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(1) Service de Maladies Infectieuses et Tropicales (2) Service de Neurologie

EFFICACY AND TOLERANCE OF COTRIMOXAZOLE AS A FIRST LINE TREATMENT OF TOXOPLASMA ENCEPHALITIS IN MARTINIQUE S. Abel 1 , A. Foltzer 1 , Ph. Cabre 2 , D. Smadja 2 , B. Liautaud 1 , A. Cabié 1. (1) Service de Maladies Infectieuses et Tropicales (2) Service de Neurologie

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(1) Service de Maladies Infectieuses et Tropicales (2) Service de Neurologie

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  1. EFFICACY AND TOLERANCE OF COTRIMOXAZOLE AS A FIRST LINE TREATMENT OF TOXOPLASMA ENCEPHALITIS IN MARTINIQUES. Abel1, A. Foltzer1, Ph. Cabre2, D. Smadja2, B. Liautaud1, A. Cabié1 (1) Service de Maladies Infectieuses et Tropicales (2) Service de Neurologie CHU de Fort-de-France, Martinique

  2. MAIN CENTRAL NEUROLOGICAL DISEASES IN HIV INFECTED PATIENTS

  3. TOXOPLASMA ENCEPHALITIS IN AIDS PATIENTS • Major cause of morbidity and mortality • Often revealing HIV infection • Uneasy Diagnosis • Clinical • TDM or MRI where available • Probability based treatment • Sulfadiazine + pyriméthamine + acide folinique • Bad tolerance • Not always available • No IV form available • Costly • Need for Alternative choice of treatment

  4. TREATMENT OF TOXOPLASMOSIS WITH COTRIMOXAZOLE

  5. Efficacy and tolerance of Cotrimoxazole as a first line treatment of Toxoplasma Encephalitis in Martinique • Patients and methods • Open label prospective study, from August 1993 to December 2002 • Inclusion criteria • HIV seropositive status • Neurological disorders compatible with the diagnosis of toxoplasma encephalitis • Brain Scan imaging judged typical of TE by the radiologist, or • Abnormal brain scan imaging not typical of TE but with no other identified cause of laboratory workup • CD4 < 200 /mm3 • Exclusion criteria • Cotrimoxazole prophylaxis with good compliance • History of cotrimoxazole intolerance • Toxoplasma negative serology

  6. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE • Patients and methods • Induction therapy • [TMP (10 mg/kg) + SMZ (50 mg/kg)] /day • Intravenous or oral route • During 6 to 8 weeks • Until resolution of radiological lesions • Follow-up • Clinical and biological • CT or RMI at day 15, and between 4 to 8 weeks • Maintenance therapy • [TMP (160mg) + SMZ (800 mg)] x 1 /day (1 double-strength tablet)

  7. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE • Results • 61 patients (36 men and 25 women), 39.1 years MSM 15% IV drug use 8% Hetero. 77% HIV transmission group

  8. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE • HIV infection at time of toxoplasma encephalitis (TE) diagnosis

  9. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Clinical and radiographic features at presentation

  10. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Efficacy • In an intent-to-treat analysis

  11. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Tolerance

  12. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Relapses • 17 of 50 patients (34%) • Median time of relapse = 22 weeks • Always in patients with poor observance of maintenance therapy • Treatment of relapses • Cotrimoxazole = 75% • Efficacy = 87.5%

  13. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Survival after TE Since 1997 Probability of survival, % Logrank p =0.1 Before 1997 12 months Survival = 0.71 Months from TE diagnosis

  14. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Follow-up at 31/10/2003 Lost of follow-up 15% Patients dead 47% TE = 2/29 Patients alive 38%

  15. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Follow-up at 31/10/2003 Patients dead 47% TE = 2/29 Lost of follow-up 15% Patients alive 38%

  16. EFFICACY AND TOLERANCE OF TREATMENTS OF TOXOPLASMOSIS ENCEPHALITIS

  17. Randomized trial of trimethoprim-sulfamethoxazole versus pyrimethamine-sulfadiazine for therapy of toxoplasmic encephalitis in patients with AIDSTorre et al, AAC 1998.

  18. STRONG POINTS OF COTRIMOXAZOLE IN TOXOPLASMA ENCEPHALITIS 1- MMWR June 2002

  19. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLEConclusion • Induction phase • Isosporiasis • Pneumocystosis • Nocardiosis • Toxoplasmosis ? • Prophylaxis • Bacterial infections • Pneumocystosis • Toxoplasmosis Using CTX, which offers the great flexibility of either oral or IV administration, as a first line medication in the management of opportunistic infections in HIV positive patients in the Caribbean and particularly in resource poor settings is a simplified cost-effective strategy and could be part of the algorithms designed for the management of HIV positive patients.

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