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Acta Trop. 2013 Sep;127(3):236-44. doi: 10.1016/j.actatropica.2013.05.006. Epub 2013 May 23.

Meta-analysis of prevention and treatment of toxoplasmic encephalitis in HIV-infected patients.

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1
Department of Parasitology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China.

Abstract

Toxoplasmic encephalitis (TE) is one of the most common central nervous system (CNS) opportunistic infections in HIV-infected patients. It can be prevented and treated through drug regimen. However, drugs have serious adverse effects sometimes. The purpose of this review is to determine the most effective therapy for TE in HIV-infected patients. Different primary prophylaxis and treatment regimens have been compared with regard to episodes of TE, clinical response, morbidity, and serious adverse events. In September 2012, we searched PubMed, Google Scholar, EMBASE, and CENTRAL (the Cochrane Central Register of Controlled Trials) database for randomized and quasi-randomized controlled trials of any drug regimen for primary prophylaxis and treatment of TE in HIV-infected patients. We independently extracted data and assessed eligibility and risk of bias using a standardized data collection form, and resolved any disagreement through discussion. We combined dichotomous outcomes using odds ratio (OR), presenting with 95% confidence interval (CI). Eleven trials were found to meet the inclusion criteria. Six trials compared trimethoprim-sulfamethoxazole (TMP-SMX) with dapsone-pyrimethamine (D-P) were analyzed together for the outcome of episodes of TE, morbidity, and serious adverse events. The two treatment arms did not differ for episodes of TE (OR=0.98; 95% CI: 0.48-2.00). Compared with D-P, TMP-SMX showed a beneficial trend in terms of mortality despite a lack of statistical significance (OR=0.75; 95% CI: 0.53-1.06). However, TMP-SMX is still associated with substantial toxicity and intolerance (OR=1.47; 95% CI: 0.91-2.38). Three trials compared pyrimethamine-sulfadiazine (P-S) with pyrimethamine-clindamycin (P-C) were analyzed together for the outcome of clinical response, morbidity, and serious adverse events. Compared with P-C, P-S showed a beneficial trend in terms of clinical response (OR=1.63; 95% CI: 1.05-2.51); P-S also showed a beneficial trend in terms of mortality despite a lack of statistical significance (OR=0.66; 95% CI: 0.37-1.17). However, P-S is still associated with substantial toxicity and intolerance (OR=3.08; 95% CI: 1.82-5.24). Two trials compared P-S with TMP-SMX were analyzed together for the outcome of clinical response, morbidity, and serious adverse events. The two treatment arms did not differ for clinical response (OR=0.90; 95% CI: 0.39-2.06). Compared with TMP-SMX, P-S showed a beneficial trend in terms of mortality despite a lack of statistical significance (OR=0.12; 95% CI: 0.01-1.39). However, P-S is still associated with substantial toxicity and intolerance (OR=2.91; 95% CI: 0.99-8.55). The available evidence fails to identify any one superior regimen for the primary prophylaxis and treatment of TE. The choice of therapy will often be directed by available therapy. Although current evidence does not allow a definitive recommendation, administration of TMP-SMX for primary prophylaxis and treatment of TE in patients with HIV infection is consistent with the available data.

KEYWORDS:

D-P; P-C; P-S; TMP-SMX; Toxoplasmic encephalitis

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