A retrospective study of intravenous pentamidine for Pneumocystis jirovecii pneumonia prophylaxis in adult patients with hematologic malignancies-its utility during respiratory virus pandemics

OBJECTIVES

In hematology, prophylaxis for Pneumocystis jirovecii pneumonia (PCP) is recommended for patients undergoing hematopoietic stem cell transplantation and in selected categories of intensive chemotherapy for hematologic malignancies. Trimethoprim-sulfamethoxazole (TMP-SMX) is the recommended first-line agent; however, its use is not straightforward. Inhaled pentamidine is the recommended second-line agent; however, aerosolized medications were discouraged during respiratory virus outbreaks, especially during the COVID-19 pandemic, in view of potential contamination risks. Intravenous (IV) pentamidine is a potential alternative agent. We evaluated the effectiveness and tolerability of IV pentamidine use for PCP prophylaxis in adult allogeneic hematopoietic stem cell transplantation recipients and patients with hematologic malignancies during COVID-19.

RESULTS

A total of 202 unique patients who received 239 courses of IV pentamidine, with a median of three doses received (1-29). The largest group of the patients (49.5%) who received IV pentamidine were undergoing or had received a hematopoietic stem cell transplant. The most common reason for not using TMP-SMX prophylaxis was cytopenia (34.7%). We have no patients who had breakthrough PCP infection while on IV pentamidine. None of the patients developed an infusion reaction or experienced adverse effects from IV pentamidine.

CONCLUSIONS

Pentamidine administered IV monthly is safe and effective.

Evaluation of pentamidine tolerability and efficacy between CYP2C19 phenotypes

Intravenous pentamidine is used for prophylaxis against Pneumocystis jirovecii pneumonia, an infection seen in hematopoietic stem cell transplant recipients. Pentamidine is partially metabolized by CYP2C19, which is vulnerable to pharmacogenetic variation. This retrospective study evaluated allogeneic hematopoietic stem cell transplant patients who received intravenous pentamidine as P. jirovecii pneumonia prophylaxis. The primary objective was the association between CYP2C19 phenotype and discontinuation of pentamidine due to drug-related side effects based on univariate logistic regression (N = 81). Ten patients (12.3%) discontinued pentamidine because of side effects. There was no difference in discontinuation between phenotype groups (p = 0.18) or discontinuation due to side effects (p = 0.76). Overall, no association was seen between phenotypes and pentamidine-related side effects (p = 0.475). Drug discontinuation rates and P. jirovecii pneumonia infection rates were low.

Using pentamidine to treat cutaneous leishmaniasis in children: a 10-year study in French Guiana

There are little data on pentamidine as a treatment for paediatric cutaneous leishmaniasis (CL). The objective of this study was to describe the effectiveness and safety of pentamidine over a 10-year period. Every child seen in French Guiana between 2010 and 2020 with proven CL and treated with pentamidine was included. In total, 55 children met the inclusion criteria - 23 girls and 32 boys. There were 38 patients (38/55, 69%) with a > 50% improvement at 1 month after pentamidine treatment and a complete cure at 3 months; 16 children had a < 50% improvement at 1 month and were given a second dose. Of these 16, 8 showed a complete cure at 3 months, 5 were lost to follow-up and 3 showed therapeutic failure at 3 months. The overall cure rate was 84% (46/55) after one or two doses. In terms of the safety of pentamidine, no severe adverse events (grade ≥ 3) were reported.

Adequacy to diagnostic recommendations in patients with Pneumocystis jirovecii pneumonia treated with intravenous pentamidine

Objetivos

Determinar la tasa de confirmación microbiológica en el diagnóstico de la neumonía por Pneumocystis jirovecii en pacientes tratados con pentamidina intravenosa y la potencial correlación con la efectividad y seguridad del tratamiento.

Material y métodos

Estudio retrospectivo unicéntrico (2010-2020), que incluyó aquellos pacientes que recibieron tratamiento con pentamidina intravenosa durante al menos 48 horas. Se registró el procedimiento de recogida de la muestra y el análisis microbiológico realizado. Se determinó la eficacia según la tasa de mortalidad a los 14 días e ingreso en Unidad de Vigilancia Intensiva (UVI), y el control de la enfermedad, mediante la duración de estancia hospitalaria y tiempo desde la finalización del tratamiento hasta el alta. El perfil de seguridad se evaluó según la Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

Resultados

Un total de 17 pacientes con neumonía por P. jirovecii fueron tratados con pentamidina (76,5% hombres (n=13); edad media [desviación estándar]: 58,6 [15,5]).

En el 47,1% (n=8) de los casos se estableció una confirmación microbiológica del patógeno. El empleo dirigido con pentamidina redujo de forma significativa el tiempo desde la finalización del tratamiento hasta el alta hospitalaria (p=0,019). El perfil de seguridad fue aceptable, apareciendo toxicidad grado I en un paciente.

Conclusiones

El estudio muestra como más del 50% de los pacientes reciben tratamiento a partir de un diagnóstico presuntivo y sin ajustarse a las recomendaciones establecidas, repercutiendo en la duración de ingreso y recuperación del pa-ciente. Serán necesarios futuros estudios con un mayor tamaño muestral para consolidar los resultados obtenidos.

Comparative study on liposomal amphotericin B and other therapies in the treatment of mucosal leishmaniasis: A 15-year retrospective cohort study

Background

Liposomal amphotericin B (L-AMB) has been used for mucosal leishmaniasis (ML), but comparative studies on L-AMB and other drugs used for the treatment of ML have not been conducted. The present study aimed to evaluate the outcome of patients with ML who were treated with L-AMB.

Methods

This is a 15-year retrospective study of Brazilian patients with a confirmed diagnosis of ML. The therapeutic options for the treatment of ML consisted of L-AMB, amphotericin B lipid complex (ABLC), deoxycholate amphotericin B (d-AMB), itraconazole, antimonial pentavalent, or pentamidine. Healing, cure rate and adverse effects (AEs) associated with the drugs used to treat this condition were analyzed.

