Dihydropteroate synthase mutations in Pneumocystis pneumonia: impact of applying different definitions of prophylaxis, mortality endpoints and mutant in a single cohort

Abstract Pneumocystis jirovecii dihydropteroate synthase (DHPS) gene mutations are well-reported. Although sulfa prophylaxis generally is associated with DHPS mutant infection, whether mutant infection is associated with poorer clinical outcomes is less clear. The differing definitions of sulfa prop...

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Published in:Medical mycology (Oxford) 2013-08, Vol.51 (6), p.568-575
Main Authors: Yoon, Christina, Subramanian, Anuradha, Chi, Amy, Crothers, Kristina, Meshnick, Steven R., Taylor, Steve M., Beard, Charles B., Jarlsberg, Leah G., Lawrence, Gena G., Avery, Melissa, Swartzman, Alexandra, Fong, Serena, Roth, Brenna, Huang, Laurence
Format: Article
Language:English
Subjects:
Adult
Antifungal Agents - therapeutic use
Chemoprevention - methods
Dihydropteroate Synthase - genetics
Drug Resistance, Fungal
Female
HIV Infections - complications
Human immunodeficiency virus
Humans
Male
Middle Aged
Mutant Proteins - genetics
Mutation
Pneumocystis
Pneumocystis carinii - enzymology
Pneumocystis carinii - genetics
Pneumonia, Pneumocystis - microbiology
Pneumonia, Pneumocystis - prevention & control
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Summary:Abstract Pneumocystis jirovecii dihydropteroate synthase (DHPS) gene mutations are well-reported. Although sulfa prophylaxis generally is associated with DHPS mutant infection, whether mutant infection is associated with poorer clinical outcomes is less clear. The differing definitions of sulfa prophylaxis and the different mortality endpoints used in these studies may be one explanation for the conflicting study results. Applying different definitions of prophylaxis, mortality endpoints and DHPS mutant to 301 HIV-infected patients with Pneumocystis pneumonia, we demonstrate that prophylaxis, irrespective of definition, increased the risk of infection with pure mutant (any prophylaxis: AOR 4.00, 95% CI: 1.83-8.76, P < 0.001) but not mixed genotypes (any prophylaxis: AOR 0.78, 95% CI: 0.26-2.36, P = 0.65). However, infection with mutant DHPS, irrespective of definition, was not associated with increased mortality (all-cause or PCP death) at the three time-intervals examined (all P > 0.05). Future studies should standardize key variables associated with DHPS mutant infection as well as examine DHPS mutant subtypes (pure mutant vs. mixed infections) - perhaps even individual DHPS mutant genotypes - so that data can be pooled to better address this issue.
ISSN:1369-3786
1460-2709
DOI:10.3109/13693786.2013.770604