction (PCR)-based diagnostic assays, and the emerging data regarding the possible development of trimethoprim-sulfamethoxazole-resistant Pneumocystis. In addition, the recognition that patients without PCP may nevertheless be carriers of or colonized with Pneumocystis, and observations that suggest a role for Pneumocystis in the progression of pulmonary disease, combine to signal the need for a comprehensive and accessible review. In May 2005, the American Thoracic Society sponsored a one-day workshop, "Recent Advances and Future Directions in Pneumocystis Pneumonia (PCP)," which brought together 45 Pneumocystis researchers. The workshop included 21 presentations on diverse topics, which are summarized in this report. The workshop participants identified priorities for future research, which are summarized in this document.

Novel non-classical C9-methyl-5-substituted-2,4-diaminopyrrolo[2,3-d]pyrimidines as potential inhibitors of dihydrofolate reductase and as anti-opportunistic agents

Six novel C9-methyl-5-substituted-2,4-diaminopyrrolo[2,3-d]pyrimidines 18-23 were synthesized as potential inhibitors of dihydrofolate reductase (DHFR) and as anti-opportunistic agents. These compounds represent the only examples of 9-methyl substitution in the carbon-carbon bridge of 2,4-diaminopyrrolo[2,3-d]pyrimidines. The analogs 18-23 were synthesized in a concise eight-step procedure starting from the appropriate commercially available aromatic methyl ketones. The key step involved a Michael addition reaction of 2,4,6-triaminopyrimidine to the appropriate 1-nitroalkene, followed by ring closure of the nitro adducts via a Nef reaction. The compounds were evaluated as inhibitors of DHFR from Pneumocystis carinii (pc), Toxoplasma gondii (tg), Mycobacterium avium (ma) and rat liver (rl). The biological result indicated that some of these analogs are potent inhibitors of DHFR and some have selectivity for pathogen DHFR. Compound 23 was a two digit nanomolar inhibitor of tgDHFR with 9.6-fold selectivity for tgDHFR.

Absence of dihydropteroate synthase mutations in Pneumocystis jirovecii from Brazilian AIDS patients

Several studies from developed countries have documented the association between trimethoprim-sulfamethoxazole prophylaxis failure and mutations in the Pneumocystis jirovecii gene coding for dihydropteroate synthase (DHPS). DNA was extracted from Giemsa-stained smears of 70 patients with P. jirovecii pneumonia seen in Porto Alegre, Brazil, from 1997 to 2004. Successful PCR amplification of the DHPS locus was obtained in 57 of 70 cases (81.4%), including five cases (8.7%) that had used sulfa prophylaxis. No DHPS gene mutations were seen. These results suggest that DHPS mutations are currently as rare in Brazil as in other developing countries.

In vitro selection and in vivo efficacy of piperazine- and alkanediamide-linked bisbenzamidines against Pneumocystis pneumonia in mice

Bisbenzamidines, such as pentamidine isethionate, are aromatic dicationic compounds that are active against Pneumocystis and other microbes but are oftentimes toxic to the host. To identify potential anti-Pneumocystis agents, we synthesized bisbenzamidine derivatives in which the parent compound pentamidine was modified by a 1,4-piperazinediyl, alkanediamide, or 1,3-phenylenediamide moiety as the central linker. Several of the compounds were more active against P. carinii and less toxic than pentamidine in cytotoxicity assays. For this study, we evaluated nine bisbenzamidine derivatives representing a range of in vitro activities, from highly active to inactive, for the treatment of pneumocystosis in an immunosuppressed mouse model. Six of these in vitro-active compounds, 01, 02, 04, 06, 100, and 101, exhibited marked efficacies against infection at a dose of 10 mg/kg of body weight, and four compounds, 01, 04, 100, and 101, showed significant increases in survival versus that of untreated infected control mice. Compound 100 was highly efficacious against the infection at 20 mg/kg and 40 mg/kg, with > 1,000-fold reductions in burden, and resulted in improved survival curves versus those for pentamidine-treated mice (at the same doses). All six bisbenzamidine compounds that exhibited high in vitro activity significantly decreased the infection in vivo; two compounds, 12 and 102, with marked to moderate in vitro activities had slight or no activity in vivo, while compound 31 was inactive in vitro and was also inactive in vivo. Thus, the selection of highly active compounds from in vitro cytotoxicity assays was predictive of activity in the mouse model of Pneumocystis pneumonia. We conclude that a number of these bisbenzamidine compounds, especially compound 100, may show promise as new anti-Pneumocystis drugs.