Results

In 71 patients, a total of 105 treatments were evaluated. The outcome of the treatment with each drug was compared, and results showed that L-AMB was superior to other therapeutic regimens (P = 0.001; odds ratio [OR] = 4.84; 95% confidence interval [CI] = 1.78–13.17). d-AMB had worse AEs than other treatment regimens (P = 0.001, OR = 0.09; 95% CI = 0.09–0.43). Approximately 66% of the patients presented with AEs during ML treatment. Although L-AMB was less nephrotoxic than d-AMB, it was associated with acute kidney injury compared with other drugs (P <0.05).

Conclusion

L-AMB was more effective than other therapies for the treatment of ML. However, a high incidence of toxicity was associated with its use. Therapeutic choices should be reassessed, and the development of new drugs is necessary for the treatment of ML.

An open label randomized clinical trial comparing the safety and effectiveness of one, two or three weekly pentamidine isethionate doses (seven milligrams per kilogram) in the treatment of cutaneous leishmaniasis in the Amazon Region

Background

American Cutaneous Leishmaniasis (ACL), a vector borne disease, is caused by various species of Leishmania and in the Amazonas, Leishmania guyanensis is predominant. The recommended drugs for treatment of cutaneous leishmaniasis (CL) in Brazil are pentavalent antimonials, pentamidine isethionate (PI) and amphotericin B. Pentamidine was initially used as metanolsulfonate or mesylate (Lomidine) at a dose of 4 mg/kg/daily, containing 2.3mg of base. This drug was withdrawn from the market in the eighties, and currently is available as PI. The PI dose required to achieve an equivalent dose of pentamidine base is 7 mg/kg, rather than the 4 mg/kg that is currently recommended in Brazil.

Objectives

The aim of this study was to evaluate the efficacy and safety of PI in a single dose, two or three doses of 7 mg/kg body weight, intramuscularly, with an interval of seven days between each dose.

Materials and methods

This study was conducted as a controlled, randomized, open–label clinical trial for a total number of 159 patients with CL. Individuals aged 16–64 years with one to six lesions of confirmed CL based on amastigotes visualization in direct examination of Giemsa stained of dermal scraping from the border of the lesion with no previous treatment for CL and no abnormal values for liver enzymes were eligible to participate in the study. Patients with history of diabetes, cardiac, renal, and hepatic disease as well as pregnant women were excluded. Cure was defined as complete healing in the diameters of the ulcers and lesions skin six months after the end of the treatment.

Results

From November 2013 to December 2015, 159 patients were screened and allocated in three groups for treatment with PI: i) 53 patients were treated with a single dose intramuscularly injection of 7 mg/kg body weight; ii) 53 received two doses of 7 mg/kg within an interval of seven days; and iii) 53 were treated with three doses of 7mg/kg with an interval of seven days between each dose. In 120 patients, L. guyanensis was identified. A cure rate of 45%, 81.1% and 96.2% were observed in the first, second and third group, respectively. The cure in the three PI dose group was higher compared to the single-dose (p<0.0001) and two-dose groups (p = 0.03). No serious adverse events occurred.

Conclusion

The present study shows that PI is a safe drug and its efficacy varied with the number of doses. The administration of PI in patients with ACL, predominantly caused by L. guyanensis, was mostly efficient in three or two doses of 7 mg/kg.

Trial registration

ClinicalTrials.gov NCT02919605

Ninety percent of all cases of CL are concentrated in five countries, including Brazil. Brazil is among the most endemic countries in the Americas. According to the Brazilian Ministry of Health, 30,000 new cases are diagnosed every year and the prevalent species are L. braziliensis and L. guyanensis. In the region of Manaus (Western Amazon), L. guyanensis is responsible for 95% of the cases of CL. The recommended drugs for treatment of CL in Brazil are pentavalent antimonials, PI and amphotericin B (AmB). Pentavalent antimonial is the first-line treatment in Brazil, and AmB is recommended as second-line. The recommended dose for the treatment of CL is 10–20 mg/kg/day of meglumine antimoniate for a period of 20 days. Its efficacy varies from 26.3% to 81.6%. For treatment with AmB, the patient must come to the hospital and be monitored for renal function for several hours. We report a phase II pilot study comprising 159 patients with CL due to L. guyanensis treated with PI. The patients were randomly divided in three groups: 53 received a single intramuscular injection of 7mg/kg PI salt; 53 received a regimen of two intramuscular injections of 7 mg/kg within a seven-day interval; and 53 were treated with three intramuscular injections of 7 mg/kg with a seven-day interval between each dose. All patients live in the region of Manaus and were monitored at Tropical Medicine Foundation of Amazonas. Patients underwent a dermatological and laboratorial examination at the start of the study and at weeks 1 and 4. PI was well tolerated and no severe adverse effects were detected. After a 6-month follow-up, we observed 81.% and 96.2% effectiveness for the cure rates in the groups receiving two and three intramuscular injections of 7 mg/kg PI in ACL patients at one-week intervals between doses, respectively. Only 45.3% of the patients treated with a single dose of the medication were considered to be cured. The use of PI in the aforementioned doses is the best option to treat ACL in this region given the long distance, the difficulty in accessing health centers, and the L. (V.) guyanensis predominance in the Brazilian Amazon. We recommend either two or three weekly doses of PI at 7 mg/kg for the treatment of ACL patients in the region.

Efficacy, Safety, and Dose of Pafuramidine, a New Oral Drug for Treatment of First Stage Sleeping Sickness, in a Phase 2a Clinical Study and Phase 2b Randomized Clinical Studies

Background

Sleeping sickness (human African trypanosomiasis [HAT]) is caused by protozoan parasites and characterized by a chronic progressive course, which may last up to several years before death. We conducted two Phase 2 studies to determine the efficacy and safety of oral pafuramidine in African patients with first stage HAT.

Methods

The Phase 2a study was an open-label, non-controlled, proof-of-concept study where 32 patients were treated with 100 mg of pafuramidine orally twice a day (BID) for 5 days at two trypanosomiasis reference centers (Angola and the Democratic Republic of the Congo [DRC]) between August 2001 and November 2004. The Phase 2b study compared pafuramidine in 41 patients versus standard pentamidine therapy in 40 patients. The Phase 2b study was open-label, parallel-group, controlled, randomized, and conducted at two sites in the DRC between April 2003 and February 2007. The Phase 2b study was then amended to add an open-label sequence (Phase 2b-2), where 30 patients received pafuramidine for 10 days. The primary efficacy endpoint was parasitologic cure at 24 hours (Phase 2a) or 3 months (Phase 2b) after treatment completion. The primary safety outcome was the rate of occurrence of World Health Organization Toxicity Scale Grade 3 or higher adverse events. All subjects provided written informed consent.

