2004, Number 1
<< Back Next >>
Gac Med Mex 2004; 140 (1)
Pneumonia Dueto Pneumocystis carinii in HIV-Infected Children.
Morales-Aguirre JJ, Villalobos-Acosta CP, Linares-Salas VH, Solís-Ortega AM, Gómez-Barreto D, Cashat-Cruz M
Language: Spanish
References: 118
Page: 59-70
PDF size: 579.00 Kb.
ABSTRACT
Introduction of new antiretroviral agents and development
of new prophylaxis schedules against opportunistic
microorganisms have allowed increase in survival as well
as better quality of life in HIV-infected patients. These new
treatment schedules have changed the epidemiology of
opportunistic infections that previous to use of highly active
antiretroviral therapy (HAART), fomerly occurred with
high frequency in HIV-infected children. Specifically,
pneumonia due to Pneumocystis carinii formerly occurred
in 12 to 80% of these patients and was associated with high
mortality. Currently, with use of combined antiretroviral
therapy (ART) and prophylactic treatments important
reduction of PCP has been observed. However, despite
these benefits ART is not yet available for many patients
from several developing countries who are at risk for
opportunistic infections, mainly due to Pneumocystis carinii,
which can affect life expectancy. Therefore, the purpose of
this paper was a review of epidemiologic, clinical, and
therapeutic characteristics of P. carinii pneumonia in HIVinfected
children.
REFERENCES
Saunders-Laufer D, DeBruin W, Edelson PJ. Pneumocystis carinii infection in HIV-infected children. Pediatr Clin North Am 1991;38:69-88.
Gottlieb MS, Schroff R, Schanker HM, et al. Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men. N Engl J Med 1981;305:1425-31.
Masur H, Michelis MA, Greene JB, et al. An outbreak of communityacquired Pneumocystis carinii pneumonia. N Engl J Med. 1981;305:1431-38.
Walzer PD, Pel DP, Krogstad DJ, et al. Pneumocystis carinii pneumonia in the United States. Ann Intern Med. 1974;80:83-93.
Frame P. Pneumocystis carinii infection and AIDS. In: Crowe S, Hoy J, Mills J, editors. Management of the HIV-infected patient. New York: Cambridge University Press;1996 pp. 298-315.
Dohn M, Baugman R, Vigdorth E, et al. Equal survival for first, second, and third episodes of Pneumocystis carinii pneumonia in AIDS patients. Arch Intern Med 1992;152:2465-70.
Dankner WM, Lindsey JC, Levin MJ, et al. Correlates of opportunistic infections in children infected with the human immunodeficiency virus managed before highly active antiretroviral therapy. Pediatr Infect Dis J 2001;20:40-8.
Simonds RJ, Oxtoby MJ, Caldwell MB, et al. Pneumocystis carinii pneumonia among US children with perinatally acquired HIV infection. JAMA 1993;270:470-3.
Centers for Disease Control and Prevention. Guidelines for prophylaxis against Pneumocystis carinii pneumonia for children infected with HIV. MMWR 1991;40:1-13.
Thea DM, Lambert G, Weedon J, et al. Benefits of primary prophylaxis before 18 months of age in reducing the incidence of Pneumocystis carinii pneumonia and early death in a cohort of 112 HIV-infected infants. Pediatrics 1996;97:59-64.
Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 1997;9(1):1-37.
Scott GB, Hutto C, Makuch RW, et al. Survival in children with perinatally acquired HIV type 1 infection. N Engl J Med 1989;321:1791-96.
The European Collaborative Study Group. Children born to women with HIV-1 infection: Natural history and risk of transmission. Lancet 1991;337:253-60.
The European Collaborative Study Group. CD4 T Cell count as predictor of Pneumocystis carinii pneumonia in children born to mothers infected with HIV. Br Med J 1994;308:437-40.
Gibb DM, Davidson CF, Holland FJ, et al. Pneumocystis carinii pneumonia in vertically acquired HIV infection in the British Isles. Arch Dis Child 1994;70:241-4
Masur H, Lane HC, Kovacs JA, et al. Pneumocystis pneumonia: From bench to clinic. Ann Intern Med 1989;111:813.