Oral trimethoprim-sulphamethoxazole levels in stable HIV-infected children

BACKGROUND

Effective treatment of Pneumocystis jiroveci pneumonia (PCP) requires therapeutic serum concentrations of 5-10 microg/ml trimethoprim (TMP); consequently intravenous trimethoprim-sulphamethoxazole (TMP-SMZ) is recommended therapy. However, oral therapy is desirable as the intravenous route is costly, time-consuming, more difficult to administer and carries a risk of needlestick injury.

OBJECTIVE

To investigate whether therapeutic TMP levels for treatment of PCP can be attained with oral therapy in HIV-infected children.

METHODS

A prospective dose-escalation study was undertaken of serum TMP levels attained following oral doses of TMP of 5 mg/kg, 10 mg/kg or 20 mg/kg in stable HIV-infected children. Children who received a 20 mg/kg dose were randomised to get a second dose (5 or 10 mg/kg TMP) at 6 hours. TMP levels were measured at baseline, peak (3 hours), and trough (6 hours) using liquid chromatography. An additional TMP level was taken at 9 hours in those who received a second TMP dose.

RESULTS

Median (25th-75th percentile) peak serum TMP levels following a 5 mg/kg, 10 mg/kg or 20 mg/kg oral loading dose were 0.93 (0.5-1.5) microg/ml, 1.94 (1.4-2.2) microg/ml and 7.68 (6.1-7.8) microg/ml respectively. Peak TMP levels at 9 hours after a second TMP dose of 5 or 10 mg/kg were 6.98 (3.4-8.8) microg/ml and 9.25 (8.2-10.3) microg/ml respectively.

CONCLUSION

Therapeutic concentrations of TMP for treatment of P. jiroveci can be attained with an oral loading dose of 20 mg/kg and sustained with a second dose at 6 hours of either 5 mg or 10 mg/kg in stable HIV-infected children.

[Immunological regulation and treatment of Brucea javanica and Fructus Psoraleae on rats with Pneumocystis carinii pneumonia]

OBJECTIVE

To study the immunological regulation and treatment of Brucea javanica and Fructus Psoraleae, traditional Chinese medicine, on rats with Pneumocystis carinii pneumonia (PCP).

METHODS

Rats were injected subcutaneously by dexamethasone. When the rats got Pc infected, they were divided into two groups: rats in one group were treated with the mixture of Brucea javanica and Fructus Psoraleae and another group was used as infected control. Control with normal rats was also established. Observations were made on the number of cysts in lungs and the changes of CD4+ T cells, CD8+ T cells and TNF-alpha in the serum to demonstrate the immunological regulation and killing effect of the medicine on cysts in the infected rats.

RESULTS

The body weight of the rats treated with Brucea javanica and Fructus Psoraleae increased considerably than that of immunosuppressed rats and the normal control. The damaged lung got improved and repaired, and a significant cyst reduction was shown in the treated group. The CD4+ T cells, CD8+ T cells and level of TNF-alpha in serum also increased in the treated group significantly.

CONCLUSION

The mixture of Brucea javanica and fructus psoraleae plays an immunological regulation on rats with Pneumocystis carinii pneumonia and shows certain killing effect on the cysts.

[Pneumocystis pneumonia in newborns: a challenge in contemporary intensive care]

Pneumocystis jiroveci (P. jiroveci) is the etiological agent of pneumocystis pneumonia (PCP) in immunodeficient patients. The increased interest of clinicians in this particular pathogen during the past decade was prompted by rising numbers of patients with immunosuppression caused by AIDS, chemotherapy, or organ transplantation. Premature, seriously ill infants at intensive care units constitute a potential risk group for infection with P. jiroveci. Recent advances in medical sciences, owing mainly to developments in molecular biology, permitted the verification of the taxonomic position of pathogens and contributed to a better understanding of new aspects of pathophysiology and pathogenesis of PCP. It has been demonstrated that the genus Pneumocystis represents a heterogeneous group of opportunistic fungi exhibiting narrow host specificity. Pneumocystis jiroveci is the species which is specific for humans. The present paper outlines the clinical symptoms of PCP in infants, currently used diagnostic methods, and treatment procedures in PCP.

