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Cotrimoxazole Prophylaxis for Toxoplasmosis
- Eric Caumes, MD;
- Francois Lheriteau, MD; and
- Marc Gentilini, MD
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TO THE EDITOR:
Carr and colleagues [1] reported the efficacy of low-dose cotrimoxazole as primary prophylaxis against toxoplasmic encephalitis in patients with the acquired immunodeficiency syndrome (AIDS). In their retrospective study, one double-strength tablet (trimethoprim, 160 mg, plus sulfamethoxazole, 800 mg), was given twice daily, 2 days per week. Another prospective study [2] showed a similar efficacy with one double-strength tablet daily. However, up to 90% of the Paris population is infected with Toxoplasma gondii compared with less than 50% in the United States [3]. Prospective European studies suggest that the cotrimoxazole dose can influence outcome [4, 5].
We reviewed all cases of toxoplasmosis occurring between October 1989 and November 1991 among patients with AIDS treated at our institution, where first-line prophylaxis for Pneumocystis carinii infection is cotrimoxazole (one double-strength tablet daily). Seventy-two patients presented with one episode of toxoplasmosis. Forty-three received monthly aerosolized pentamidine, 24 received no prophylaxis, and 1 received combination therapy with pyrimethamine, 50 mg weekly, and dapsone, 50 mg daily. Of the 72 episodes of toxoplasmosis, 5 occurred in patients treated with cotrimoxazole. At diagnosis, these patients had a median CD4 cell count of 3/mm3 (range, 2 to 5/mm3) and had been receiving cotrimoxazole for a median of 9 months (range, 1 to 11 months).
Our data suggest that French patients should receive at least one double-strength tablet daily. This determination is in agreement with two prospective studies of European patients showing the failure of three double-strength cotrimoxazole tablets per week [4] and the efficacy of two double-strength tablets per day [5]. Unfortunately, a 50% reduction in the dose of cotrimoxazole was necessary in 44% of these latter patients because of hematotoxicity [5]. One double-strength tablet appears to be effective, except in patients with advanced immunodepression (that is, a CD4 cell count < 10/mm3).
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