Simpson B, Shapiro ED, Andiman WA. Prospective cohort study of children born to human immunodeficiency virus-infected mothers, 1985 through 1997: trends in the risk of vertical transmission, mortality and acquired immunodeficiency syndrome indicator diseases in the era before highly active antiretroviral therapy. Pediatr Infect Dis J 2000;19:618-24.
Abrams EJ, Weedon J, Bertolli J, et al. Aging cohort of perinatally human immunodeficiency virus-infected children in New York City. Pediatr Infect Dis J 2001;20:511-17.
Abrams EJ. Opportunistic infections and other clinical manifestations of HIV disease in children. Pediatr Clin North Am 2000;47:79-108.
Barnhart HX, Caldwell MB, Thomas P, et al. Natural history of human immunodeficiency virus disease in perinatally infected children: an analysis from the pediatric spectrum of disease project. Pediatrics 1996;97:710-16.
Johann-Liang R, Cervia JS, Noel GJ. Characteristics of human immunodeficiency virus-infected children at the time of death: an experience in the 1990s. Pediatr Infect Dis J 1997;16:1145-50.
Chokephaibulkit K, Wanachiwanawin D, Chearskul S, et al. Pneumocystis carinii severe pneumonia among human immunodeficiency virus-infected children in Thailand: the effect of a primary prophylaxis strategy. Pediatr Infect Dis J 1999;18:147-52.
Abouya YL, Beaumel A, Lucas S, et al. Pneumocystis carinii pneumonia: an uncommon cause of death in African patients with acquired immunodeficiency syndrome. Am Rev Respir Dis 1992;145:617-20.
Lucas SB, Peacock CS, Hounnou A, et al. Disease in children infected with HIV in Abidjan, Cote d'Ivoire. Br Med J 1996;312:335-8.
Ikeogu MO, Wolf B, Mathe S. Pulmonary manifestations in HIV seropositive and malnutrition in Zimbabwe. Arch Dis Child 1997;76:124-8.
Jeena PM, Coovadia HM, Chrystel V. Pneumocystis carinii and cytomegalovirus infections in severely ill HIV-infected African infants. Ann Trop Paediatr 1996;16:361-8.
Chintu C, Mudenda V, Lucas S, et al. Lung diseases at necropsy in African children dying from respiratory illnesses: a descriptive necropsy study. Lancet 2002;360:985-90.
Zar HJ, Dechaboon A, Tech DM, et al. Pneumocystis carinii pneumonia in South African children infected with human immunodeficiency virus. Pediatr Infect Dis J 2000;19:603-7.
Bye MR, Bernstein LJ, Glaser J, Kleid D. Pneumocystis carinii pneumonia in children with AIDS. Pediatr Pulmonol 1990;9:251-3.
Notterman DA, Greenwald BM, Di Maio-Hunter et al. Outcome after assisted ventilation in children with acquired immunodeficiency syndrome. Crit Care Med 1990;18:18-20.
Marolda J, Pace B, Bonforte RJ, et al. Outcome of mechanical ventilation in children with acquired immunodeficiency syndrome. Pediatr Pulmonol 1989;7:230-4.
Zar HJ, Hanslo D, Tannenbaum E, et al. A etiology and outcome of pneumonia in human immunodeficiency virus-infected children hospitalized in South Africa. Acta Paediatr 2001;90:119-25.
Graham SM, Mtitimila EI, Kamanga HS, et al. Clinical presentation and outcome of Pneumocystis carinii pneumonia in Malawian children. Lancet 2000;355:369-73.
Morales AJ, Cashat CM, Avila FC. Characteristics of a cohort of HIVinfected children in Mexico. 36TH IDSA 1998, 21-24 November, 1998. Denver, Colorado, USA.
Villalobos AC, Morales AJ, Nandi LM, et al. Trends in infectious diseases and mortality in a cohort of HIV-infected children under ART in Mexico. Abstract 786. 39th Annual Meeting of the Infectious Diseases Society of America. IDSA 2001, San Francisco, California, USA.
Connor E, Bagarazzi M, McSherry G, et al. Clinical and laboratory correlates of Pneumocystis carinii pneumonia in children infected with HIV. JAMA 1991;265:1693-7.
Falloon J, Eddy J, Wiener L, Pizzo PA. Human immunodeficiency virus infection in children. J Pediatr 1989;114:1-30.
