Pneumocystis jirovecii pneumonia
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
high-risk for Pneumocystis pneumonia (PCP) infection
primary prophylaxis
Indications for primary prophylaxis in HIV-positive adults or adolescents who do not have symptoms or signs of PCP include:[32]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/pneumocystis-pneumonia CD4 cell count <100 cells/microliter; CD4 cell count between 100 and 200 cells/microliter is plasma HIV RNA levels are above detection limits.
Prophylactic agent of choice is trimethoprim/sulfamethoxazole (TMP/SMX), in the absence of contraindications. Alternatives for patients, regardless of Toxoplasma gondii serostatus, include dapsone plus pyrimethamine plus leucovorin, or atovaquone. Alternatives for patients who are seronegative for Toxoplasma gondii include dapsone, aerosolized pentamidine, or intravenous pentamidine.[32]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/pneumocystis-pneumonia
PCP prophylaxis should be discontinued when patients have CD4 cell count ≥200 cells/microliter for ≥3 consecutive months. Discontinuing PCP prophylaxis in patients on antiretroviral medication with suppressed viral loads and CD4 counts 100 to 200 cells/microliter for ≥3 to 6 months may be considered. PCP prophylaxis should be restarted in patients with CD4 count <100 cells/microliter regardless of the HIV viral load, and in patients with CD4 count ≥100 cells/microliter to <200 cells/microliter who do not have suppressed viral loads. PCP prophylaxis should be continued for life in patients who develop PCP despite CD4 count >200 cells/microliter.[32]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/pneumocystis-pneumonia
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting dapsone, if possible.
Primary options
sulfamethoxazole/trimethoprim: 80-160 mg orally once daily
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
Secondary options
sulfamethoxazole/trimethoprim: 160 mg orally three times weekly
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
OR
dapsone: 100 mg orally once daily, or 50 mg orally twice daily
OR
dapsone: 50 mg orally once daily
and
pyrimethamine: 50 mg orally once weekly
and
leucovorin: 25 mg orally once weekly
OR
dapsone: 200 mg orally once weekly
and
pyrimethamine: 75 mg orally once weekly
and
leucovorin: 25 mg orally once weekly
OR
atovaquone: 1500 mg orally once daily
OR
pentamidine inhaled: 300 mg by nebulizer once monthly
OR
pentamidine: 300 mg intravenously every 28 days
primary prophylaxis
Indications for primary prophylaxis in children include: HIV-positive infants ages 1-12 months regardless of CD4 cell count or percentage; HIV-positive children ages 1 to <6 years with CD4 count <500 cells/microliter or CD4 percentage <15%; HIV-positive children ages ≥6 to 12 years with CD4 cell count <200 cells/microliter or CD4 percentage <15%; HIV-indeterminate infants of HIV-positive mothers.[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full
Prophylactic agent of choice is trimethoprim/sulfamethoxazole (TMP/SMX), in the absence of contraindications. In patients who cannot tolerate TMP/SMX, other options include dapsone, atovaquone, or aerosolized pentamidine. Intravenous pentamidine may be considered in children ages >2 years when other options are not available.[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full
Children born to HIV-positive mothers should receive prophylaxis with TMP/SMX beginning at 4-6 weeks. Children who are HIV-positive at birth should be treated through their first year of life, at which time the need for ongoing PCP prophylaxis should be reassessed based on the age-specific CD4 count and percentage thresholds described previously. HIV-indeterminate infants of HIV-positive mothers should receive prophylaxis until they are determined to be HIV-uninfected.
Consideration can be given to discontinuation of PCP prophylaxis when, after receiving antiretroviral therapy for ≥6 months, CD4 percentage is ≥15% or CD4 cell count is ≥200 cells/microliter for patients ages ≥6 years and CD4 percentage is ≥15% or CD4 cell count is ≥500 cell/microliter for patients ages 1 to 6 years for >3 consecutive months. PCP prophylaxis should not be discontinued in HIV-infected infants ages <1 year.