QSAR analysis of 2,4-diaminopyrido[2,3-d]pyrimidines and 2,4-diaminopyrrolo[2,3-d]pyrimidines as dihydrofolate reductase inhibitors

Dihydrofolate reductase (DHFR) plays a ubiquitous role in the biosynthesis of DNA, RNA and essential amino acid methionine, and exhibits potential application in the treatment and prophylaxis of AIDS-associated opportunistic microbial infections. In this study, a series of DHFR analogs of 2,4-diaminopyrido[2,3-d]pyrimidines and 2,4-diaminopyrrolo[2,3-d]pyrimidines were subjected to quantitative structure-activity relationship (QSAR) analysis. The results showed that the electronic properties, energy of lowest unoccupied molecular orbital (LUMO) and Z-component of dipole moment (DPL3) of the molecule could be explored to design the potent DHFR inhibitors. LUMO is indicative of pi-bonding interaction of species crucial for the electrophilicity of the molecules. This suggests that molecules are able to interact with electron-rich area at the receptor site. DPL3 is related to the molecular charge distribution in Z-component. These electronic parameters can be altered through the incorporation of electronegative groups. The QSAR study provides important structural insights for designing the potent DHFR inhibitors.

Design, synthesis, and antifolate activity of new analogues of piritrexim and other diaminopyrimidine dihydrofolate reductase inhibitors with omega-carboxyalkoxy or omega-carboxy-1-alkynyl substitution in the side chain

As part of a search for dihydrofolate reductase (DHFR) inhibitors combining the high potency of piritrexim (PTX) with the high antiparasitic vs mammalian selectivity of trimethoprim (TMP), the heretofore undescribed 2,4-diamino-6-(2',5'-disubstituted benzyl)pyrido[2,3-d]pyrimidines 6-14 with O-(omega-carboxyalkyl) or omega-carboxy-1-alkynyl groups on the benzyl moiety were synthesized and tested against Pneumocystis carinii, Toxoplasma gondii, and Mycobacterium avium DHFR vs rat DHFR. Three N-(2,4-diaminopteridin-6-yl)methyl)-2'-(omega-carboxy-1-alkynyl)dibenz[b,f]azepines (19-21) were also synthesized and tested. The pyridopyrimidine with the best combination of potency and selectivity was 2,4-diamino-5-methyl-6-[2'-(5-carboxy-1-butynyl)-5'-methoxy]benzyl]pyrimidine (13), with an IC(50) value of 0.65 nM against P. carinii DHFR, 0.57 nM against M. avium DHFR, and 55 nM against rat DHFR. The potency of 13 against P. carinii DHFR was 20-fold greater than that of PTX (IC(50) = 13 nM), and its selectivity index (SI) relative to rat DHFR was 85, whereas PTX was nonselective. The activity of 13 against P. carinii DHFR was 20 000 times greater than that of TMP, with an SI of 96, whereas that of TMP was only 14. However 13 was no more potent than PTX against M. avium DHFR, and its SI was no better than that of TMP. Molecular modeling dynamics studies using compounds 10 and 13 indicated a slight binding preference for the latter, in qualitative agreement with the IC(50) data. Among the pteridines, the most potent against P. carinii DHFR and M. avium DHFR was the 2'-(5-carboxy-1-butynyl)dibenz[b,f]azepinyl derivative 20 (IC(50) = 2.9 nM), whereas the most selective was the 2'-(5-carboxy-1-pentynyl) analogue 21, with SI values of >100 against both P. carinii and M. avium DHFR relative to rat DHFR. The final compound, 2,4-diamino-5-[3'-(4-carboxy-1-butynyl)-4'-bromo-5'-methoxybenzyl]pyrimidine (22), was both potent and selective against M. avium DHFR (IC(50) = 0.47 nM, SI = 1300) but was not potent or selective against either P. carinii or T. gondii DHFR.

