Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection

Briel M, Bucher H, Boscacci R, Furrer H

Published Online:

January 21, 2009

Pneumocystis jiroveci pneumonia (PCP), formerly called Pneumocystis carinii pneumonia, is the most common opportunistic infection among patients infected with HIV. In 1990, based on evidence from five randomized control trials, an expert panel recommended the use of corticosteroids for HIV-infected patients with PCP and substantial hypoxemia (low levels of oxygen in the blood). The objective of this systematic review was to assess the effects of adjunctive corticosteroids on mortality, and the need for mechanical ventilation in patients co-infected with HIV and PCP. Six studies were included in this review and meta-analysis. While the number and size of the trials investigating adjunctive corticosteroids for HIV-infected patients co-infected with PCP is small, evidence from this review suggests a beneficial effect for patients with substantial hypoxemia.

Abstract (click to read)

Background:

Pneumocystis jiroveci pneumonia (PCP) remains the most common opportunistic infection in patients infected with the human immunodeficiency virus (HIV). Among patients with HIV infection and PCP the mortality rate is 10 to 20% during the initial infection and increases substantially with the need for mechanical ventilation. It was suggested that in these patients corticosteroids adjunctive to standard treatment for PCP could prevent the need for mechanical ventilation and decrease mortality.

Objectives:

To assess the effects of adjunctive corticosteroids on overall mortality and the need for mechanical ventilation in HIV-infected patients with PCP and substantial hypoxemia (arterial oxygen partial pressure <70 mmHg or alveolar-arterial gradient >35 mmHg on room air).

Search strategy:

We searched Medline (January 1980-December 2004), EMBASE (January 1985-December 2004) and The Cochrane Library (Issue 4, 2004) without language restrictions to identify randomised controlled trials that compared adjunctive corticosteroids to control in HIV-infected patients with PCP. We further reviewed the reference lists from previously published overviews, we searched UptoDate version 2005 and Clinical Evidence Concise (Issue 12, 2004), contacted experts of the field, and searched reference lists of identified publications for citations of additional relevant articles.

Selection criteria:

Trials were considered eligible for this review if they compared corticosteroids to placebo or usual care in HIV-infected patients with PCP in addition to baseline treatment with trimethoprim-sulfamethoxazole, pentamidine or dapsone-trimethoprim, used random allocation, and reported mortality data. We excluded trials in patients with no or mild hypoxemia (arterial oxygen partial pressure >70 mmHg or an alveolar-arterial gradient <35 mmHg on room air) and trials with a follow-up of less than 30 days.

Data collection and analysis:

Two teams of reviewers independently evaluated the methodology and extracted data from each primary study. We pooled treatment effects across studies and calculated a weighted average risk ratio of overall mortality in the treatment and control groups by using a random effects model.

Main results:

Six studies were included in the review and meta-analysis. Risk ratios for overall mortality for adjunctive corticosteroids were 0.56 (95% confidence interval [CI], 0.32-0.98) at 1 month and 0.68 (95% CI, 0.50-0.94) at 3-4 months of follow-up. To prevent 1 death, numbers needed to treat are 9 patients in a setting without highly active antiretroviral therapy (HAART) available, and 23 patients with HAART available. Only the 3 largest trials provided data on the need for mechanical ventilation with a risk ratio of 0.38 (95% CI, 0.20-0.73) in favour of adjunctive corticosteroids.

Authors' conclusions:

The number and size of trials investigating adjunctive corticosteroids for HIV-infected patients with PCP is small, but evidence from this review suggests a beneficial effect for patients with substantial hypoxemia.

This record should be cited as:

Briel M, Bucher H, Boscacci R, Furrer H. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006150. DOI: 10.1002/14651858.CD006150

Assessed as up to date:

May 24, 2006

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Primary Review Group:

HIV/AIDS Group

Health topics:

Infectious disease > HIV/AIDS > Opportunistic infections: prophylaxis & treatment

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection

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