Findings/Conclusion

Pafuramidine for the treatment of first stage HAT was comparable in efficacy to pentamidine after 10 days of dosing. The cure rates 3 months post-treatment were 79% in the 5-day pafuramidine, 100% in the 7-day pentamidine, and 93% in the 10-day pafuramidine groups. In Phase 2b, the percentage of patients with at least 1 treatment-emergent adverse event was notably higher after pentamidine treatment (93%) than pafuramidine treatment for 5 days (25%) and 10 days (57%). These results support continuation of the development program for pafuramidine into Phase 3.

Sleeping sickness (human African trypanosomiasis [HAT]) is caused by parasites, and has a chronic progressive course that may last from several months to several years before death occurs. The present studies were done to assess the effectiveness and safety of oral pafuramidine versus intramuscular pentamidine (the standard treatment), in patients with first stage HAT. The results indicated that, several months after treatment, pafuramidine administered for 10 days was as effective as pentamidine administered for 7 days, and it had a better safety profile than pentamidine. With further study, pafuramidine could be a promising alternative for patients with first stage HAT. In addition, the design of the studies can be used a guide for future studies for identification and delivery of treatment to affected individuals in rural Africa.

Efficacy and Safety of Pafuramidine versus Pentamidine Maleate for Treatment of First Stage Sleeping Sickness in a Randomized, Comparator-Controlled, International Phase 3 Clinical Trial

Background

Sleeping sickness (human African trypanosomiasis [HAT]) is a neglected tropical disease with limited treatment options that currently require parenteral administration. In previous studies, orally administered pafuramidine was well tolerated in healthy patients (for up to 21 days) and stage 1 HAT patients (for up to 10 days), and demonstrated efficacy comparable to pentamidine.

Methods

This was a Phase 3, multi-center, randomized, open-label, parallel-group, active control study where 273 male and female patients with first stage Trypanosoma brucei gambiense HAT were treated at six sites: one trypanosomiasis reference center in Angola, one hospital in South Sudan, and four hospitals in the Democratic Republic of the Congo between August 2005 and September 2009 to support the registration of pafuramidine for treatment of first stage HAT in collaboration with the United States Food and Drug Administration. Patients were treated with either 100 mg of pafuramidine orally twice a day for 10 days or 4 mg/kg pentamidine intramuscularly once daily for 7 days to assess the efficacy and safety of pafuramidine versus pentamidine. Pregnant and lactating women as well as adolescents were included.

The primary efficacy endpoint was the combined rate of clinical and parasitological cure at 12 months. The primary safety outcome was the frequency and severity of adverse events. The study was registered on the International Clinical Trials Registry Platform at www.clinicaltrials.gov with the number ISRCTN85534673.

Findings/Conclusions

The overall cure rate at 12 months was 89% in the pafuramidine group and 95% in the pentamidine group; pafuramidine was non-inferior to pentamidine as the upper bound of the 95% confidence interval did not exceed 15%. The safety profile of pafuramidine was superior to pentamidine; however, 3 patients in the pafuramidine group had glomerulonephritis or nephropathy approximately 8 weeks post-treatment. Two of these events were judged as possibly related to pafuramidine. Despite good tolerability observed in preceding studies, the development program for pafuramidine was discontinued due to delayed post-treatment toxicity.

Sleeping sickness, or human African trypanosomiasis (HAT), is a neglected tropical disease. Because only 2 treatment options are available to treat persons with stage 1 disease, and both require parenteral administration, oral drugs would be of great benefit to the affected population. In this Phase 3, multi-center, randomized, open-label, parallel-group study, we compared oral pafuramidine with intramuscular pentamidine in persons in sub-Sahara Africa with first stage HAT. At 12 months, the overall cure rates (combined clinical and parasitological cure) were similar: 89% in the pafuramidine group and 95% in the pentamidine group. At 24 months, the cure rates continued to be high: 84% and 89%, respectively. Pafuramidine’s safety profile was superior to the comparator drug, and it was consistent with the overall safety profile seen in previous Phase 2 studies. Upon further analysis, however, a renal safety issue was identified as being possibly related to pafuramidine and further clinical development was halted. Nevertheless, the clinical studies conducted in the pafuramidine development program provide a model for future studies in rural Africa.

Use of Pentamidine As Secondary Prophylaxis to Prevent Visceral Leishmaniasis Relapse in HIV Infected Patients, the First Twelve Months of a Prospective Cohort Study

Background

Visceral leishmaniasis (VL) has become an important opportunistic infection in persons with HIV-infection in VL-endemic areas. The co-infection leads to profound immunosuppression and high rate of annual VL recurrence. This study assessed the effectiveness, safety and feasibility of monthly pentamidine infusions to prevent recurrence of VL in HIV co-infected patients.

Methods

A single-arm, open-label trial was conducted at two leishmaniasis treatment centers in northwest Ethiopia. HIV-infected patients with a VL episode were included after parasitological cure. Monthly infusions of 4mg/kg pentamidine-isethionate diluted in normal-saline were started for 12months. All received antiretroviral therapy (ART). Time-to-relapse or death was the primary end point.

Results

Seventy-four patients were included. The probability of relapse-free survival at 6months and at 12 months was 79% and 71% respectively. Renal failure, a possible drug-related serious adverse event, occurred in two patients with severe pneumonia. Forty-one patients completed the regimen taking at least 11 of the 12 doses. Main reasons to discontinue were: 15 relapsed, five died and seven became lost to follow-up. More patients failed among those with a CD4+cell count ≤ 50cells/μl, 5/7 (71.4%) than those with counts above 200 cells/μl, 2/12 (16.7%), (p = 0.005).

Conclusion

Pentamidine secondary prophylaxis led to a 29% failure rate within one year, much lower than reported in historical controls (50%-100%). Patients with low CD4+cell counts are at increased risk of relapse despite effective initial VL treatment, ART and secondary prophylaxis. VL should be detected and treated early enough in patients with HIV infection before profound immune deficiency installs.