After PCP prophylaxis has been discontinued, the CD4 percentage and CD4 count should be reassessed at least every 3 months and prophylaxis resumed based on the age-specific CD4 count and percentage thresholds described previously.
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting dapsone, if possible.
Primary options
sulfamethoxazole/trimethoprim: children ≥2 months of age: 5-10 mg/kg orally once daily; or 2.5 to 5 mg/kg twice daily given on 2 or 3 days per week either on consecutive days or on alternate days; maximum 320 mg/day
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
Secondary options
dapsone: children ≥1 month of age: 2 mg/kg orally once daily, maximum 100 mg/day; or 4 mg/kg orally once weekly, maximum 200 mg/dose
OR
atovaquone: children 1-3 months of age: 30-40 mg/kg orally once daily; children 4-24 months of age: 45 mg/kg orally once daily; children >24 months of age: 30-40 mg/kg orally once daily; maximum 1500 mg/day
OR
pentamidine inhaled: children ≥5 years of age: 300 mg by nebulizer once monthly
OR
pentamidine: children ≥2 years of age: 4 mg/kg intravenously once monthly
primary prophylaxis
There are specific recommendations for PCP prophylaxis in patients who do not have HIV infection but are otherwise immunocompromised, for example during treatment for cancer.[47]Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018 Oct 20;36(30):3043-54. https://ascopubs.org/doi/10.1200/JCO.18.00374?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed http://www.ncbi.nlm.nih.gov/pubmed/30179565?tool=bestpractice.com [98]Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128. https://www.atsjournals.org/doi/10.1164/rccm.2008-740ST?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/21193785?tool=bestpractice.com [101]Cooley L, Dendle C, Wolf J, et al. Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. Intern Med J. 2014 Dec;44(12b):1350-63. https://www.doi.org/10.1111/imj.12599 http://www.ncbi.nlm.nih.gov/pubmed/25482745?tool=bestpractice.com [108]Maertens J, Cesaro S, Maschmeyer G, et al. ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother. 2016 Sep;71(9):2397-404. https://www.doi.org/10.1093/jac/dkw157 http://www.ncbi.nlm.nih.gov/pubmed/27550992?tool=bestpractice.com [109]Classen AY, Henze L, von Lilienfeld-Toal M, et al. Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors: 2020 updated guidelines of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO/DGHO). Ann Hematol. 2021 Jun;100(6):1603-20. https://www.doi.org/10.1007/s00277-021-04452-9 http://www.ncbi.nlm.nih.gov/pubmed/33846857?tool=bestpractice.com Local guidelines should be consulted for information on suitable regimens.
In the 2018 American Society of Clinical Oncology and Infectious Diseases Society of America guidelines on antimicrobial prophylaxis in adults with cancer-related immunosuppression, indications for PCP prophylaxis include: patients receiving chemotherapy regimens associated with >3.5% risk of PCP infection (e.g., those with ≥20 mg/day prednisone equivalents for ≥1 month or those taking purine analogs).[47]Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018 Oct 20;36(30):3043-54. https://ascopubs.org/doi/10.1200/JCO.18.00374?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed http://www.ncbi.nlm.nih.gov/pubmed/30179565?tool=bestpractice.com
Trimethoprim/sulfamethoxazole (TMP/SMX) is the preferred first-line antibiotic, with aerosolized pentamidine, dapsone, or atovaquone if patients are intolerant to TMP/SMX.
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting dapsone, if possible.
Primary options
sulfamethoxazole/trimethoprim: 160 mg orally three times weekly
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
Secondary options
dapsone: 50 mg orally twice daily, or 100 mg once daily
OR
pentamidine inhaled: 300 mg by nebulizer once monthly
OR
atovaquone: 1500 mg orally once daily
primary prophylaxis
There are specific recommendations for PCP prophylaxis in patients who do not have HIV infection but are otherwise immunocompromised, for example following solid-organ transplant.[47]Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018 Oct 20;36(30):3043-54. https://ascopubs.org/doi/10.1200/JCO.18.00374?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed http://www.ncbi.nlm.nih.gov/pubmed/30179565?tool=bestpractice.com [98]Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128. https://www.atsjournals.org/doi/10.1164/rccm.2008-740ST?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/21193785?tool=bestpractice.com Local guidelines should be consulted for information on suitable regimens.