Rogers MF, Thomas PA, Starcher ET, Noa MC, et al. Acquired immunodeficiency syndrome in children: Report of the Centers for Diseases Control National Surveillance 1982 to 1985. Pediatrics 1987;79:1008-14.
Pauline T, Tejinder S, Rosalyn W, et al. Trends in survival for children reported with maternally acquired immunodeficiency syndrome in New York City 1982-1989. Pediatr Infect Dis J 1992;11:34-39.
Turner BJ, Denison M, Eppes SC, et al. Survival experience of 789 children with the acquired immunodeficiency syndrome. Pediatr Infect Dis J 1993;12:310-20.
Krasinski K, Borkowski W, Holzman RS. Prognosis of human immunodeficiency virus infection in children and adolescents. Pediatr Infect Dis J 1989;8:216-20.
Maldonado YA, Araneta RG, Hersch AL, et al. Pneumocystis carinii pneumonia prophylaxis and early clinical manifestation of perinatal human immunodeficiency virus type 1 infection. Pediatr Infect Dis J 1998;17:398-402.
Bernstein LJ, Bye MR, Rubinstein A. Prognostic factors and life expectancy in children with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia. AJDC 1989;143:775-8.
Haverkos HW. Assesment of therapy for Pneumocystis carinii pneumonia: PCP Therapy Project Group. Am J Med 1984;76:501-8.
Murray JF, Felton CP, Garay SM, et al. Pulmonary complications of the acquired immunodeficiency syndrome. N Engl J Med 1984;310:1682-8.
Wharton JM, Coleman DL, Wofsy CB, et al. Trimethoprim/Sulfamethoxasole or pentamidine for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. Ann Intern Med 1986;105:37-44.
Sax PE. Antiretrovirals and PCP survival. AIDS Clin Care 2003: Available at: http://www.medscape.com/viewarticle/449287
Morris A. Improved survival with highly active antiretroviral therapy in HIV infected patients with severe Pneumocystis carinii pneumonia. AIDS 2003;17:73-80.
Martino M, Tovo PA, Balducci M, et al. Reduction in mortality with availability of antiretroviral therapy for children with perinatal HIV-1 infection. JAMA 2000;190-7.
Llopiz MA, Cashat CM, Morales AJ, Moreno MH, Gomez BD. Survival trends of HIV pediatric patients in Mexico: a treatment scheme comparison and the impact of HAART therapy (1986-2001). WePeC6062 XIV International AIDS Conference 2002 Barcelona, España Julio 7-12 2000.
Edman JC, Kovacs JA, Masur H, et al. Ribosomal RNA sequences shows Pneumocystis carinii to be member of the fungi. Nature 1988;334:519-22.
Stringer SL, Stringer JR, Blaser MA, et al. Pneumocystis carinii; sequence from ribosomal RNA implies a close relationship with fungi. Exp Parasitol 1989;68:450-61.
Pixley F, Wakerfield A, Baerji S, et al. Mitochondrial gene sequences show fungal homology for Pneumocystis carinii. Mol Microbiol 1991;5:1347-51.
Furrer H, Egger M, Opravil M, et al. Discontinuation of primary prophylaxis against Pneumocystis carinii pneumonia in HIV-1-infected adults treated with combination antiretroviral therapy. N Engl J Med 1999; 340:1301-1306.
Walzer PD. Pneumocystis carinii: Recent advances in basic biology and their clinical application. AIDS 1993;7:1293.
Sringer JR. Pneumocystis carinii: What is it exactly?. Clin Microbiol Rev 1996;9:489-98.
Cushion MT. Analyses of the developmental stages of Pneumocystis carinii, in vitro. Lab Invest 1988;58:324-331.
Lee CH, Helweg-Larsen J, Tang X, et al. Update on Pneumocystis carinii f sp. Hominis typing based on nucleotide sequence variations in internal transcribed spacer regions of rRNA genes. J Clin Microbiol 1998;36:734-741.
Beard CB, Carter JL, Keely SP, et al. Genetic variations in Pneumocystis carinii isolates from different geographic regions. Emerg Infect Dis 2000;6:265-272.
Nahimana A, Blanc DS, Francioli P, et al. Typing of Pneumocystis carini f sp. Hominis by PCR-SSCP to indicate a high frequency of co-infections. J Med Microbiol 2000;49:753-758.