Relapse of visceral leishmaniasis (VL) among HIV co-infected patients occurs universally. Evidence on the use of secondary prophylaxis especially in anthroponotic transmission regions was lacking. It was found out now that secondary prophylaxis in addition to antiretroviral therapy for VL in people with HIV infection is useful to decrease the relapse rate. However, this intervention is more effective when started before profound immune deficiency. Patients with low CD4 cell counts continued to relapse significantly despite the use of secondary prophylaxis as compared to those with high CD4 cell counts. Earlier VL case detection and management is crucial. This is the first adequately powered trial that has addressed the use of secondary prophylaxis for prevention of VL relapse in HIV co-infected patients.

Comparison between one and two injections of pentamidine isethionate, at 7 mg/kg in each injection, in the treatment of cutaneous leishmaniasis in French Guiana

In a retrospective study set in French Guiana, the efficacy and tolerance of the intramuscular treatment of cutaneous leishmaniasis (CL) with a single injection of pentamidine isethionate, at 7 mg/kg, were compared with those observed, earlier, using two such injections (given 48 h apart). Although 83.6% of the 281 patients given two injections each were cured, the single-injection protocol was generally as effective, curing 78.8% of 137 patients. The single-injection protocol was also associated with fewer adverse effects than the two-injection. In the treatment of "difficult" cases (those with satellite papules or relatively high numbers of amastigotes in their lesions), however, the two-injection protocol appeared significantly more effective than the single-injection. In French Guiana, therefore, patients with CL should be given one injection with pentamidine isethionate and only be given a second, 48 h later, if they have satellite papules and/or relatively high numbers of amastigotes in their lesions.

Efficacy of the diamidine DB75 and its prodrug DB289, against murine models of human African trypanosomiasis

The choice of drugs for the treatment of sleeping sickness is extremely limited. To redress this situation, the recently synthesised diamidine, 2,5-bis(4-amidinophenyl)-furan (DB75, furamidine) and its methamidoxime prodrug, 2,5-bis(4-amidinophenyl)-furan-bis-O-methylamidoxime (DB289, pafuramidine) were, together with pentamidine, evaluated for efficacy in acute rodent models. The activity was compared in three common mouse models that mimic the first stage of human African trypanosomiasis. The mice were infected with the pleomorphic T .b. rhodesiense strains KETRI2537 and STIB900 or with the monomorphic T. b. brucei strain STIB795. Importantly, DB75 showed activity superior to that of pentamidine at comparable doses in all three mouse models. Complete cures were achieved with oral dosing of the prodrug DB289 in all three models without any overt toxicity. This shows that the prodrug strategy was successful in terms of reducing toxicity and increasing efficacy and oral bioavailability.

[Renal insufficiency caused by medicines, diagnostic processes, toxins]

The significance of acute renal insufficiency has grown in the past decade. The increase in the prevalence and mortality of the disease has played a role in this tendency. When judging the significance of acute renal insufficiency, one cannot ignore the fact that the rate of acute renal insufficiency emerging due to medical interventions is rising. The wide-spread diagnostic processes, the interventions and the medicines also promote the emergence of acute renal insufficiency. As for prevention, it is a key task to recognize the high-risk population, assess the renal function and utilize the nephroprotective facilities.

Perioral numbness associated with intravenous pentamidine administration

OBJECTIVE

To report a case of perioral numbness associated with intravenous pentamidine.

CASE SUMMARY

A 56-year-old female with acute myelogenous leukemia in remission developed Pneumocystis carinii infection. Treatment was initiated with trimethoprim/sulfamethoxazole (TMP/SMX), but the patient subsequently developed a rash on day 10 of treatment. TMP/SMX was discontinued and intravenous pentamidine was started in order to complete a 21 day treatment course for P. carinii pneumonia (PCP). However, on day 3 of pentamidine treatment, the patient reported perioral numbness during the infusion. The numbness disappeared soon after completion of the infusion but recurred with all subsequent pentamidine infusions.

DISCUSSION

Paresthesias in general and facial area numbness in particular have been reported with pentamidine administration. While it is possible such adverse events may be a result of pentamidine's effect on serum electrolytes and glucose, especially hypocalcemia and hypoglycemia, these laboratory values were not grossly affected by pentamidine in our patient. The Naranjo probability scale revealed a probable adverse reaction of perioral numbness associated with intravenous pentamidine.

CONCLUSIONS

Pentamidine is considered an alternative agent to TMP/SMX in the treatment of PCP. Although they do not commonly occur, paresthesias have been reported with pentamidine therapy. Healthcare practitioners should be aware of this type of event in association with pentamidine administration, especially as it may not be associated with overt serum glucose or electrolyte disturbances.

Early-onset pentamidine-associated second-degree heart block and sinus bradycardia: case report and review of the literature

Although various manifestations of pentamidine-induced cardiotoxicity have been reported, to our knowledge, second-degree heart block associated with this agent has not been described. In addition, cardiac adverse effects usually develop after at least 6 days of therapy. We describe a 54-year-old, human immunodeficiency virus-positive man with a history of sulfonamide allergy who received treatment with pentamidine for Pneumocystis jiroveci pneumonia. After only the third dose of pentamidine, it was noted that the patient's heart rate had decreased to 48 beats/minute. Subsequently, five episodes of Wenckebach (Mobitz type 1) heart block with a ventricular rate of 28 beats/minute were observed on continuous cardiac telemetry. Serum electrolyte and creatinine levels remained within normal limits. Within 4 days of discontinuing the pentamidine, the patient's heart rate stabilized at 80 beats/minute without further intervention. Clinicians should be vigilant when monitoring for cardiotoxicity in patients receiving pentamidine throughout the duration of therapy. In addition, they should continue to reserve its use for moderate-to-severe Pneumocystis jiroveci pneumonia for which trimethoprim-sulfamethoxazole is ineffective or contraindicated.

