Pneumocystis jirovecii Pneumonia (PcP)
Pneumocystis jirovecii Pneumonia (PcP)
Primary Prophylaxis
Start: if CD4 count < 200 cells/μL, CD4 percentage < 14%, oral thrush or relevant concomitant immunosuppression, see Primary Prophylaxis of OIs
Stop: if CD4 count > 100 cells/μL and HIV-VL undetectable over 3 months
Drug / Dose | Comments | |
---|---|---|
Negative or positive serology for toxoplasmosis |
TMP-SMX |
In case of non-severe TMP-SMX allergy and if other therapeutic options are not available/not clinically appropriated, desensitization can be attempted * |
Negative serology for toxoplasmosis | pentamidine 300 mg in 6 mL sterile water x 1 inhalation/month |
Does not prevent the rare extrapulmonary manifestations of P. jirovecii |
Negative serology for toxoplasmosis | dapsone 100 mg qd po |
Check for G6PD-deficiency |
Negative serology for toxoplasmosis |
atovaquone suspension 1500 mg qd po (with food) |
|
Positive serology for toxoplasmosis | dapsone 200 mg/week po + pyrimethamine 75 mg/week po + folinic acid 25-30 mg/week po |
Check for G6PD-deficiency |
Positive serology for toxoplasmosis | atovaquone suspension 1500 mg qd po (with food) +/- pyrimethamine 75 mg/week po + folinic acid 25-30 mg /week po |
* for protocols see: J. Allerg. Clin. Immunol 1994; 93:1001-1005; J Infect Dis 2001 Oct 15;184(8):992-7
Diagnosis and treatment
Diagnosis:
Definitive diagnosis: Cough and dyspnea on exertion AND microorganism identification by cytology / histopathology of induced sputum (sensitivity up to 80%), broncho-alveolar lavage (sensitivity > 95%) or bronchoscopic tissue biopsy (sensitivity > 95%)
Presumptive diagnosis: CD4 count < 200 cells/μL AND dyspnea / desaturation on exertion and cough AND radiology compatible with PcP AND no evidence for bacterial pneumonia AND response to PcP treatment. SARS-CoV-2 pneumonia can resemble PcP and should therefore be included in the differential diagnoses.
Notes on treatment:
treat at least 21 days, then secondary prophylaxis until CD4 count > 100 cells/μL and HIV-VL undetectable over 3 months. See also Anti-infective/ART interaction table for treatment optimization
Drug / Dose | Comments | |
---|---|---|
Preferred therapy |
TMP-SMX |
Monitor myelotoxicity (mainly neutropenia), kidney function and electrolytes (mainly high potassium) |
+ prednisone |
Benefit of corticosteroids if started within 72 hours after start of treatment | |
Alternative therapy for moderate to severe PcP | primaquine 30 mg (base) qd po |
Check for G6PD deficiency |
+ clindamycin 600-900 mg tid iv/po |
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OR pentamidine 4 mg/kg qd iv (infused over 60 min.) |
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For each regimen:
|
Benefit of corticosteroids if started within 72 hours after start of treatment
Some studies support the addition of caspofungin or other echinocandins to standard treatment in persons with moderate-severe PcP (can be considered, but not mandatory) |
|
Alternative therapy for mild to moderate PcP |
primaquine |
Check for G6PD deficiency |
+ clindamycin |
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OR atovaquone suspension 750 mg bid po (with food) |
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OR |
Check for G6PD deficiency. In case of rash: reduce dose of TMP (50%), antihistamines |
|
+ trimethoprim |
Secondary Prophylaxis / Maintenance Therapy
Stop: if CD4 count > 100 cells/μL and HIV-VL undetectable over 3 months
Drug / Dose | Comments | |
---|---|---|
Negative or positive serology for toxoplasmosis |
TMP-SMX 400/80 mg qd po or 160/800 mg x 3/week po |
|
Negative serology for toxoplasmosis | pentamidine 300 mg in 6 mL sterile water x 1 inhalation/month |
Not to use in the rare case of extrapulmonary manifestations of P. jirovecii |
Negative serology for toxoplasmosis | dapsone 100 mg qd po |
Check for G6PD-deficiency |
Negative serology for toxoplasmosis | atovaquone suspension 1500 mg qd po (with food) |
|
Positive serology for toxoplasmosis | dapsone 200 mg/week po + pyrimethamine 75 mg/week po + folinic acid 25-30 mg/week po |
Check for G6PD-deficiency |
Positive serology for toxoplasmosis | atovaquone suspension 1500 mg qd po (with food) +/- pyrimethamine 75 mg/week po + folinic acid 25-30 mg/week po |