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 800/160 mg 3 x/week po or 400/80 mg qd po or 800/160 mg qd po po
Negative serology for toxoplasmosis	pentamidine 300 mg in 6 mL aqua 1 x 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

Treatment

Treat at least 21 days, then secondary prophylaxis until CD4 count > 200 cells/μL and HIV-VL undetectable over 3 months
Diagnosis:

Definitive diagnosis: Cough and dyspnoea on exertion AND microorganism identification by cytology / histopathology of induced sputum (sensitivity up to 80%), bronchoalveolar lavage (sensitivity > 95%) or bronchoscopic tissue biopsy (sensitivity > 95%)
Presumptive diagnosis: CD4 count < 200 cells/ μL AND dyspnoea / desaturation on exertion and cough AND radiology compatible with PcP AND no evidence for bacterial pneumonia AND response to PcP treatment

	Drug / Dose	Comments
Preferred therapy	TMP-SMX 5 mg/kg tid TMP iv/po + 25 mg/kg tid SMX iv/po
+ prednisone 40 mg bid po 5 days 40 mg qd po 5 days 20 mg qd po 10 days if PaO₂ <10 kPa or <70 mmHg or alveolar/arterial O₂ gradient>35 mmHg. Start prednisone preferentially 15-30 min before TMP/SMX.	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
or pentamidine 4 mg/kg qd iv (infused over 60 min.)
For each regimen: + prednisone 40 mg bid po 5 days 40 mg qd po 5 days 20 mg qd po 10 days if PaO₂ <10 kPa or <70 mmHg or alveolar/arterial O₂ gradient>35 mmHg. Start prednisone preferentially 15-30 min before TMP/SMX. Some experts recommend adding caspofungin or other echinocandins 70 mg iv day 1, then 50 mg qd iv to standard treatment in person with severe PcP (requiring intensive care unit admission).	Benefit of corticosteroids if started within 72 hours after start of treatment
Alternative therapy for mild to moderate PcP	primaquine 30 mg (base) qd po	Check for G6PD deficiency
+ clindamycin 600-900 mg tid iv/po
or atovaquone suspension 750 mg bid po (with food)
or dapsone 100 mg qd po	Check for G6PD deficiencyIn case of rash: reduce dose of TMP (50%), antihistamines
+ trimethoprim 5 mg/kg tid po

Drug / Dose

Comments

Preferred therapy

TMP-SMX
5 mg/kg tid TMP iv/po
+ 25 mg/kg tid SMX iv/po

+ prednisone
40 mg bid po 5 days
40 mg qd po 5 days
20 mg qd po 10 days
if PaO₂ <10 kPa or <70 mmHg or alveolar/arterial O₂ gradient>35 mmHg. Start prednisone preferentially 15-30 min before TMP/SMX.

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

or
pentamidine
4 mg/kg qd iv (infused over 60 min.)

For each regimen:
+ prednisone
40 mg bid po 5 days
40 mg qd po 5 days
20 mg qd po 10 days
if PaO₂ <10 kPa or <70 mmHg or alveolar/arterial O₂ gradient>35 mmHg. Start prednisone preferentially 15-30 min before TMP/SMX.

Some experts recommend adding
caspofungin or other echinocandins
70 mg iv day 1, then 50 mg qd iv
to standard treatment in person with severe PcP (requiring intensive care unit admission).

Benefit of corticosteroids if started within 72 hours after start of treatment

Alternative therapy for mild to moderate PcP

primaquine
30 mg (base) qd po

Check for G6PD deficiency

+ clindamycin
600-900 mg tid iv/po

or
atovaquone suspension
750 mg bid po (with food)

or
dapsone
100 mg qd po

Check for G6PD deficiencyIn case of rash: reduce dose of TMP (50%), antihistamines

+ trimethoprim
5 mg/kg tid po

Secondary Prophylaxis/ Maintenance Therapy

Stop: if CD4 count > 200 cells/μL and HIV-VL undetectable over 3 months

	Drug / Dose	Comments
Negative or positive serology for toxoplasmosis	TMP-SMX 800/160 mg 3 x/week po or 400/80 mg qd po
Negative serology for toxoplasmosis	pentamidine 300 mg in 6 mL sterile water 1 x 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