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When the book is wrong

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A 38-year-old woman, who had received a kidney transplant 4 years previously, was admitted to the intensive care unit for severe pneumocystis pneumonia. The fi rst-line therapy was intravenous

co-trimoxazole (trimethoprim/sulfamethoxazole). However, after

10 days, she developed confl uent exanthema of the trunk and cotrimoxazole was suspected as the

cause. A cutaneous biopsy confi rmed the clinical suspicion. Co-trimoxazole was stopped and the eruption progressively disappeared.

Intravenous pentamidine (Pentacarinat) was proposed as an

alternative because it is the second- line therapy approved by the Belgian

version of the “Sanford Guide to antimicrobial therapy 2005–2006” for severe pneumocystosis.1 However,

the proposal was rejected in

accordance with a note in the Belgian Pentacarinat prescribing information (Sanofi -Aventis) that Pentacarinat is contraindicated if sulphonamide hyper sensitivity is suspected. This note also appears in the 23rd edition of a Compendium whose publication is supervised by the government.2

The combination of clindamycin and primaquine, the third alternative treatment recommended by the Sanford Guide, was started. But after 48 h, the patient developed

primaquine-induced methaemo globinaemia and the treatment was

stopped. At this point, no alternative treatment could be given for this severe pneumocystosis.

Since no other international drugs database mentioned pentamidine’s contraindication if sulphonamide hy per sensitivity was suspected, we contacted Sanofi -Aventis Belgium for an additional explanation. We were told that the notice had been written on governmental instruction. We therefore questioned the Belgian Ministry of Social Aff airs, Health and Environment, but no medical evidence for the instruction could be provided. We therefore commenced intravenous pentamidine treatment, and the patient was discharged from the intensive-care unit after 21 days. As a result of our investigation, the drug information notice will be modifi ed as soon as possible by the Belgian Ministry of Social Aff airs, Health and Environment and by Sanofi -Aventis Belgium. This case report emphasises the fact that even

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an offi cial book can contain some mistakes: keeping a critical mind remains essential.

We thank François Gemenne for correction of the text. We declare that we have no conflict of interest.

*P Leclercq, R Betz, B Lambermont, P Leonard, F Frippiat

philleclercq@belgacom.net

Medical Intensive Care Unit (PL, RB, BL) and Infectious Disease Unit (PL, FF), CHU Sart-Tilman, B35, 4000 Liège, Belgium

1 Sanford J, Gilbert D, Moellering R, et al. The Sanford guide to antimicrobial therapy 2005–2006: 19th Belgian/Luxembourg edn. Vermont: Antimicrobial Therapy Inc, 2005: 161–62.

2 Neels L, ed. Compendium, 23rd edn. Brussels: Pharma.be, 2005: 1897–98.

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