[Management of American cutaneous leishmaniasis. Outcome apropos of 326 cases treated with high-dose pentamidine isethionate]

The purpose of this retrospective analysis was to evaluate the outcome of pentamidine isethionate treatment (4 mg/kg of Pentamidine by the intramuscular route on Days 1 and 3) of cutaneous leishmaniasis in 326 cases that occurred during an outbreak among French military personnel in French Guyana from 1998 to 1999. A great difference was found between the 205 patients treated in French Guyana (series G) and 32 patients treated at the Laveran Military Hospital in Marseille, France (series L). Failure rate, i.e. 25% in series L versus 5% in series G, was significantly correlated with the delay to treatment which was much longer in series L. Extensive rhabdomyolysis was observed in all cases tested: this side-effect has not been reported. Based on these findings and a review of the literature on pentamidine isethionate, the authors recommend prompt treatment using lower doses. Other treatment alternatives for American cutaneous leishmaniasis are also presented including two of the latest developments in the field, i.e., oral treatment using miltefosine and topical treatment using agents such as paromomycine.

The pulmonary effects of long-term exposure to aerosol pentamidine: a 5-year surveillance study in HIV-infected patients

STUDY OBJECTIVES

To assess the effects of long-term exposure to aerosolized pentamidine (AP) for the prophylaxis of Pneumocystis carinii pneumonia on the pulmonary function.

DESIGN

The results of pulmonary function tests (PFTs) over a period of 5 years were retrospectively analyzed in a cohort of HIV-infected individuals.

SETTING

A government-funded AP clinic in a large metropolitan center in Canada.

PATIENTS

Among the cohort of 1,850 HIV-positive patients who received regular AP prophylaxis between 1989 and 2001 at the AP clinic, 83 received AP for >or= 5 years. Of these 83 patients, baseline and long-term follow-up PFT data were available for 79. These subjects formed the study population for this analysis.

RESULTS

The cohort was divided according to smoking status (smokers, 48%). The rate of decline of FEV(1) in the smokers over the 5-year period was statistically significant but was comparable to that expected of healthy smokers. As for the nonsmokers, there was no significant reduction in FEV(1). Flow rates at low lung volumes (ie, forced expiratory flow at 50% and 75% of FEV(1)) and low FEV(1)/FVC ratios showed significant declines in both smokers and nonsmokers. On the other hand, no significant changes in FVC, total lung capacity, residual volume, or diffusing capacity of the lung for carbon monoxide were observed. The apparent slight reduction in flow rates seems to be at the level of the small airways.

CONCLUSIONS

The PFT data suggest that AP can be well-tolerated over a 5-year period in HIV-infected patients with only modest reduction in flow rates at the level of the small airways, especially in smokers.

Aerosolized pentamidine prophylaxis against AIDS-related Pneumocystis carinii pneumonia and its short- and long-term effects on pulmonary function in the Japanese

We evaluated the incidence of prophylaxis failure with aerosolized pentamidine (AP) for Pneumocystis carinii pneumonia (PCP) in Japanese patients with human immunodeficiency virus (HIV) infection, and we examined the short- and long-term effects of AP on pulmonary function. The patients inhaled 300 mg of pentamidine by ultrasonic nebulizer, after the inhalation of procaterol (80 micrograms), every 4 weeks. PCP developed in 2 of 16 patients receiving primary prophylaxis with AP, and in 4 of 13 patients with secondary prophylaxis. The CD4(+) T-lymphocyte count was very low in the patients with prophylaxis failure. The chest radiographic presentations were atypical in 4 of the 6 patients with prophylaxis failure. There were no significant changes in the vital capacity (VC), VC/predictive VC (%VC), forced expiratory volume in 1 s (FEV(1.0)), FEV(1.0)/forced vital capacity (FEV(1.0)%), and maximum expiratory flow rate at 25% of vital capacity (MEF(25))/height comparing values before and after initial AP treatment. However, a reduction of oxygen saturation (SpO(2)) of over 3% was noted in 4 patients during the initial AP administration. In 9 patients receiving AP prophylaxis for more than 36 months, we compared the pulmonary function parameters between the baseline and final observations (mean, 52.7 months). There were no changes in VC, %VC, FEV(1.0,) FEV(1.0)%, and SpO(2), but there was a statistically significant decline in MEF(25)/height after long-term AP treatment. We concluded that the incidence of prophylaxis failure with AP for PCP in Japanese patients was similar to that in Western patients, and that long-term AP treatment affected MEF(25)/height in spite of the safe pulmonary effects in short-term AP inhalation.

[A comparative study between the efficacy of pentamidine isothionate given in three doses for one week and N-methil-glucamine in a dose of 20mgSbV/day for 20 days to treat cutaneous leishmaniasis]

Seventy-nine patients with cutaneous leishmaniasis were included in this study. The experimental group (n = 38) was treated with pentamidine isothionate in a dose of 4mg/kg/day on alternate days, for one week. The control group (n = 41) was treated with N-methylglucamine in a dose of 20mgSbV/kg/day for 20 days. Twenty-one isolates were identified using monoclonal antibody technique. We characterized Leishmania (Viannia) braziliensis, most frequently. There was a cure rate of 71.05% of the patients in the experimental group and 73.17% in the control group (p = 0.47). We found a statistical significance regarding frequency of ECG alterations between the experimental and control group (p<0.05). In our study pentamidine was as effective as antimonial for the treatment of american cutaneous leishmaniasis. It proved to be a safer drug considering heart toxicity. Moreover, it requires less time to complete the treatment.

Pentamidine, the drug of choice for the treatment of cutaneous leishmaniasis in Surinam

BACKGROUND

Cutaneous leishmaniasis is an endemic disease in Surinam. The disease was treated until the early 1970s with pentavalent antimony. Pentamidine mesylate was introduced by Niemel in 1973 for the treatment of cutaneous leishmaniasis in Surinam.

MATERIALS AND METHODS

In this retrospective study, we evaluate the results of treatment with pentamidine mesylate in 235 patients and with pentamidine isethionate in 80 patients.

RESULTS

In the pentamidine mesylate- and pentamidine isethionate-treated groups, a cure rate (healing without relapse) of nearly 90% was found. Relapses were seen in approximately 10% of patients in both groups. Minor side-effects, such as pain at the injection site, bitter taste, and nausea, were seen with both drugs in about 65% of patients. Complaints of the respiratory tract were seen in less than 10% of patients in the pentamidine isethionate-treated group, but were uncommon in the pentamidine mesylate-treated group.

CONCLUSIONS

Pentamidine mesylate and isethionate have similar safety, efficacy, and side-effect profiles in the treatment of cutaneous leishmaniasis in Surinam.