Activity of Hoechst 33258 against Pneumocystis carinii f. sp. muris, Candida albicans, and Candida dubliniensis

Hoechst 33258 is a compound that binds nucleic acids. We report that Hoechst 33258 exhibits antimicrobial activity against Pneumocystis carinii f. sp. muris in a mouse model for P. carinii pneumonia and against Candida albicans and Candida dubliniensis in vitro. Relative to saline treatment, a 14-day, daily treatment of mice with 37.5 mg of Hoechst 33258/kg of body weight after inoculation with P. carinii reduced by about 100-fold the number of P. carinii organisms detected by either PCR or by microscopy after silver staining. For comparison, treatment based on a dose of 15 to 20 mg of the trimethoprim component in trimethoprim-sulfamethoxazole/kg reduced the number of P. carinii by about fourfold. In vitro inhibition of P. carinii group I intron splicing was observed with a 50% inhibitory concentration (IC50) of 30 microM in 2 or 4 mM Mg2+, suggesting RNA as a possible target. However, Hoechst 33258 inhibits growth of Candida strains with and without group I introns. IC50s ranged from 1 to 9 microM for strains with group I introns and were 12 and 32 microM for two strains without group I introns. These studies demonstrate that compounds that bind fungal nucleic acids have the potential to be developed as new therapeutics for Pneumocystis and possibly other fungi, especially if they could be directed to structures that are not present in mammalian cells, such as self-splicing introns.

Highly active anti-Pneumocystis carinii compounds in a library of novel piperazine-linked bisbenzamidines and related compounds

Trimethoprim-sulfamethoxazole and pentamidine isethionate have been used extensively for the prophylaxis and therapy of pneumonia caused by Pneumocystis jirovecii. Problems associated with toxicity and potential emerging resistance for both therapies necessitate the development of safe and effective analogs or new treatment strategies. In the present study, a library of 36 compounds was synthesized by using the pentamidine molecule as the parent compound modified by a 1,4-piperazinediyl moiety as the central linker to restrict conformation flexibility. The compounds were evaluated for anti-Pneumocystis carinii activity in a bioluminescent ATP-driven assay. Four of the compounds were highly active, with 50% inhibitory concentration (IC(50)) values of <0.01 microg/ml; four had very marked activity (IC(50) < 0.10 microg/ml); ten had marked activity (IC(50) < 1.0 microg/ml); nine had moderate activity (IC(50) < 10 microg/ml); one had slight activity (IC(50) = 34.1 microg/ml); and the remaining eight did not demonstrate activity in this assay system. The high level of activity was specifically associated with an alkyl chain length of five to six carbons attached to one of the nitrogens of the bisamidinium groups. None of the highly active compounds and only one of the very marked compounds exhibited any toxicity when evaluated in three mammalian cell lines. The strategy of substitution of 1,4-piperazine-linked bisbenzamidines produced compounds with the highest level of activity observed in the ATP assay and holds great promise for the development of efficacious anti-P. carinii therapy.

Dihydropteroate synthase gene mutations in Pneumocystis and sulfa resistance

We review studies of dihydropteroate synthase gene mutations in Pneumocystis jirovecii and summarize the evidence for resistance to sulfamethoxazole and dapsone.

Pneumocystis pneumonia (PCP) remains a major cause of illness and death in HIV-infected persons. Sulfa drugs, trimethoprim-sulfamethoxazole (TMP-SMX) and dapsone are mainstays of PCP treatment and prophylaxis. While prophylaxis has reduced the incidence of PCP, its use has raised concerns about development of resistant organisms. The inability to culture human Pneumocystis, Pneumocystis jirovecii, in a standardized culture system prevents routine susceptibility testing and detection of drug resistance. In other microorganisms, sulfa drug resistance has resulted from specific point mutations in the dihydropteroate synthase (DHPS) gene. Similar mutations have been observed in P. jirovecii. Studies have consistently demonstrated a significant association between the use of sulfa drugs for PCP prophylaxis and DHPS gene mutations. Whether these mutations confer resistance to TMP-SMX or dapsone plus trimethoprim for PCP treatment remains unclear. We review studies of DHPS mutations in P. jirovecii and summarize the evidence for resistance to sulfamethoxazole and dapsone.

