WHO Protocol for Treating Respiratory Infections in HIV Patients Questioned
A Kenyan study of the effectiveness of following the WHO protocol for respiratory tract infections in HIV patients has demonstrated that the recommended treatments "often failed those diagnosed with pneumonia," the Lancet reports. The research team, led by Christina Mwachari of the Center for Respiratory Disease Research, diagnosed 597 cases of RTI in 251 of 380 HIV patients at a Nairobi outpatient clinic between July 1997 and January 1999, according to the study published in the Aug. 1 issue of the Journal of Acquired Immune Deficiency Syndromes. Patients who were older and widowed and who had lower T-cell counts and less education were at greatest risk of RTIs. The WHO recommended "first-line" therapy ampicillin was successful in treating 79% of the cases and the second-line therapy trimethoprim and sulfamethoxazole was successful in 10% of the cases. "Non-protocol" antibiotics were required to treat 11% of the cases (Ashraf, Lancet, 8/18). The WHO protocol was "significantly more successful in patients with bronchitis," with only 3% of bronchitis cases requiring non-protocol treatment versus 32% of pneumonia cases. Most of the pneumonia patients who did not respond to either first- or second-line WHO therapies responded to oral erythromycin or azithromycin.
Significance of the Findings
According to Mwachari, RTIs are the "most common cause of morbidity and mortality in HIV-1-positive individuals in sub-Saharan Africa." The failure of WHO-recommended treatments in nearly a third of pneumonia patients "suggest[s] that research is urgently needed to identify alternative treatment strategies for these patients," Reuters Health reports. Although they were largely successful, "[w]ithout more supportive evidence, oral ampicillin and trimethoprim-sulfamethoxazole cannot be recommended for treatment of pneumonia in our population of HIV-1-infected adults," Mwachari said, adding that those with "clinical signs and symptoms suggestive of pneumonia might benefit from treatment with a macrolide antibiotic and should be hospitalized if symptoms worsen or persist" (Reuters Health/HIVandHepatitis.com, 8/16). According to Robert Scherpbier, a task manager for WHO's StopTB program who coordinates the RTI treatment guidelines, Mwachari's recommendation to use a macrolide is "consistent with guidelines of, for example, the American Thoracic Society." However, "[i]ts appropriateness for clinicians in developing countries depends on its inclusion in the national essential drug list," he said. WHO is planning on revising the guidelines soon and Mwachari's recommendations "should be considered," he added (Lancet, 8/18).