T wave alternans and Torsades de Pointes after the use of intravenous pentamidine

We report the case of a patient in whom dramatic T wave alternans with brief bouts of torsades de pointes and QT prolongation occurred in association with intravenously administered pentamidine. This ECG marker of a potentially fatal side effect, although uncommon, should be looked for in patients requiring the use of this drug.

[Rhabdomyolysis induced by pentamidine (Pentacarinat) during treatment of cutaneous leishmaniasis: 2 cases]

INTRODUCTION

We report 2 patients who developed pentamidine-induced rhabdomyolysis during treatment of leishmaniasis. This potentially harmful side effect of pentamidine has only been reported exceptionally until now.

CASE REPORTS

In January 2001, we treated 2 patients, aged 31 and 38 years, with 600 mg pentamidine administered intramuscularly twice in 48 hours. The two patients developed rhabdomyolysis with elevated CPK (respectively 30-70-x normal) and myoglobinemia (respectively 20-28-x normal) levels. Outcome was good under hyperhydratation and alkaline diuresis.

DISCUSSION

This underestimated side effect of pentamidine treatment is not mentioned in recent articles on the topic. In case of such treatment however, these biological parameters should be monitored in order to establish the real frequency of this side-effect.

[Guidelines for Prevention of Pneumocystis carinii Pneumonitis in Children and Adolescents with Cancer]

Pneumocystis carinii pneumonitis (PCP) is one of the most important opportunistic infections in children and adolescents with cancer. Its high frequency and a considerable mortality have led to primary chemoprophylaxis in patients with hematological malignancies and following allogeneic hematopoietic stem cell transplantation. Although less well characterized, patients with autologous stem cell transplantation and patients with dose-intensive chemotherapy for pediatric solid tumors may have a similarly high risk for PCP based on their profound T-cell depletion. For more than two decades, effective chemoprophylaxis for PCP has been available. Trimethoprim and sulfamethoxazole (TMP/SMX) is the prophylactic modality of first choice. The combination has been shown to be almost 100 % efficacious in pediatric cancer patients at highest risk, and it is usually well tolerated in this setting. Secondary alternatives to TMP/SMX include oral dapsone, oral atovaquone, and aerosolized pentamidine-isethionate. These modalities are less effective than TMP/SMX, and have been evaluated predominantly in HIV-infected patients. This article reviews epidemiology and current approaches to chemoprophylaxis for PCP in children and adolescents with cancer and/or hematopoietic stem cell transplantation, and provides evidence-based guidelines for indications and modalities of PCP prophylaxis in this population.

Complications during clinical courses of Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome

OBJECTIVE

To describe the incidence of complications before and during therapy of Pneumocystis carinii pneumonia (PCP) in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

A retrospective review of the patient's medical records.

PATIENTS

A total of 29 patients with AIDS and PCP who were admitted to the AIDS Clinical Center, International Medical Center of Japan from July 1996 to November 1999.

RESULTS

Adverse effects were found in 24 (88.9%) of 27 patients treated with trimethoprim/sulfamethoxazole (T/S), 6 (46.1%) of 13 treated with parenteral pentamidine, and 2 (20%) of 10 treated with inhaled pentamidine. Infectious and/or non-infectious complications were found in 25 (86.2%) of 29 study patients. Regarding infectious complications, 16 (55.2%) were found on admission and 10 cases (34.5%) with infectious complications were identified during admission; including oral candidiasis (37.9% and 17.2%, respectively) and genital herpes (3.4% and 6.9%, respectively). Cytomegalovirus antigenemia was detected in 4 cases (13.8%) on admission and 12 cases (41.4%) during admission. Non-infectious complications affected 11 cases (37.9%) on admission, and 6 cases (20.7%) during admission, the latter included heart failure (10.3%) and pneumothorax (6.9%). PCP was successfully treated in all but one patient who suffered from repeated pneumothorax.

CONCLUSION

Treatment of PCP can be problematic and it is important to be aware of the high incidence of various complications that can occur during the treatment of PCP.

Treatment of Old World cutaneous leishmaniasis by pentamidine isethionate. An open study of 11 patients

BACKGROUND

Pentavalent antimonial derivatives (PAD), especially meglumine antimoniate (Glucantime((R))), are usually considered as the first-line drugs for Old World leishmaniasis, but their potential toxicity and the number of required injection, either intralesional or intramuscular, prompt to search for alternative treatments.

OBJECTIVE

To evaluate the efficiency and tolerance of pentamidine isethionate in Old World leishmaniasis.

METHODS

An open pilot study included 11 patients from two regional academic centers, with varied parasitological forms of Old World leishmaniasis, treated with three strictly intramuscular injections of 4 mg/kg of base-pentamidine every other day.

RESULTS

Tolerance was good overall, and 8/11 (73%) of patients responded well with a quick healing of their lesions, little scarring and no relapse.

CONCLUSION

Pentamidine isethionate is a safe and effective first-line treatment for Old World leishmaniasis. Larger-scale prospective studies comparing several dosage regimens of pentamidine and pentamidine isethionate to PAD are warranted.

Atovaquone suspension compared with aerosolized pentamidine for prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected subjects intolerant of trimethoprim or sulfonamides

Atovaquone suspensions (750 mg and 1500 mg once a day) were compared with aerosolized pentamidine (300 mg once a month) for the prevention of Pneumocystis carinii pneumonia (PCP) in subjects with human immunodeficiency virus (HIV) infection who were intolerant to trimethoprim or sulfonamides (or both). Median time using the assigned therapy was 6.6 months, and the median follow-up was 11.3 months. Intent-to-treat analyses (n=549) showed no statistically significant differences among subjects with regard to the incidence of PCP (26%, 22%, and 17%, respectively) or mortality (20%, 13%, and 18%, respectively). The incidence of treatment-limiting adverse events with atovaquone was significantly higher (P<.01). There was, however, no significant difference in the time using therapy. Incidences of PCP and death were higher in subjects receiving 750 mg of atovaquone than in subjects receiving 1500 mg. Atovaquone suspension at 1500 mg once a day has an efficacy similar to that of aerosolized pentamidine for prevention of PCP in HIV-infected subjects and is a safe, effective alternative in those who are intolerant to trimethoprim or sulfonamides.

