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Patients with AIDS and Mycobacterium avium complex (MAC) bacteremia are at high risk for relapse and emergence of resistant isolates during monotherapy with clarithromycin. Ninety-five AIDS patients with MAC bacteremia received clarithromycin plus clofazimine, with or without ethambutol, in a prospective, multicenter, randomized open-label trial. Of 80 patients with positive baseline cultures, sterilization or a 2 log10 reduction in colony-forming units of MAC in two consecutive blood cultures occurred in 69% of both groups. There were nine relapses in the two-drug arm and three in the three-drug arm. Kaplan-Meier estimates of risk of relapse at 36 weeks were 68% and 12%, respectively (P = .004). All relapse isolates were resistant to clarithromycin. Median time to clarithromycin resistance was 16 weeks with two drugs and 40 weeks with three drugs (P = .004). Ethambutol reduced relapses and emergence of clarithromycin resistance and should be considered an essential component of clarithromycin-based therapies for MAC bacteremia.

Eight patients (6, cryptococcal meningitis; 2, high-titer cryptococcal antigenemia) were treated with 800 mg/day fluconazole to assess the safety and efficacy of high-dose fluconazole as primary therapy. Five patients with meningitis had resolution of clinical symptoms and all 6 had negative cerebrospinal fluid (CSF) cultures by day 82 (median, 21 days). One meningitis patient developed neurologic deterioration and was switched to amphotericin B at day 18, but CSF culture was negative on day 15 of fluconazole therapy. In 2 patients with cryptococcal antigenemia, clinical symptoms resolved and serum antigen titers declined rapidly; they did not progress to meningitis. Therapy was well tolerated, with mainly gastrointestinal side effects. Four patients had mild increases in liver enzymes; another had a threefold increase in alkaline phosphatase. Mean steady-state serum level of fluconazole was 45 +/- 15 micrograms/mL, and paired CSF and serum levels were 40 +/- 14 and 49 +/- 14 micrograms/mL, respectively. High-dose fluconazole appears safe and effective for cryptococcal disease in AIDS patients.

Many patients infected with human immunodeficiency virus (HIV) yield syncytium-inducing (SI) virus isolates that are cytopathic in cell culture. The presence of SI virus was assessed in 325 persons entering 11 antiretroviral therapy trials and correlated with both CD4 cell declines and clinical end points. Adjusted mean rates of CD4 cell count decline were 40 and 102 cells/year in the non-SI (NSI) and SI groups, respectively (P < .0001). Rates of decline in 16 persons converting from NSI to SI virus averaged 31 cells/year before conversion and 142 cells/year afterward (P = .04). In a nested case-control analysis, persons who experienced surrogate marker end points or opportunistic infections were 2.3-3.5 times more likely to have SI virus than were controls (P = .01-.04) but who died were similar to controls with respect to virus phenotype (P = .70). Presence of the SI phenotype of HIV is a strong predictor of decline in CD4 cell count and progression of disease; however, controlling for the CD4 cell count, the SI phenotype did not increase the immediate risk of death.