LETTER
Cotrimoxazole Prophylaxis for Toxoplasmosis
Eric Caumes;
Francois Lheriteau; and
Marc Gentilini
1 March 1993 | Volume 118 Issue 5 | Page 395
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).
1. Carr A, Tindall B, Brew BJ, Marriott DJ, Harkness JL, Penny R, et al. Low-dose trimethoprim-sulfamethoxazole prophylaxis for toxoplasmic encephalitis in patients with AIDS. Ann Intern Med. 1992; 117:106-11.
2. Hardy D, Holzman R, Feinberg J, Finklestein D. Trimethoprim-sulfamethoxazole vs aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in AIDS patients: a prospective, randomized, controlled clinical trial (Abstract 018). In: Program and Abstracts of the third European Conference on Clinical Aspects and Treatment of HIV Infection, Paris, France; May 1992.
3. McCabe R, Remington JS. Toxoplasmosis: the time has come. N Engl J Med. 1988; 318:313-5.
4. Mallolas J, Zamora L, Gattel JM, Miro JM, Soriano E, Garcia San Miguel J. Primary prophylaxis for PCP and cerebral toxoplasmosis in HIV-infected patients: a randomized trial comparing cotrimoxazole, aerosolized pentamidine, and dapsone plus pyrimethamine (Abstract 035). In: Program and Abstracts of the third European Conference on Clinical Aspects and Treatment of HIV Infection, Paris, France; May 1992.
5. Reynes J, Atoui N, Lassonnery N, et al. Cotrimoxazole in primary prophylaxis of cerebral toxoplasmosis in HIV-infected patients (Abstract P242) In: Program and Abstracts of the third European Conference on Clinical Aspects and Treatment of HIV Infection, Paris, France; May 1992.
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