Sulfa use, dihydropteroate synthase mutations, and Pneumocystis jirovecii pneumonia

Meta-analysis shows increased risk for DHPS mutations in patients exposed to sulfa prophylaxis for PCP, but clinical relevance of mutations is not known.

A systematic review was conducted to examine the associations in Pneumocystis jirovecii pneumonia (PCP) patients between dihydropteroate synthase (DHPS) mutations and sulfa or sulfone (sulfa) prophylaxis and between DHPS mutations and sulfa treatment outcome. Selection criteria included study populations composed entirely of PCP patients and mutation or treatment outcome results for all patients, regardless of exposure status. Based on 13 studies, the risk of developing DHPS mutations is higher for PCP patients receiving sulfa prophylaxis than for PCP patients not receiving sulfa prophylaxis (p < 0.001). Results are too heterogeneous (p < 0.001) to warrant a single summary effect estimate. Estimated effects are weaker after 1996 and stronger in studies that included multiple isolates per patient. Five studies examined treatment outcome. The effect of DHPS mutations on treatment outcome has not been well studied, and the few studies that have been conducted are inconsistent even as to the presence or absence of an association.

Iron chelator daphnetin against Pneumocystis carinii in vitro

BACKGROUND

Although there are several drugs and drug combinations for the treatment of Pneumocystis carinii (P. carinii) pneumonia, all drugs have the toxicity as well as low efficacy. Iron chelators have been proposed as a source of new drugs for combating these infections. We hypothesized that iron chelators would suppress the growth of P. carinii by deprivation of the nutritional iron required for growth. In this study, a short-term axenic culture system of P. carinii was established. Daphnetin (7,8-dihydroxycoumarin), a known iron chelator, was demonstrated to exhibit in vitro activity against P. carinii in this system.

METHODS

P. carinii organisms were obtained from the lungs of immunosuppressed rats. The culture system consisted of Iscove Dulbecco Eagle's Minimum Essential Medium (IMDM), supplemented with S-adenosyl-L-methionine, N-acetylglucosamine, putrescine, L-cysteine, L-glutamine, 2-mercaptoethanol, and fetal bovine serum, and was maintained at 37 degrees C, in 5% CO(2), 95% O(2), at the optimal pH of 8.0. The culture system was used to assess the effect of daphnetin on the proliferation of P. carinii organisms. The ultrastructures of the treated organisms were observed by transmission electron microscopy.

RESULTS

The number of cysts and trophozoites increased 8- to 9-fold and 11- to 12-fold, respectively, after 10 days of culture. Daphnetin was found to suppress the growth of P. carinii in a dose-dependent manner at concentrations between 1 micromol/L and 20 micromol/L. The inhibitory activity was suppressed by the chelation of daphnetin with ferrous sulfate in a 2:1 molar ratio, but it was not suppressed by mixing the culture medium with magnesium sulfate. Reduction of P. carinii numbers after treatment with daphnetin correlated with morphological changes in the organisms, as determined by transmission electron microscopy.

CONCLUSIONS

Daphnetin can suppress the growth of P. carinii in vitro. The efficacy of daphnetin in suppressing the the growth of P. carinii in vitro is related to its ability to chelate iron.

Preliminary in vitro studies on two potent, water-soluble trimethoprim analogues with exceptional species selectivity against dihydrofolate reductase from Pneumocystis carinii and Mycobacterium avium