The 2019 American Society of Transplantation guidelines recommend PCP prophylaxis for all solid-organ transplant recipients for at least 6-12 months and for programs with incidence of PCP infection among recipients of at least 3% to 5%.[47]Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018 Oct 20;36(30):3043-54. https://ascopubs.org/doi/10.1200/JCO.18.00374?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed http://www.ncbi.nlm.nih.gov/pubmed/30179565?tool=bestpractice.com Lifelong prophylaxis may be indicated for small bowel and lung transplant recipients and patients with a history of previous PCP infection. Continuation or resumption of prophylaxis is generally indicated for patients treated with augmented immunosuppression for graft rejection, those with cytomegalovirus infection, patients receiving corticosteroids (e.g., >20 mg/day of prednisone for ≥2 weeks) and during prolonged neutropenia or flares of autoimmune disease.
Prophylactic agent of choice is trimethoprim/sulfamethoxazole (TMP/SMX), in the absence of contraindications. In patients who cannot tolerate TMP/SMX, other options include dapsone, atovaquone, aerosolized pentamidine, or clindamycin plus pyrimethamine (this combination has not been studied adequately in children and is recommended for adults only).[49]Fishman JA, Gans H, AST Infectious Diseases Community of Practice. Pneumocystis jiroveci in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13587. http://www.ncbi.nlm.nih.gov/pubmed/31077616?tool=bestpractice.com
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting dapsone, if possible.
Primary options
sulfamethoxazole/trimethoprim: children ≥2 months of age: 5-10 mg/kg orally once daily, or 5-10 mg/kg/day orally given in 2 divided doses on 2 or 3 days per week, maximum 320 mg/day; adolescents and adults: 160 mg orally once daily or three times weekly, or 80 mg orally once daily
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
Secondary options
dapsone: children ≥1 month of age: 2 mg/kg orally once daily (maximum 100 mg/day), or 4 mg/kg once weekly (maximum 200 mg/dose); adolescents and adults: 50-100 mg orally once daily
OR
atovaquone: children 1-3 months of age: 30-40 mg/kg orally once daily, maximum 1500 mg/day; children 4-24 months of age: 45 mg/kg orally once daily, maximum 1500 mg/day; children >24 months of age: 30-40 mg/kg orally once daily, maximum 1500 mg/day; adolescents and adults: 1500 mg orally once daily
OR
pentamidine inhaled: children, adolescents, and adults: 300 mg by nebulizer every 3-4 weeks
Tertiary options
clindamycin: adults: 300 mg orally once daily or three times weekly
and
pyrimethamine: adults: 15 mg orally once daily or three times weekly
primary prophylaxis
There are specific recommendations for PCP prophylaxis in patients who do not have HIV infection but are otherwise immunocompromised, for example following hematopoietic cell transplant.[47]Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018 Oct 20;36(30):3043-54. https://ascopubs.org/doi/10.1200/JCO.18.00374?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed http://www.ncbi.nlm.nih.gov/pubmed/30179565?tool=bestpractice.com [101]Cooley L, Dendle C, Wolf J, et al. Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. Intern Med J. 2014 Dec;44(12b):1350-63. https://www.doi.org/10.1111/imj.12599 http://www.ncbi.nlm.nih.gov/pubmed/25482745?tool=bestpractice.com [108]Maertens J, Cesaro S, Maschmeyer G, et al. ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother. 2016 Sep;71(9):2397-404. https://www.doi.org/10.1093/jac/dkw157 http://www.ncbi.nlm.nih.gov/pubmed/27550992?tool=bestpractice.com [109]Classen AY, Henze L, von Lilienfeld-Toal M, et al. Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors: 2020 updated guidelines of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO/DGHO). Ann Hematol. 2021 Jun;100(6):1603-20. https://www.doi.org/10.1007/s00277-021-04452-9 http://www.ncbi.nlm.nih.gov/pubmed/33846857?tool=bestpractice.com Local guidelines should be consulted for information on suitable regimens.