Exposure of health care workers to pentamidine isethionate

Pentamidine isethionate is currently used for the prophylaxis and treatment of Pneumocystis carinii pneumonia. Its use has been associated with a number of symptoms in staff administering treatment, and there are some additional concerns about possible adverse health effects of long term exposure. The aim of this study was to quantify exposure of health care staff administering nebulized pentamidine to patients. Personal breathing zone and static air samples at the height of the patient's head were collected during the nebulization of pentamidine to nine sequential outpatients attending a haemophilia unit. These were analysed using a standard method allowing the exposure of staff to be estimated. The duration of treatment varied between 15 and 60 min. Personal breathing zone samples showed exposure to be between 2 and 100 micrograms/m3. Static samples showed the concentration of pentamidine in the room varied from 15 to 2,100 micrograms/m3. While these exposures were relatively low, they were higher than some other studies have reported, and may pose some risk of adverse effects to staff. Some simple measures could reduce staff exposure.

The efficacy of pentamidine combined with allopurinol and immunotherapy for the treatment of patients with diffuse cutaneous leishmaniasis

A new treatment regimen was tested on patients with incurable diffuse cutaneous leshmaniasis (DCL) infected with Leishmania mexicana mexicana in Mexico. Two patients with advanced stages of the disease were treated with polychemotherapy (pentamidine and allopurinol) combined with recombinant human interferon-gamma (rIFN-gamma). For determination of the best medication, parasites isolated from patient lesions were exposed to available drugs both as promastigotes and as intracellular amastigotes. A synergistic effect was observed in vitro for the combination of pentamidine and allopurinol. Both patients were treated and recovered rapidly, but one of them developed insulin-dependent type I diabetes because of pentamidine toxicity. The complication was controlled and both patients were discharged with an apparent parasitologic cure, but after 3 months the two patients began to relapse. Our results suggest that allopurinol-pentamidine polychemotherapy, involving reduced dosage of pentamidine, combined with rIFN-gamma is an alternative for DCL patients infected with L. m. mexicana.

[Incidence of bacterial pneumonia in HIV-positive patients treated with preventive co-trimoxazole or pentamidine]

BACKGROUND

Besides Pneumocystis carinii bacterial pathogens represent the most common aetiology of pulmonary infections in HIV-positive patients. However, the impact of PCP prophylaxis on the incidence of bacterial pneumonia in HIV-positive patients using pentamidine or co-trimoxazole is still unknown.

PATIENTS AND METHODS

We analysed retrospectively the data of 80 consecutive HIV-positive patients with a CD4-cell count < 300/microliter. The total observation period was 1993 patient months. Type and duration of chemoprophylaxis, frequency of bacterial pneumonia, PCP, extrapulmonary bacterial infections and cerebral toxoplasmosis were documented in a standardised manner. For statistical analysis we used the Kaplan-Meier test for the time to a recurrence of the various infections under both prophylaxis regimens and the Odds ratio for determination of the relative risk.

RESULTS

We followed up 47 patients inhaling 300 mg pentamidine monthly for a total of 1133 months and 33 patients taking 480 mg co-trimoxazole per day p.o. for a total of 860 months. There were no statistically significant differences between the two groups in respect of demographic parameters, stage and therapy of HIV infection and distribution of risk groups. We found seven bacterial pneumonias in the co-trimoxazole group and 13 in the pentamidine group (not significant); the most common causative organisms were S. pneumoniae (n = 4), S. aureus (n = 3) and H. influenzae (n = 3). Furthermore, in the pentamidine group 12 PCP and nine cases of toxoplasma encephalitis were observed, whereas none of these infections occurred in the co-trimoxazole group (p < 0.05). Two of the patients taking co-trimoxazole and 15 of those inhaling pentamidine had extrapulmonary bacterial infections (p < 0.05), the most frequently identified pathogen being S. aureus (n = 7). The two prophylaxis groups did not differ significantly with regard to laboratory data, course and therapy of the bacterial pneumonias.

CONCLUSION

There was no significant influence of chemoprophylaxis on the incidence of bacterial pneumonia in patients with advanced HIV-disease in our study. Since S. pneumoniae represents the most common causative agent, we suggest immunisation with a polyvalent pneumococcal vaccine at an early stage of HIV-infection.

[Treatment of mucocutaneous leishmaniasis with pentamidine isothionate]

BACKGROUND

The mucocutaneous form of New World cutaneous leishmaniasis is caused, theoretically, by Leishmania (viannia) braziliensis. Pentad valency antimonic compounds are widely used for treatment of New World cutaneous leishmaniasis. The rate of recurrence is often high when these drugs are used for mucocutaneous forms. Pentamidine has been considered as a second line treatment although little data is available.

PATIENTS AND METHODS

Seventeen patients with mucocutaneous leishmaniasis were treated with pentamidine isothionate, 4 mg/kg every 48 hours. A complete oto-rhino-laryngological examination was performed once a week to determine the course of the lesions. Treatment was discontinued when the lesions healed. A follow-up oto-rhinolaryngological examination was also performed after treatment withdrawal and every three months thereafter for an undetermined period.

RESULTS

Lesions healed with pentamidine isothionate in 16 patients (94%). Mean dosage required was 2872 mg (2025-4320 mg) for a mean treatment duration of 22 days (12-32 days). Mean follow-up was 13.3 months (3-37 months). Leishmaniasis relapsed in one patient 4 months after treatment withdrawal.

DISCUSSION

Pentamidine isothionate is an effective treatment for mucocutaneous leishmaniasis, providing cure with a low rate of recurrence.

[Acute myelogenous leukemia with hyperkalemia induced by pentamidine administration]

A 27-year-old male with acute myelogenous leukemia received an allogeneic bone marrow transplantation (allo-BMT). Pneumocystis carinii pneumonia developed on day 65 after the allo-BMT. The patient was intravenously treated with pentamidine. This resulted in a prompt improvement of his dyspnea and fever, but hyperkalemia occurred during the pentamidine therapy. Treatment with pentamidine was stopped and emergent treatment was started. Nevertheless, the serum potassium level rose to 7.7 mEq/l. Urgent dialysis was performed and the serum potassium level fell to 5.0 mEq/l after treatment. Careful monitoring of the serum potassium level is recommended during intravenous therapy with pentamidine.

