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 |
|
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 |
Treatment
- Treat at least 21 days, then secondary prophylaxis until CD4 count > 100 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%), broncho-alveolar 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. SARS-CoV-2 pneumonia can resemble PcP and should therefore be included in the differential diagnoses
Drug / Dose | Comments | |
---|---|---|
Preferred therapy |
TMP-SMX |
|
+ 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 |
||
or pentamidine 4 mg/kg qd iv (infused over 60 min.) |
||
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 |
||
or atovaquone suspension 750 mg bid po (with food) |
||
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 800/160 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 |