Empiric Outpatient Management of HIV-Related Pneumonia: Economical or Unwise?
Authors: Henry Masur
Journal: Annals of Internal Medicine (1996)

Editorials15 February 1996Empiric Outpatient Management of HIV-Related Pneumonia: Economical or Unwise?Henry Masur, MD and James Shelhamer, MDHenry Masur, MDNational Institutes of Health, Bethesda, MD 20892.Search for more papers by this author and James Shelhamer, MDNational Institutes of Health, Bethesda, MD 20892.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-124-4-199602150-00011 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail When immunologically normal patients present with pneumonia that is not severe enough to require immediate hospitalization, most health care providers initiate empiric oral therapy with a macrolide or tetracycline after a radiologic and laboratory evaluation that rarely extends further than a chest radiograph, leukocyte count determination, and perhaps a Gram stain of sputum [1]. Empiric therapy is directed against the common, treatable, community-acquired pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species.For immunosuppressed patients, health care providers have hesitated to use such an empiric management approach because the range of potential pathogens is so ...References1. Niederman MS, Bass JB Jr, Campbell GD, Fein AM, Grossman RF, Mandell LA, et al. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Thoracic Society. Medical Section of the American Lung Association. Am Rev Respir Dis. 1993; 148:1418-26. Google Scholar2. “United States Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) guidelines for the prevention of opportunistic infections in persons infected with the human immunodeficiency virus: a summary. MMWR Morb Mortal Wkly Rep. 1995; 44(RR8):1-34.” Google Scholar3. Luft BJ, Remington JS. Toxoplasmic encephalitis in AIDS. Clin Infect Dis. 1992; 15:211-22. Google Scholar4. Wallace JM, Rao AV, Glassroth J, Hansen NI, Rosen MJ, Arakaki C, et al. Respiratory illness in persons with human immunodeficiency virus infection. The Pulmonary Complications of HIV Infection Study Group. Am Rev Respir Dis. 1993; 148:1523-9. Google Scholar5. Munoz A, Schrager LK, Bacellar H, Speizer I, Vermund SH, Detels R, et al. Trends in the incidence of outcomes defining acquired immunodeficiency syndrome (AIDS) in the Multicenter AIDS Cohort Study: 1985-1991. Am J Epidemiol. 1993; 137:423-38. Google Scholar6. Bozzette SA, Sattler FR, Chiu J, Wu AW, Gluckstein D, Kemper C, et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in acquired immunodeficiency syndrome. California Collaborative Treatment Group. N Engl J Med. 1990; 323:1451-7. Google Scholar7. “Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in acquired immunodeficiency syndrome. The National Institutes of Health-University of California Expert Panel for Corticosteroids as Adjunctive Therapy for Pneumocystis Pneumonia. N Engl J Med. 1990; 323:1500-4.” Google Scholar8. Podzamczer D, Salazar A, Jiminez J, Consiglio E, Santin M, Casanova A, et al. Intermittent trimethoprim-sulfamethoxazole compared with dapsone-pyrimethamine for the simultaneous primary prophylaxis of Pneumocystis pneumonia and toxoplasmosis in patients infected with HIV. Ann Intern Med. 1995; 122:755-61. Google Scholar9. Bozzette SA, Finkelstein DM, Spector SA, Frame P, Powderly WG, He W, et al. A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group. N Engl J Med. 1995; 332:693-9. Google Scholar10. Saah AJ, Hoover DR, Peng Y, Phair JP, Visscher B, Kingsley LA, et al. Predictors for failure of Pneumocystis carinii pneumonia prophylaxis. JAMA. 1995; 273:1197-202. Google Scholar11. Masur H. Prevention and treatment of pneumocystis pneumonia. N Engl J Med. 1992; 327:1853-60. Google Scholar12. Hawley PH, Ronco JJ, Guillemi SA, Quieffin J, Russell JA, Lawson LM, et al. Decreasing frequency but worsening mortality of acute respiratory failure secondary to AIDS-related Pneumocystis carinii pneumonia. Chest. 1994; 106:1456-9. Google Scholar13. Vanhems P, Toma E. Evaluation of a prognostic score. Pneumocystis carinii pneumonia in HIV-infected patients. Chest. 1995; 107:107-12. Google Scholar14. Bennett CL, Weinstein RA, Shapiro MF, Kessler HA, Dickinson GM, Peterson B, et al. A rapid preadmission method for predicting inpatient course of disease for patients with HIV-related Pneumocystis carinii pneumonia. Am J Respir Crit Care Med. 1994; 150:1503-7. Google Scholar15. Tu JV, Biem HJ, Detsky AS. Bronchoscopy versus empirical therapy in HIV-infected patients with presumptive Pneumocystis carinii pneumonia. A decision analysis. Am Rev Respir Dis. 1993; 148:370-7. Google Scholar16. Blumberg HM, Watkins DL, Berschling JD, Antle A, Moore P, White N, et al. Preventing the nosocomial transmission of tuberculosis. Ann Intern Med. 1995; 122:658-63. Google Scholar17. Klein RS, Motyl M. Frequency of pulmonary tuberculosis in patients undergoing sputum induction for diagnosis of suspected Pneumocystis carinii pneumonia. AIDS. 1993; 7:1351-3. Google Scholar18. Shelhamer JH, Ognibene FP, Macher AM, Tuazon C, Steiss R, Longo D, et al. Persistence of Pneumocystis carinii in lung tissue of acquired immunodeficiency syndrome patients treated for pneumocystis pneumonia. Am Rev Respir Dis. 1984; 130:1161-5. Google Scholar Author, Article, and Disclosure InformationAuthors: Henry Masur, MD; James Shelhamer, MDAffiliations: National Institutes of Health, Bethesda, MD 20892.Corresponding Author: Henry Masur, MD, National Institutes of Health, Building 10, Room 4D43, 10 Center Drive, MSC 1662, Bethesda, MD 20892-1662.Current Author Addresses: Drs. Masur and Shelhamer: National Institutes of Health, Building 10, Room 4D43, 10 Center Drive, MSC 1662, Bethesda, MD 20892-1662. 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