Pneumocystis jirovecii pneumonia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

Antipneumocystic medication is used with concomitant steroids in order to avoid inflammation, which causes an exacerbation of symptoms about four days after treatment begins if steroids are not used. By far the most commonly used medication is a combination of trimethoprim and sulfamethoxazole (co-trimoxazole, with the tradenames Bactrim, Septrin, or Septra), but some patients are unable to tolerate this treatment due to allergies. Other medications that are used, alone or in combination, include pentamidine, trimetrexate, dapsone, atovaquone, primaquine, and clindamycin. Treatment is usually for a period of about 21 days.

Pentamidine is less often used as its major limitation is the high frequency of side effects. These include acute pancreatitis, renal failure, hepatotoxicity, leukopenia, rash, fever and hypoglycaemia.

Guidelines

To read about guidelines for prevention and treatment of Pneumocystis pneumonia Infections in HIV-Infected Adults and Adolescents, click here.

Antimicrobial Regimen

• Pneumocystis jirovecii pneumonia

• 1. Preventing First Episode of PCP (Primary Prophylaxis)

• Preferred regimen: TMP-SMX 1 Double-Strength(DS) PO daily OR TMP-SMX 1 Single-Strength(SS) PO daily
• Alternative regimen(1): TMP-SMX 1 Double-Strength(DS) tid weekly OR Dapsone 100 mg PO daily or 50 mg PO BID
• Alternative regimen(2): Dapsone 50 mg PO daily AND (Pyrimethamine 50 mg + Leucovorin 25 mg) PO weekly
• Alternative regimen(3): Dapsone 200 mg AND Pyrimethamine 75 mg AND Leucovorin 25 mg PO weekly
• Alternative regimen(4): Aerosolized Pentamidinec 300 mg via Respigard II™ nebulizer every month
• Alternative regimen(5): Atovaquone 1500 mg PO daily with food
• Alternative regimen(6): Atovaquone 1500 mg AND Pyrimethamine 25 mg AND Leucovorin 10 mg PO daily with food

• 2. Treatment of Pneumocystis Pneumonia

• 2.1. Moderate to Severe PCP

• Preferred regimen: TMP-SMX (TMP 15–20 mg and SMX 75–100 mg)/kg/day IV given q6h or q8h
• Note: May switch to PO after clinical improvement
• Alternative regimen(1): Pentamidine 4 mg/kg IV once daily infused over at least 60 minutes
• Note: May reduce the dose to 3 mg/kg IV once daily because of toxicities.
• Alternative regimen(2): Primaquine 30 mg (base) PO once daily AND (Clindamycin [IV 600 mg q6h or 900 mg q8h] or [PO 450 mg q6h or 600 mg q8h])

• Note(1): Duration of PCP treatment is 21 days
• Note(2): Adjunctive corticosteroid may be indicated in some moderate to severe cases.Prednisone doses (beginning as early as possible and within 72 hours of PCP therapy) (AI):
• Note(3): Prednisone doses (beginning as early as possible and within 72 hours of PCP therapy)

• Days 1–5 40 mg PO BID
• Days 6–10 40 mg PO daily
• Days 11–21 20 mg PO daily

• 2.2. Mild to Moderate PCP

• Preferred regimen: TMP-SMX (TMP 15–20 mg/kg/day and SMX 75–100 mg/kg/day), given PO in 3 divided doses OR TMP-SMX Double-Strength(DS) - 2 tablets tid
• Alternative regimen(1): Dapsone 100 mg PO daily AND TMP 15 mg/kg/day PO (3 divided doses)
• Alternative regimen(2): Primaquine 30 mg (base) PO daily AND Clindamycin PO (450 mg q6h or 600 mg q8h)
• Alternative regimen(3): Atovaquone 750 mg PO BID with food

• Note: Duration of PCP treatment is 21 days

• 3. Preventing Subsequent Episode of PCP (Secondary Prophylaxis)

• Preferred regimen: TMP-SMX 1 Double-Strength(DS) PO daily OR TMP-SMX 1 Single-Strength(SS) PO daily
• Alternative regimen(1): TMP-SMX 1 Double-Strength(DS) tid weekly OR Dapsone 100 mg PO daily or 50 mg PO BID
• Alternative regimen(2): Dapsone 50 mg PO daily AND (Pyrimethamine 50 mg + Leucovorin 25 mg) PO weekly
• Alternative regimen(3): Dapsone 200 mg AND Pyrimethamine 75 mg AND Leucovorin 25 mg PO weekly
• Alternative regimen(4): Aerosolized Pentamidinec 300 mg via Respigard II™ nebulizer every month
• Alternative regimen(5): Atovaquone 1500 mg PO daily with food
• Alternative regimen(6): Atovaquone 1500 mg AND Pyrimethamine 25 mg AND Leucovorin 10 mg PO daily with food