The 2009 multisociety-sponsored North American and European guidelines for preventing infectious complications following hematopoietic cell transplantation recommend PCP prophylaxis for all allogeneic hematopoietic cell transplant recipients and for autologous hematopoietic cell transplant recipients with significant immunosuppression (i.e., patients with underlying hematologic malignancies, those receiving intensive conditioning regimens or graft manipulation, or those who have recently received purine analogs or high-dose corticosteroids).[47]Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018 Oct 20;36(30):3043-54. https://ascopubs.org/doi/10.1200/JCO.18.00374?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed http://www.ncbi.nlm.nih.gov/pubmed/30179565?tool=bestpractice.com For allogeneic hematopoietic cell transplant recipients, PCP prophylaxis is recommended from engraftment until at least 6 months after transplantation. Initiating PCP prophylaxis for 1-2 weeks prior to transplantation may be considered on the basis of underlying disease, prior chemotherapy, and pretransplant conditioning regimens. For autologous hematopoietic cell transplant recipients with significant immunosuppression, PCP prophylaxis is recommended from engraftment until 3-6 months after transplantation. PCP prophylaxis should be extended for longer than 6 months in allogeneic or autologous hematopoietic cell transplant recipients who continue to receive immunosuppressive drugs (e.g., prednisone or cyclosporine) or have chronic graft-versus-host disease.[48]Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009 Oct;15(10):1143-238. https://www.bbmt.org/article/S1083-8791(09)00300-0/fulltext http://www.ncbi.nlm.nih.gov/pubmed/19747629?tool=bestpractice.com
Prophylactic agent of choice is trimethoprim/sulfamethoxazole (TMP/SMX), in the absence of contraindications. In patients who cannot tolerate TMP/SMX, alternative options include atovaquone, dapsone, aerosolized pentamidine, or intravenous pentamidine.[48]Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009 Oct;15(10):1143-238. https://www.bbmt.org/article/S1083-8791(09)00300-0/fulltext http://www.ncbi.nlm.nih.gov/pubmed/19747629?tool=bestpractice.com
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting dapsone, if possible.
Primary options
sulfamethoxazole/trimethoprim: children ≥2 months of age: 150 mg/square meter of body surface area/day orally (multiple regimens exist); adolescents and adults: 80-160 mg orally once daily, or 160 mg three times weekly
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
Secondary options
dapsone: children ≥1 month of age: 2 mg/kg orally once daily, maximum 100 mg/day; adolescents and adults: 50 mg orally twice daily, or 100 mg once daily
OR
atovaquone: children: 15 mg/kg orally twice daily, or 30 mg/kg once daily; adolescents and adults: 750 mg orally twice daily, or 1500 mg once daily
OR
pentamidine inhaled: children ≤5 years of age: 9 mg/kg by nebulizer once monthly; children >5 years of age: 300 mg by nebulizer once monthly; adolescents and adults: 300 mg by nebulizer every 3-4 weeks
OR
pentamidine: children: 4 mg/kg intravenously every 2-4 weeks
More pentamidineA dose reduction may be required if toxicities occur.
adults or adolescents: HIV-positive
pharmacotherapy
Defined as having both a room air pO₂ ≥70 mmHg and an A-a gradient ≤35 mmHg.
Treatment of choice is trimethoprim/sulfamethoxazole (TMP/SMX).[32]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/pneumocystis-pneumonia
Alternative treatments should only be used if patients are intolerant to TMP/SMX and cannot be managed supportively, or if there is evidence of treatment failure. Because patient symptoms and signs often worsen within the first 3-5 days of treatment, treatment failure is considered if the patient has worsening clinical status after at least 4-8 days of therapy.[32]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/pneumocystis-pneumonia Alternative treatment regimens include dapsone plus trimethoprim, clindamycin plus primaquine, or atovaquone.
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting primaquine or dapsone, if possible.
Duration of therapy is 21 days.
