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

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