Stringer JR, Beard CB, Miller RF, Wakefield AE. A new name ( Pneumocystis jiroveci) for Pneumocystis from humans. Emerg Infect Dis 2002;8:1-10.
Hughes WT. Natural mode of acquisition for de novo infection with Pneumocystis carinii. J Infect Dis 1982;145:842-8.
Vogel P, Miller CJ, Lowenstime LL, Lackner AA. Evidence for horizontal transmission of Pneumocystis carinii pneumonia in simian immunodeficiency virus-infected rhesus macaques. J Infect Dis 1993;168:836-43.
Walzer P, Kim C, Cushion M. Pneumocystis carinii. In: Walzer P, Genta R, editors. Parasitic infections in the compromised host. New York: Marcel Dekker; 1989. pp 83-178.
Sternberg RI. Pneumocystis carinii alters surfactant protein A concentrations in bronchoalveolar lavage fluid. J Lab Clin Med 1995;125:462.
Walzer PD. Infections for Pneumocystis carinii In: Harrison principios de medicina interna ch. 211. 14th. edition Ed Mc Graw Hill; 1996 pp.1330-1332.
Dutz W. Pneumocystis carinii pneumonia. Pathol Annu 1970;5:309-41.
Hughes WT. Pneumocystis carinii pneumonia: new approaches to diagnosis, treatment and prevention. Pediatr Infect Dis J 1991;10:391-9.
Hanson C, Shearer T. AIDS and other acquired immunodeficiency diseases. In: Feigin RD, Cherry JD (editors) Textbook of pediatric infectious diseases, 4th. ed. ch. 80. W.B. Saunders Co.; pp. 954-979.
Hughes WT. Pneumocystis carinii pneumonia, in Pizzo PA, Wilfer CM (eds) Pediatric AIDS: The challenge of HIV infection in infants, children and adolescents (eds) Philadelphia PA, Williams and Wilkins, 1994, pp:405-418.
Raviglione M. Extrapulmonar pneumocystosis: the first 50 cases. Rev Infect Dis 1990;12:1127-38.
Chen A, Zaidi AKM, Mueller BV, et al. Pneumocystis carinii presents as a mediastinal mass in a child with acquired immunodeficiency syndrome. Pediatr Infect Dis J 1999;18:827-31.
Huang L, Stansell J, Osmond D, et al. Performance of an algorithm to detect Pneumocystis carinii pneumonia in symptomatic HIV-infected persons. Chest 1999;115:1025-1032.
Bye MR, Bernstein LJ, Shah K, et al. Diagnosis lavage in children with AIDS. Pediatr Pulmonol 1987;3:425-8.
Kovacs J, Ng V, Masur H, et al. Diagnosis of Pneumocystis carinii pneumonia: improved detection in sputum with use of monoclonal antibodies. N Engl J Med 1988;318:589-93.
Wakefield AE, Pixley FJ, Banerji S, et al. Amplification of mitochondrial ribosomal RNA sequences form Pneumocystis carinii DNA of rat and human origin. Mol Biochem Parasitol 1990;43:69-76.
Lu JJ, Chen CH, Bartlett MS, et al. Comparison of six different PCR methods for detection of Pneumocystis carinii. J Clin Microbiol 1995;33:2785-88.
Olsson M, Elvin K, Lofdahl S, Linder E. Detection of Pneumocystis carinii DNA in sputum and bronchoalveolar lavage samples by polymerase chain reaction. J Clin Microbiol 1993;31:221-6.
Sing A, Trebesius K, Roggenkamp A, et al. Evaluation of diagnostic value and epidemiological implications of PCR for Pneumocystis carinii in different immunosuppressed and immunocompetent patient groups. J Clin Microbiol 2000;38:1461-1467.
Chanock SJ, Luginbuhl LM, McIntosh K, et al. Life-threatening reaction to trimethoprim/sulfamethoxazole in pediatric human immunodeficiency virus infection. Pediatr Infect Dis J 1994;93:519.
Rieder MJ, King SM, Read S. Adverse reaction to trimethroprimsulfamethoxazole among children with human immunodeficiency virus infection. Pediatr Infect Dis J 1997;16:1028.