Primary options
sulfamethoxazole/trimethoprim: 15-20 mg/kg/day orally given in 3 divided doses, or 320 mg orally three times daily
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
Secondary options
dapsone: 100 mg orally once daily
and
trimethoprim: 15 mg/kg/day orally given in 3 divided doses
OR
clindamycin: 450 mg orally four times daily, or 600 mg three times daily
and
primaquine phosphate: 30 mg orally once daily
More primaquine phosphateDose refers to primaquine base.
OR
atovaquone: 750 mg orally twice daily
pharmacotherapy ± mechanical ventilation
Defined by either a room air pO₂ <70 mmHg or an A-a gradient >35 mmHg.
Patients with respiratory compromise should be admitted to the hospital, possibly to the intensive care unit, and may require mechanical ventilation.
Treatment of choice is intravenous trimethoprim/sulfamethoxazole (TMP/SMX).[32]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/pneumocystis-pneumonia Alternative treatment regimens include either clindamycin plus primaquine, or intravenous pentamidine. Clindamycin plus primaquine may be more effective and less toxic than intravenous pentamidine.[100]Benfield T, Atzori C, Miller RF, et al. Second-line salvage treatment of AIDS-associated Pneumocystis jiroveci pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008 May 1;48(1):63-7. http://www.ncbi.nlm.nih.gov/pubmed/18360286?tool=bestpractice.com Alternative treatments should only be used if patients are intolerant to TMP/SMX and cannot be managed supportively, or if there is evidence of treatment failure. As patients often worsen within the first 3-5 days of treatment, treatment failure is considered if the patient has worsening clinical status after at least 4-8 days of therapy.[32]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/pneumocystis-pneumonia
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting primaquine, if possible.
Duration of therapy is 21 days.
Primary options
sulfamethoxazole/trimethoprim: 15-20 mg/kg/day intravenously given in divided doses every 6-8 hours
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component. May switch to oral formulation after clinical improvement.
Secondary options
pentamidine: 4 mg/kg intravenously every 24 hours
More pentamidineA dose reduction may be required if toxicities occur.
OR
clindamycin: 600 mg intravenously every 6 hours, or 900 mg every 8 hours; 450 mg orally four times daily, or 600 mg three times daily
and
primaquine phosphate: 30 mg orally once daily
More primaquine phosphateDose refers to primaquine base.
corticosteroid
Treatment recommended for ALL patients in selected patient group
All patients should be given a corticosteroid, started as early as possible, preferably within the first 72 hours.[99]Ewald H, Raatz H, Boscacci R, et al. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV infection. Cochrane Database Syst Rev. 2015 Apr 2;(4):CD006150. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006150.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/25835432?tool=bestpractice.com
Primary options
prednisone: 40 mg orally twice daily for 5 days, followed by 40 mg once daily for 5 days, followed by 20 mg once daily for 11 days
OR
methylprednisolone: 30 mg intravenously twice daily for 5 days, followed by 30 mg once daily for 5 days, then 15 mg once daily until patient can be given oral prednisone
children: HIV-positive or at risk for HIV
pharmacotherapy
Defined as having both a room air pO₂ ≥70 mmHg and an A-a gradient ≤35 mmHg.
Treatment of choice is trimethoprim/sulfamethoxazole (TMP/SMX).[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full
Alternative treatments should be given if the child does not tolerate TMP/SMX or if there is clinical treatment failure after 5-7 days.[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full Alternative treatment regimens include intravenous pentamidine, atovaquone, dapsone plus trimethoprim, or primaquine plus clindamycin.[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting primaquine or dapsone, if possible.
Duration of therapy is 21 days.
Primary options
sulfamethoxazole/trimethoprim: children ≥2 months of age: 15-20 mg/kg/day intravenously given in divided doses every 6 hours
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component. Switch to oral dose (same total daily dose given in 3-4 divided doses) in patients with mild-to-moderate disease after acute pneumonitis has resolved.
Secondary options
pentamidine: 4 mg/kg intravenously every 24 hours
More pentamidineA dose reduction may be required if toxicities occur. May switch to a suitable oral regimen (e.g., atovaquone) if there is clinical improvement after 7-10 days.
