Cotrimoxazole in Zambian Infants (TZI)

The treatment of pneumonia is fraught with complications in areas where there is a high rate of HIV infection. The World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) recommends that, in areas of high HIV prevalence, infants be provided with the antibiotic co-trimoxazole as a prophylactic treatment against the most common opportunistic infection afflicting HIV-infected children, Pneumocystis jiroveci pneumonia (PCP). Because it is technically difficult and costly to determine which infants are HIV-infected until they are 12 to 15 months old, this treatment must be given to all children who are HIV-exposed, meaning those born to mothers who are HIV-positive but have indeterminate HIV status. An important problem with this approach is that widespread use of a broad-spectrum antibiotic such as co-trimoxazole may produce antibiotic resistance to other pathogens that themselves are also significant causes of pneumonia or sepsis.

To better understand the effect of co-trimoxazole on the resistance among pathogens such as S. pneumoniae, Drs. Chris Gill, Davidson Hamer, William MacLeod, and Donald Thea of the Center for Global Health & Development, and collaborators at the Tropical Diseases Research Centre in Ndola, Zambia, implemented a study among a group of Zambian infants exposed to HIV who had received co-trimoxazole prophylaxis. While co-trimoxazole use suppressed colonization of S. pneumoniae by about 7%, within six weeks of starting the medication they were more than three times as likely as to be colonized by co-trimoxazole-resistant pneumococci in their throat and nasal cavities. In addition, they were almost twice as likely as other infants to be colonized with bacteria resistant to clindamycin.

The policy implications of these findings are not yet clear. Minimizing the unnecessary exposure of children to co-trimoxazole and thereby diminishing the prevalence of resistant S. pneumoniae is an important public health goal. Programs of early infant diagnosis, which are becoming more widespread, will help minimize the number of children with unknown infection status who will need to be given prophylaxis with co-trimoxazole.

Boston University is a member of the World Health Organization Collaborating Center on Pharmaceutical Policy (WHOCCP).

This project is one activity of the CGHD’s Child and Family Applied Research project (CFAR).

Project Details

Principal Investigator Christopher Gill
Boston University Co-Investigators Davidson Hamer, William MacLeod, Donald Thea
Collaborators Tropical Diseases Research Centre, Ndola
Country(ies) Zambia
Dates of Research 2003 – 2004