Chaisson R, Bishai W. The management of Pneumocystis carinii, toxoplasmosis, and HSV infections in patients with HIV disease. HIV Clin Manage 1999;7:1-29.
Bozzette S, Sather F, Chiu J, et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. N Engl J Med 1990;323:1451-1457.
Montaner J, Lawson L, Levitt N, et al. Corticosteroids prevent early deterioration in patients with moderately severe Pneumocystis carinii pneumonia and the acquired immunodeficiency syndrome. Ann Intern Med 1990;113:14-20.
Gagnon S, Boota AM, Fischl MA, et al. Corticosteroids as adjunctive therapy for severe Pneumocystis carinii pneumonia in the Acquired immunodeficiency syndrome. N Engl J Med 1990;323:1444.
McLaughlin GE, Virdee SS, Schleien CL, et al. Effect of corticosteroids on survival of children with acquired immunodeficiency syndrome and Pneumocystis carinii-related respiratory failure. J Pediatr 1995;126:821- 4.
Sleasman JW, Hemenway C, Klein AS, et al. Corticosteroids improve survival of children with AIDS and Pneumocystis carinii pneumonia. Am J Dis Child 1993;147:30.
American Academy of Pediatrics. Infecciones por Pneumocystis carinii. En: Pickering LK, Peter G, Baker CJ, Gerber MA, MacDonald NE, Orenstein WA Patriarca P, editors. Red Book. Enfermedades Infecciosas en Pediatría. Informe del Comité de Enfermedades Infecciosas de la American Academy of Pediatrics. Ed. Médica Panamericana;. 25ª Edición. Buenos Aires, Argentina 2001; pp. 452-456.
Israele V, Wittek A, Courville T, et al. Pneumocystis carinii pneumonia in infants with CD4 counts greater than 2000 cells/mm3 (abstract POB3855). Presented at the VIII International Conference on AIDS. Amsterdam The Netherlands july, 1992.
Kovacs A, Fredrick T, Church J, et al. CD4 T-Lymphocyte counts and Pneumocystis carinii pneumonia in pediatric HIV infection. JAMA 1991;265:1698
Centers for Disease Control and Prevention.1995 Revised Guidelines for children infected with or perinatally exposed to human immunodeficiency virus. MMWR 1995;44(RR-4):1-11.
Grubman S, Simonds RJ. Preventing Pneumocystis carinii pneumonia in human immunodeficiency virus-infected children: new guidelines for prophylaxis. Pediatr Infect Dis J 1996;15:165-8.
Rigaud M, Pollack H, Leibovitz E, et al. Efficacy of primary chemoprophylaxis against Pneumocystis carinii pneumonia during the first year of life in infants infected with human immunodeficiency virus type 1. J Pediatr 1994;125:476.
USPH/IDSA Guidelines for the prevention of opportunistic infection in persons infected with human immunodeficiency virus 2001.
UNAIDS Provisional WHO/UNAIDS Secretariat recommendations on the use of co-trimoxazole prophylaxis in adults and children living with HIV/ AIDS in Africa. Geneva Switzerland: UNAIDS; 2000.
Graham SM. Prophylaxis against Pneumocystis carinii pneumonia for HIVexposed infants in Africa. Lancet 2002;360:1966-8.
Ledergerber B, Mocroft A, Reiss P, et al. Discontinuation of secondary prophylaxis against Pneumocystis carinii pneumonia in patients with HIV infection who have a response to antiretroviral therapy. N Engl J Med 2001;344:168-74.
Ledergerber B, Egger M, Erard V, et al. AIDS-related opportunistic illnesses occurring after initiation of potent antiretroviral therapy. The Swiss HIV Cohort Study. JAMA 1999;282:2220-6.
Powderly WG, Landay A, Lederman MN. Recovery of the immune system with antiretroviral therapy: the end of opportunism? JAMA 1998;280:72-7.
Cohen SJ, Slieker WA, Rijkers GT, et al. Early recovery of CD4+ lymphocytes in children on highly active antiretroviral therapy. AIDS 1998;12:2155-9.
US Public Health Service and Infectious Disease Society of America. 1999 USPHS/IDSA Guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. MMWR 1999;48:4-10.