OR
atovaquone: children 1-3 months of age: 30-40 mg/kg orally once daily; children 4-24 months of age: 45 mg/kg orally once daily; children >24 months of age: 30-40 mg/kg orally once daily; maximum 1500 mg/day
OR
dapsone: 2 mg/kg orally once daily, maximum 100 mg/day
and
trimethoprim: 15 mg/kg/day orally given in 3 divided doses
OR
clindamycin: 10 mg/kg intravenously/orally every 6 hours, maximum 600 mg/dose (intravenously) or 300-450 mg/dose (orally)
and
primaquine phosphate: 0.3 mg/kg orally once daily, maximum 30 mg/day
pharmacotherapy ± mechanical ventilation
Defined by either a room air pO₂ <70 mmHg or an A-a gradient >35 mmHg.
Children with respiratory compromise should be admitted to the hospital, possibly to the intensive care unit, and given ventilation.
Treatment of choice is trimethoprim/sulfamethoxazole (TMP/SMX).[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full
Pentamidine may be used as an alternative if the child does not tolerate TMP/SMX or if there is clinical treatment failure after 5-7 days of TMP/SMX therapy.[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting primaquine, if possible.
Duration of therapy is 21 days.
Primary options
sulfamethoxazole/trimethoprim: children ≥2 months of age: 15-20 mg/kg/day intravenously given in divided doses every 6 hours
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component. Switch to oral dose (same total daily dose given in 3-4 divided doses) in patients with mild-to-moderate disease after acute pneumonitis has resolved.
Secondary options
pentamidine: 4 mg/kg intravenously every 24 hours
More pentamidineA dose reduction may be required if toxicities occur. May switch to a suitable oral regimen (e.g., atovaquone) if there is clinical improvement after 7-10 days.
corticosteroid
Treatment recommended for ALL patients in selected patient group
All patients should be given a corticosteroid, started as early as possible, preferably within the first 72 hours.[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full
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How do adjunctive corticosteroids affect outcomes of Pneumocystis jiroveci pneumonia in patients with HIV?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.998/fullShow me the answer
Primary options
prednisone: 1 mg/kg orally twice daily for 5 days, then 0.5 to 1 mg/kg orally twice daily for 5 days, then 0.5 mg/kg orally once daily for 11 days
Secondary options
prednisone: 40 mg orally twice daily for 5 days, then 40 mg once daily for 5 days, then 20 mg/kg once daily for 11 days
OR
methylprednisolone: 1 mg/kg intravenously every 6 hours on days 1-7, followed by 1 mg/kg every 12 hours on days 8-9, then 0.5 mg/kg every 12 hours on days 10-11, then 1 mg/kg every 24 hours on days 12-16
immunocompromised adults or adolescents: HIV-negative and not solid-organ transplant recipients
pharmacotherapy ± mechanical ventilation
There are specific recommendations for pharmacologic treatment of PCP in patients who do not have HIV infection but are otherwise immunocompromised, for example following transplantation or malignancy.[49]Fishman JA, Gans H, AST Infectious Diseases Community of Practice. Pneumocystis jiroveci in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13587. http://www.ncbi.nlm.nih.gov/pubmed/31077616?tool=bestpractice.com [98]Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128. https://www.atsjournals.org/doi/10.1164/rccm.2008-740ST?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/21193785?tool=bestpractice.com [101]Cooley L, Dendle C, Wolf J, et al. Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. Intern Med J. 2014 Dec;44(12b):1350-63. https://www.doi.org/10.1111/imj.12599 http://www.ncbi.nlm.nih.gov/pubmed/25482745?tool=bestpractice.com Local guidelines should be consulted for information on suitable regimens.
Patients with respiratory compromise should be admitted to the hospital, possibly to the intensive care unit, and may require mechanical ventilation.
The 2010 American Thoracic Society guidelines recommend trimethoprim/sulfamethoxazole (TMP/SMX) as the preferred treatment for PCP in immunocompromised adults. The alternative treatment options include intravenous pentamidine, atovaquone, or clindamycin plus primaquine.[98]Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128. https://www.atsjournals.org/doi/10.1164/rccm.2008-740ST?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/21193785?tool=bestpractice.com Alternative regimens should only be used if the patient does not tolerate TMP/SMX or if there is clinical treatment failure after 4-8 days of TMP/SMX therapy.
