REPLY
Cotrimoxazole Prophylaxis for Toxoplasmosis
Andrew Carr;
Brett Tindall; and
David A. Cooper
1 March 1993 | Volume 118 Issue 5 | Page 395
IN RESPONSE:
Dr. Caumes and colleagues report a retrospective study involving five presumably compliant patients who received trimethoprim-sulfamethoxazole (160 mg/800 mg) and still developed toxoplasmic encephalitis. They also refer to two recent studies that found one tablet given three times a week to be ineffective (although the abstract contains no data to support this conclusion) [1] and one tablet given twice daily to be effective but too toxic [2]. We agree that one tablet twice daily is far too toxic for many patients. Nevertheless, no study has shown a weekly dose of seven tablets to be more effective than four tablets given over the same period, although the former dose could quite possibly incur greater toxicity. Indeed, we have seen only one definite case of toxoplasmic encephalitis since mid-1987 in any patient receiving our regimen of trimethoprim-sulphamethoxazole (in addition to the one possible case reported) [3], from a total of 85 cases. It is even possible that one tablet twice daily given 2 days per week is actually more effective than one tablet daily by achieving higher peak serum levels with reduced incidence of resistance. Before endorsing any one dose of trimethoprim-sulfamethoxazole as a "best compromise" or assuming that more is better, comparative studies of different doses of trimethoprim-sulfamethoxazole are needed.
1. Mallolas J, Zamora L, Gattel JM, et al. Primary prophylaxis for PCP and cerebral toxoplasmosis in HIV-infected patients: a randomised trial comparing cotrimoxazole, aerosolised pentamidine, and dapsone plus pyrimethamine (Abstract 035). In: Abstracts of the third European Conference on Clinical Aspects and Treatment of HIV Infection, Paris, France; March 1992.
2. Reynes J, Atoui N, Lassonery N, et al. Cotrimoxazole in primary prophylaxis of cerebral toxoplasmosis in HIV-infected patients (Abstract P242). In: Abstracts of the third European Conference on Clinical Aspects and Treatment of HIV Infection, Paris, France; March 1992.
3. Carr A, Tindall B, Brew BJ, Marriott DJ, Harkness JL, Penny R, et al. Low-dose trimethoprim-sulphamethoxazole prophylaxis for toxoplasmic encephalitis in patients with AIDS. Ann Intern Med. 1992; 117:106-11.
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