Weverling GJ, Mocroft A, Ledergerber B, et al. Discontinuation of Pneumocystis carinii pneumonia prophylaxis after start of highly active antiretroviral therapy in HIV-infection. Lancet 1999;353:1293-98.
Trikalinos TA, Ioannidis PA. Discontinuation of Pneumocystis carinii prophylaxis in patients infected with human immunodeficiency virus: a meta-analysis and decision analysis. Clin Infect Dis 2001;33:1901-9.
Lopez BQ, Miro JM, Peña JM, et al. A Randomized trial of the discontinuation of primary and secondary prophylaxis against Pneumocystis carinii pneumonia after highly active antiretroviral therapy in patients with HIV infection. N Engl J Med 2001;344:159-67.
Simonds RJ, Hughes WT, Feinberg J, Navin TR. Preventing Pneumocystis carinii pneumonia in persons infected with human immunodeficiency virus. Clin Infect Dis 1995;21(Suppl):S44-S58.
Ioannidis JPA, Cappelleri JC, Skolnik PR, et al. Meta-analysis of the relative efficacy and toxicity of Pneumocystis carinii prophylactic regimens. Arch Intern Med 1996;156:177-88.
Bucher HC, Griffith L, Guyatt GH, Opravil M. Meta-analysis of prophylactic treatments against Pneumocystis carinii pneumonia and Toxoplasma encephalitis in HIV-infected patients. J Acquin Immun Defic Syndr Hum Retrovirol 1997;15:104-14.
Mirochnick M, Michaels M, Clarke D, et al. Pharmacokinetics of dapsone in children. J Pediatr 1993;12:806-9.
Gatti G, Loy A, Casazza R, et al. Pharmacokinetics of dapsone in human immunodeficiency virus-infected children. Antimicrob Agents Chemother 1995;39:1101-6.
Mirochnick M, Cooper E, Capparelli E, et al. Population Pharmacokinetics of dapsone in children with human immunodeficiency virus infection. Clin Pharmacol Ther 2001;70:24-32.
Mcintosh K, Cooper E, Xu J, et al. Toxicity and efficacy of daily vs weekly dapsone for prevention of Pneumocystis carinii pneumonia in children infected with human immunodeficiency virus. Pediatr Infect Dis J 1999;18:432-9.
Gluckstein D, Ruskin J, Nielsen D. Oral desensitization to trimethoprim/sulfamethoxazole in hypersensitive AIDS patients. IV International Conference on AIDS. Stockholm, Sweswn June 12-16, 1988; abstract 7176.
Rudin CH, Gunthard J, Zumsteg U. Successful desensitization to trimethoprim/sulfamethoxazole in a young infant with AIDS. Pediatr AIDS HIV Infect Fetus Adolesc 1995;6:212-4.
Centers for Disease Control and Prevention. 1999 USPHS/IDSA Guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency. MMWR 1999;48(RR10):1-59.
Principi N, Marchisio P, Onorato J, et al. Long term administration of aerosolized pentamidine as primary prophylaxis against Pneumocystis carinii pneumonia in infants and children with symptomatic human immunodeficiency virus infection. The Italian Pediatric Collaborative Study Group on Pentamidine. J Acquir Immune Defic Syndr Hum Retrovirol 1996;12:158-163.
Hughes W, Dorenbaum A, Yogev R, et al. Phase 1 safety and pharmacokinetics study of micronized atovaquone in human immunodeficiency virus-infected infants and children. Pediatric AIDS Clinical Trials Group. Antimicrob Agents Chemother 1998;42:1315-8.
Ngo LY, Yogev R, Dankner WM, et al. Pharmacokinetics of azithromycin administered alone and with atovaquone in human immunodeficiency virusinfected children. The ACTG 254 Team. Antimicrob Agents Chemother 1999;43:1516-9.
Dankner W, Yogev R, Hughes W, Xu J. The Pediatric ACTG 254 Team. Phase ll/lll, randomized, double-blind trial to compare atovaquone plus azithromycin to TMP/SMX in the prevention of multiple opportunistic pathogen infections (MOPPS) in HIV-infected children. Program and Abstract of Advancing Children´s Health 2000: A Joint Meeting of the Pediatric Academic Societies and the American Academy of Pediatric; May 12-16, 2000; Boston, MA, USA, abstract 1531.