HIV Prophylaxis: Following Occupational and Non-Occupational Exposure
The Patterns of Primary Cotrimoxazole Prophylaxis in Adult HIV ...
14
The Patterns of Primary Cotrimoxazole Prophylaxis in Adult HIV Patients in HIV Integrated Clinic Cipto Mangunkusumo Hospital Jakarta in 2004-2013 Ken Ayu Mastini 1 , Zubairi Djoerban 2 , Evy Yunihastuti 3 , Hamzah Shatri 4 1 Internal Medicine Department, Faculty of Medicine University of Indonesia, 2 Medical Hematology and Oncology Division, 3 Allergy and Clinical Immunology Division, 4 Psychosomatic Division, Internal Medicine Department, Faculty of Medicine University of Indonesia
Transcript of The Patterns of Primary Cotrimoxazole Prophylaxis in Adult HIV ...
The Patterns of Primary Cotrimoxazole Prophylaxis in Adult HIV Patients in HIV Integrated Clinic Cipto
Mangunkusumo Hospital Jakarta in 2004-2013
Ken Ayu Mastini1, Zubairi Djoerban2, EvyYunihastuti3, Hamzah Shatri4
1Internal Medicine Department, Faculty of Medicine University of Indonesia, 2Medical Hematology and Oncology Division, 3Allergy and
Clinical Immunology Division, 4Psychosomatic Division, Internal Medicine Department, Faculty of Medicine University of Indonesia
Background
• Cotrimoxazole is standard of primary prevention against toxoplasmosis infection and Pneumocystis jirovecii pneumonia (PCP) in patients with CD4 less than 200 cell/mm3 and tuberculosis patients.
Guideline on Cotrimoxazole Prophylaxis for HIV Related Infections Among Children, Adolescents and Adults. WHO;2006. AmmannAJ. HIV Ther. 2009;3:329–38. Pedoman Nasional Tatalaksana Klinis Infeksi HIV dan Terapi Antiretroviral pada Orang
Dewasa.Kementerian Kesehatan Republik Indonesia, 2011. Yunihastuti E, dkk. Infeksi Oportunistik pada AIDS. Jakarta:BalaiPenerbit FKUI;2005. Church JA. Lancet Infect Dis. 2014;14:892-8 Zachriah R, Harries AD, Luo C. Lancet Infect Dis. 2007;7:686–93.
International Standards for Tuberculosis Care (ISTC). The Hague: Tuberculosis Coalition for Technical Assistance, 2006.
Objective
• To know initiation, discontinuation, dosage, adverse events, duration and duration percentage of primary cotrimoxazoleprophylaxis in adult HIV patients
Methods
• Cohort retrospective study in HIV Integrated Clinic Cipto MangunkusumoHospital
Study Design
• All patients more than 18 years old from 2004 to 2013 and had indication of primary cotrimoxazole prophylaxis
Study Subjects
Results
• 3818 patients had indication of primary cotrimoxazole prophylaxis
Variable
Age Median 29 (IQR 7) years
Gender Male 3019 (79.1%)
TB coinfection 2232 (58.5%)
Clinical Stage 3-4 86%
Initial CD4 Median 51 (IQR 101) cells/mm3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Total
7488
7985
79 80 77 73 7368
78
4
2
42
6 6 87 5
6
5
2210
17 13 15 14 15 20 22 2617
Primary CTX Prophylaxis
No CTX Initiation
CTX Initiation, TB
CTX Initiation, CD4<200
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
CD4 45 41 40 49,5 61 59 62 54 43 57
CTX Primary Prophylaxis Dosage
• 3173 (99,8%) patients received 960 mg CTX
• 6 (0,2%) received 480 mg CTX, because of
– anemia (5 patients)
– Increase liver transaminase (1 patient)
• Clinicians’ knowledge about CTX primary prophylaxis dosage was adequate
Adverse Event (%)
15,4
7,85,3
16,5 16,9
7,4
38,1
Adverse Event Severity
90
89
31
44
54
40
62
9
10
56
21
30
45
27
1
1
2
16
10
8
9
0
0
2
19
6
6
2
Nausea
Vomiting
Hypersensitivity
Anemia
Leucopenia
Thrombocytopenia
↑ Liver Transaminase
grade 1
grade 2
grade 3
grade 4
Discontinuation Because of Adverse Event
90
89
31
44
54
40
62
9
10
56
21
30
45
27
1
1
2
16
10
8
9
0
0
2
19
6
6
2
Nausea
Vomiting
Hypersensitivity
Anemia
Leucopenia
Thrombocytopenia
↑ Liver Transaminase
grade 1
grade 2
grade 3
grade 4
2.1%
0
0.6%
2.4%
100% *
0.8%
0
*Median onset of CTX hypersensitivity was 30 days (IQR 30)
0 10 20 30 40 50
CD4>200, 3 months
CD4>200, 6 months
Finish TB Drug
CD4>200, 1x
CD4<200
Not discontinued, when CD4>200 2x
Discontinue Before Finish TB Drug
Not Discontinued, When Finish TB Drug
19,6
18,2
0,7
45,4
8,1
2,9
2,4
2,8
CTX Discontinuation
Inappropriate : 61,6%
Appropriate: 38,4%
CTX discontinuation in those who did not
have adverse event (N= 908)
CTX Duration Percentage
CTX Discontinuation CTX Duration Percentage (Actual/Indication Duration)
Appropriate with guideline (n= 349) 100% (IQR 0)
Inappropriate with guideline (n=559) 67% (IQR 38)
•Discontinue when CD4<200 63% (IQR 52)
•Discontinue when CD4>200, 1x 67% (IQR 33)
•Not discontinue when CD4>200, 2x 123% (IQR 52)
•Discontinue before finish TB drugs 33% (IQR 33)
•Not discontinue when finish TB drugs 200% (RIK 25%)
CTX discontinuation in those who did not
have adverse event (N= 908)
CTX Duration Based On CD4
Initial CD4 Duration p value
≤ 100 21 months (IQR 22) p <0.001
> 100 12,5 months (IQR 14,75)
Median duration was 20 months (IQR 20)
Conclusion
• Although initiation of primary cotrimoxazoleprophylaxis was done in 83% adult HIV patients with appropriate dosage, but 61,6% discontinuation was inappropriate with guideline
