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The major goal of Opportunistic Infections: Treatment and Prophylaxis is to guide cli- cians who provide care for patients suffering from an underlying immunodeficiency that may significantly weaken their immune defenses and will complicate the effective treatment of opportunistic infections. In spite of a wealth of isolated data, no single text exists in which all the essential information about various infectious opportunistic infections. Although I make no claim to completeness, it is my hope that the present book will fulfill that need. To achieve this goal, I have endeavored to integrate both results from large-scale clinical trials and trials involving small numbers of patients, as well as reports of single cases―mindful that such an approach has its limitations. Opportunistic Infections: Treatment and Prophylaxis is organized into four major parts: bacterial, viral, parasitic, and fungal diseases affecting the immunocompromised population. Each part surveys individual infections caused not only by well-known etiologic agents, but also by new and emerging species often taxonomically closely related to a major disea- producing microorganism and until recently not considered to be human pathogens (Candida spp. and nontuberculous mycobacteria, for example). For the sake of uniformity, within each part, the species have been arranged according to their taxonomic characteristics.
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The complex problems of opportunistic infections in patients suffering from an underlying immunodeficiency is a significant medical issue and calls for a concise, yet comprehensive, resource to present the essential information that clinicians require to provide effective medical care. In Opportunistic Infections: Treatment and Prophylaxis, Vassil St. Georgiev surveys the current status of all the major bacterial, viral, parasitic, and fungal infections affecting the immunocompromised population, as well as the anti-infective agents available to treat and prevent them. The author covers individual infections caused not only by well-known etiologic agents, but also by new and emerging species often closely related taxonomically to a major disease-producing microorganism and until recently not considered a human pathogen (e.g., Candida spp. and nontuberculous mycobacteria). The information presented includes data from large well-planned clinical trials, as well as reports of cases involving individuals and small numbers of patients. The latter highlight therapeutic possibilities that may otherwise go unnoticed in clinical practice or in drug research and development. Numerous examples are given of particular treatment regimens for opportunistic infections based on underlying immunologic deficiencies.
Comprehensive and up-to-date, Opportunistic Infections: Treatment and Prophylaxis organizes the wealth of information found in the medical and scientific literature and illuminates those areas of drug development and treatment that, though still not well understood, are crucial to effective patient management, infection prevention, and the development of new therapeutic modalities against infectious diseases in immunocompromised patients.
The challenges in writing a book about opportunistic infections parallel the complexities of treating a patient who is at risk for such infections. Traditionally, a team of specialists takes on these therapeutic challenges, just as collaborating authors write most of the textbooks about these infections. However, medical care of the immunocompromised patient has increasingly engaged clinicians in primary care or outpatient settings. Information that highlights the basis of treatment needs to be made rapidly available to the busy practitioner in a way that a ponderous book cannot achieve. Opportunistic Infections attempts to fill this need. That the book emphasizes evidence over opinion in its recommendations for treatment is its particular strength. Another strength is the presentation of novel data that elucidate mechanistic associations among host, pathogen, drug, and disease. The book is especially useful in its presentation of pharmacokinetic and pharmacodynamic assessments of new drugs. Certain sections of the book refer to investigational drugs, appropriately reflecting the state of the art in the treatment of many of these infections. Recommendations for treatment and prophylaxis are preceded by overall statements and followed by approaches specific to the broad classes of immunocompromised hosts. It is inevitable that, if written by a single author, a book on this complex subject will reflect the author's interests and strengths. This 545-page book dedicates more than 300 pages to the fungal pathogens, as compared with 40 pages to the more widespread viral pathogens. The bibliography provided for hyalohyphomycosis, for example, runs to an impressive 582 references, whereas 97 references are presented for tuberculosis. As a consequence, the reader will need to supplement this book on treatment approaches with others that cover additional pathogens and the syndromes they cause, such as hepatitis C and posttransplantation lymphoproliferative syndrome. Evidence of drug efficacy from clinical trials is presented alongside data from in vitro and animal models. For some of the infections covered in this book, especially those that are rare or that require alternative approaches in specific subgroups of patients, published evidence may have limitations if used as the sole basis for treatment recommendations. Depending only on published data could, for example, highlight older agents even when treatment standards have evolved or when evidence supporting changes is slow to accumulate in the literature. Furthermore, the exclusion of treatment guidelines based on collective, multi-institutional expert opinion may provide an incomplete perspective, when the basis of such guidance may be as valid as individual case reports of efficacy. The treatment recommendations for endogenous candidal endophthalmitis, for example, ignore consensus guidelines regarding the use of fluconazole (Rex J, et al. Practice guidelines for the treatment of candidiasis. Clin Infect Dis 2000;30:662-78). Equal emphasis on all types of evidence or, alternatively, inconsistency in ascribing importance to similar evidence may not provide the balance needed to guide treatment, especially when little clinical perspective is provided. For example, although the book concludes that "lack of . . . effect . . . virtually precludes . . . azole(s) in the treatment of aspergillosis," it lists clotrimazole as a treatment for pulmonary aspergillosis and excludes voriconazole, for which similar anecdotal evidence of efficacy existed at the time of the book's publication. The five-paragraph discussion on anecdotal reports of the efficacy of clotrimazole, without mention of caspofungin (shown to be efficacious in 56 patients with no other treatment options), shows that even recommendations based on published evidence are susceptible to the influence of individual perspective. That the early evidence of efficacy for both voriconazole and caspofungin is supported by the recent literature also illustrates the challenge of writing contemporaneous guidelines for these infections. The experienced clinician may find this book a useful compendium that summarizes treatment and prophylaxis options and that is a ready source of references to the literature. As a companion to a standard authoritative textbook, the book fulfills its goal of guiding clinicians in the care of immunocompromised patients who have opportunistic infections. The nature of its subject matter and the availability of other sources of information, such as online journals and hand-held computers, require that a book such as this, which highlights novel drug-efficacy data, be updated frequently. Eileen E. Navarro, M.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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