[Cerebral toxoplasmosis in HIV infected patients intolerant of cotrimoxazole]

Using results of a multicentric randomized prospective trial of primary prophylaxis of Pneumocystis carinii pneumonia in HIV-infected patients which compared sulfamethoxazole-trimethoprim and pentamidine isethionate, the risk to develop cerebral toxoplasmosis was analyzed in the two assigned groups and in the groups of patients who stopped sulfamethoxazole-trimethoprim prophylaxis. The risk to develop cerebral toxoplasmosis appeared significantly higher in the group of patients who stopped sulfamethoxazole-trimethoprim consecutively to cutaneous hypersensitivity.

Severe hyperglycemia in an HIV clinic: preexisting versus drug-associated diabetes mellitus

We determined the frequency and clinical nature of severe hyperglycemia in a university clinic for HIV-1-infected patients. The medical records of 1392 adult HIV-infected patients were reviewed for cases of severe hyperglycemia, defined as two or more serum glucose values >250 mg/dl or diabetes treatment during clinic care. Demographic information, family histories of diabetes mellitus, body weights, CD4+ lymphocyte counts, and use of corticosteroids, megestrol acetate, pentamidine, or didanosine were recorded for subjects meeting the case definition. Comparisons were made between preexisting diabetic (group 1) and incident hyperglycemic cases (group 2). Less than 2% of the total clinic population experienced severe hyperglycemia: 12 in group 1 and 13 in group 2. Group 2 had lower body weights (mean, 70.6 kg versus 90.0 kg; p < 0.05) and more advanced HIV disease (mean CD4 count, 79/mm3 versus 550/mm3; p < 0.05) than group 1. Group 2 cases had evidence of drug-associated hyperglycemia; four cases demonstrated hyperglycemia coinciding with large fluctuations in weight during megestrol therapy. Among megestrol recipients, cases did not differ from noncases in demographics, weight, or CD4 count. Severe hyperglycemia is uncommon in adult HIV-infected patients. Approximately one half of these patients have preexisting diabetic conditions; many of the remainder may have drug-induced hyperglycemia, especially as a result of corticosteroids or megestrol acetate.

Torsades de pointes complicating pentamidine therapy of Pneumocystis carinii pneumonia in acute myelogenous leukemia

Pentamidine isethionate induced torsades de pointes in a 33-year-old woman with acute myelogenous leukemia. This is the first report of Pentamidine-induced torsades de pointes in Japan for over ten years. On the 4th day of intravenous pentamidine for Pneumocystis carinii pneumonia, asymptomatic sinus bradycardia was noted with QT interval prolongation, and torsades de pointes were revealed on the 8th day. Although torsades de pointes was dissolved with discontinuation of the intravenous pentamidine and administration of magnesium sulfate, sinus bradycardia and prolonged QT interval persisted. Ventricular pacing resulted in no arrhythmia and normalization of the QT interval on the 10th day after discontinuation of pentamidine. Careful monitoring of the electrocardiogram should be carried out during intravenous pentamidine therapy.

A prospective study of the effect of I.V. pentamidine therapy on ventricular arrhythmias and QTc prolongation in HIV-infected patients

STUDY OBJECTIVES

I.V. pentamidine therapy in HIV-infected patients has been associated in case reports and one uncontrolled prospective series with frequent prolongation of the rate-corrected QT interval (QTc) and a high risk for potentially lethal ventricular arrhythmias, especially torsade de pointes. The aim of this study was to prospectively examine in a controlled manner the effect of I.V. pentamidine therapy on the QT interval and the incidence of ventricular arrhythmias.

DESIGN

Open, nonrandomized, prospective evaluation of ventricular arrhythmia incidence in HIV-infected patients receiving pentamidine or trimethoprim-sulfamethoxazole (TMP-SMX) utilizing Holter monitoring prior to and during therapy with these agents.

SETTING

Staten Island University Hospital, Staten Island, NY.

PATIENTS

Twenty-seven HIV-infected patients, of whom 16 received I.V. pentamidine and 11 received I.V. TMP-SMX.

MEASUREMENTS AND RESULTS

Study patients underwent Holter monitoring prior to therapy and during the first 3 days and last 2 days of therapy with pentamidine or TMP-SMX, 12-lead ECG prior to and every 24 to 48 h, serum electrolytes prior to and on days 3, 6, 9, and 12 of therapy, and baseline transthoracic two-dimensional and Doppler echocardiography. In the pentamidine group, the results for each monitoring period were as follows (means are presented +/- SEM): pretherapy, 1.66+/-1.03 (median=0) premature ventricular complexes (PVCs) per hour, zero nonsustained ventricular tachycardia (NSVT), zero sustained ventricular tachycardia (VT); early therapy, 1.55+/-0.91 (median=0.04) PVCs per hour, two NSVT (both < or = 5 complexes), zero sustained VT; late therapy, 1.69+/-1.17 (median=0.08) PVCs per hour, zero NSVT, zero sustained VT (p value not significant for early or late therapy as compared to pretherapy for PVCs per hour, NSVT, or sustained VT). In the TMP-SMX group, the Holter monitoring results were as follows: pretherapy, 1.36+/-1.27 (median=0) PVCs per hour, zero NSVT, zero sustained VT; early therapy, 0.71+/-0.53 (median=0.03) PVCs per hour, two NSVT, zero sustained VT; late therapy, 0.56+/-0.51 (median=0) PVCs per hour, zero NSVT, zero sustained VT (p value not significant for pretherapy, early therapy, or late therapy with TMP-SMX as compared to pentamidine for PVCs per hour, NSVT, or VT). The QTc also did not significantly differ during therapy with pentamidine as compared to TMP-SMX. The mean QTc in the pentamidine group decreased during therapy as compared to pretherapy with the difference approaching significance for days 2, 4, and 6 with pentamidine (p<0.06).

CONCLUSIONS

QTc prolongation during therapy with pentamidine in HIV-infected patients is not as frequent an occurrence as has been reported previously. In the absence of QTc prolongation, pentamidine therapy was not associated with a significant increase in PVCs, NSVT, or sustained VT as compared to pretherapy recordings or as compared to therapy with TMP-SMX.