2,4-Diamino-5-[3',4'-dimethoxy-5'-(5-carboxy-1-pentynyl)]benzylpyrimidine (6) and 2,4-diamino-5-[3',4'-dimethoxy-5'-(4-carboxyphenylethynyl)benzylpyrimidine (7) were synthesized from 2,4-diamino-5-(5'-iodo-3',4'-dimethoxybenzyl)pyrimidine (9) via a Sonogashira reaction with appropriate acetylenic esters followed by saponification, and were tested as inhibitors of dihydrofolate reductase (DHFR) from Pneumocystis carinii (Pc), Toxoplasma gondii (Tg), Mycobacterium avium (Ma), and rat in comparison with the widely used antibacterial agent 2,4-diamino-5-(3',4',5'-trimethoxybenzyl)pyrimidine (trimethoprim, TMP). The selectivity index (SI) for each compound was calculated by dividing its 50% inhibitory concentration (IC(50)) against rat DHFR by its IC(50) against Pc, Tg, or Ma DHFR. The IC(50) of 6 against Pc DHFR was 1.0 nM, with an SI of 5000. Compound 7 had an IC(50) of 8.2 nM against Ma DHFR, with an SI of 11000. By comparison, the IC(50) of TMP was 12000 nM against Pc, 300 nM against Ma, and 180000 against rat DHFR. The potency and selectivity values of 6 and 7 were not as high against Tg as they were against Pc or Ma DHFR, but nonetheless exceeded those of TMP. Because of the outstanding selectivity of 6 against Pc and of 7 against Ma DHFR, these novel analogues may be viewed as promising leads for further structure-activity optimization.

Pneumocystis pneumonia: an update

Pneumocystis pneumonia is a major cause of illness and death in immunocompromised hosts. The numbers of pneumocystis pneumonia cases in Thailand have increased each year from 1992 to 2000 and peaked in 2000 at 6,255 cases. The microbe that causes pneumocystis pneumonia in humans is called Pneumocystis jirovecii. Pneumocystis sp. was discovered nearly a century ago, but the knowledge of Pneumocystis sp. remained poorly understood, until the molecular biology techniques help scientists verify it fungus nature. In the past, Pneumocystis sp. was misclassified as protozoan due to its morphologic features. Later, it was reclassified as fungus due to DNA analysis. Cotrimaxazole, the combination of trimethoprim-sulfamethoxazole, is the drug of choice for treatment and prophylaxis of pneumocystis pneumonia. However, increasing evidence of mutations in the enzyme dihydropteroate synthase (DHPS), the target of sulfa drugs represent emergence of sulfa resistance.

Novel bisbenzamidines as potential drug candidates for the treatment of Pneumocystis carinii pneumonia

A series of pentamidine congeners has been synthesized and screened for their in vitro activity against Pneumocystis carinii. Among the tested compounds, bisbenzamidines linked by a flexible pentanediamide or hexanediamide chain (7 and 9) emerged as exceptionally potent agents that were more effective and less toxic than pentamidine in the assays described in this study.

[Genotypic resistance to sulfamide drugs among patients with Pneumocystis jiroveci pneumonia]

BACKGROUND AND OBJECTIVE

The absence of culture methods to recognize the presence of resistance to sulfa or sulfone drugs in Pneumocystis jiroveci has led to develop molecular techniques based on the identification of mutations in the dihydropteroate synthase gene (DHPS). The aim of this study was to determine the frequency of these mutations in our geographical area, since in Spain there is no information concerning this issue.

PATIENTS AND METHOD

The study included all Pneumocystis pneumonia cases identified in our hospital during two years. Diagnosis was made by nested PCR in bronchoalveolar lavage samples. DHPS-3 and DHPS-4 primers were used to amplify the DHPS gene and mutations associated with sulfa resistance were identified using a restriction fragment length polymorphism assay.

RESULTS

In 9 out of the 12 cases identified, DHPS could be amplified (75%) from which 3 (33.3%) showed some mutation linked to sulfa resistance.

CONCLUSIONS

In our area, we have found a relatively high frequency of pneumonia caused by P. jiroveci's strains with mutations associated with sulfa resistance.

Failure of Low‐Dose Atovaquone Prophylaxis againstPneumocystis jiroveciInfection in Transplant Recipients

Trimethoprim-sulfamethoxazole is the preferred agent for prophylaxis against Pneumocystis jiroveci pneumonia. Alternative agents are used in treating patients who do not tolerate this medication. We report 2 cases of prophylaxis failure in patients receiving low-dose atovaquone. We discuss the use of atovaquone as an alternative agent for prophylaxis in transplant recipients.