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting primaquine or dapsone, if possible.
Duration of therapy is 14-21 days.
Primary options
sulfamethoxazole/trimethoprim: 15-20 mg/kg/day intravenously/orally given in divided doses every 6-8 hours
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
Secondary options
pentamidine: 4 mg/kg intravenously every 24 hours
More pentamidineA dose reduction may be required if toxicities occur.
OR
atovaquone: 750 mg orally twice daily
OR
clindamycin: 600 mg intravenously every 6 hours, or 900 mg every 8 hours; 450 mg orally four times daily, or 600 mg three times daily
and
primaquine phosphate: 30 mg orally once daily
corticosteroid
Treatment recommended for SOME patients in selected patient group
The use of adjuvant corticosteroids in HIV-negative-associated severe PCP has been controversial, with meta-analyses of observational studies reporting conflicting findings regarding mortality, including in hypoxemic patients.[61]Pareja JGR, Garland R, Koziel H. Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia. Chest. 1998 May;113(5):1215-24. http://www.ncbi.nlm.nih.gov/pubmed/9596297?tool=bestpractice.com [103]Injean P, Eells SJ, Wu H, et al. A systematic review and meta-analysis of the data behind current recommendations for corticosteroids in non-HIV-related PCP: knowing when you are on shaky foundations. Transplant Direct. 2017 Feb 15;3(3):e137. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367754 http://www.ncbi.nlm.nih.gov/pubmed/28361121?tool=bestpractice.com [104]Wieruszewski PM, Barreto JN, Frazee E, et al. Early corticosteroids for Pneumocystis pneumonia in adults without HIV are not associated with better outcome. Chest. 2018 Sep;154(3):636-44. https://journal.chestnet.org/article/S0012-3692(18)30648-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29705221?tool=bestpractice.com [105]Inoue N, Fushimi K. Adjunctive corticosteroids decreased the risk of mortality of non-HIV Pneumocystis pneumonia. Int J Infect Dis. 2019 Feb;79:109-15. https://www.ijidonline.com/article/S1201-9712(18)34950-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/30529109?tool=bestpractice.com [106]Ding L, Huang H, Wang H, et al. Adjunctive corticosteroids may be associated with better outcome for non-HIV Pneumocystis pneumonia with respiratory failure: a systemic review and meta-analysis of observational studies. Ann Intensive Care. 2020 Mar 20;10(1):34. https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-020-00649-9 http://www.ncbi.nlm.nih.gov/pubmed/32198645?tool=bestpractice.com [107]Fujikura Y, Manabe T, Kawana A, et al. Adjunctive corticosteroids for Pneumocystis jirovecii pneumonia in non-HIV-infected patients: a systematic review and meta-analysis of observational studies [in Spanish]. Arch Bronconeumol. 2017 Feb;53(2):55-61. https://www.archbronconeumol.org/en-adjunctive-corticosteroids-for-pneumocystis-jirovecii-articulo-S1579212916301872 http://www.ncbi.nlm.nih.gov/pubmed/27616706?tool=bestpractice.com
Primary options
prednisone: 40 mg orally twice daily for 5 days, followed by 40 mg once daily for 5 days, followed by 20 mg once daily for 11 days
OR
methylprednisolone: 30 mg intravenously twice daily for 5 days, followed by 30 mg once daily for 5 days, then 15 mg once daily until patient can be given oral prednisone
immunocompromised adults or adolescents or children: HIV-negative and solid-organ transplant recipients
pharmacotherapy ± mechanical ventilation
There are specific recommendations for pharmacologic treatment of PCP in patients who do not have HIV infection but are otherwise immunocompromised, for example following transplantation.[49]Fishman JA, Gans H, AST Infectious Diseases Community of Practice. Pneumocystis jiroveci in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13587. http://www.ncbi.nlm.nih.gov/pubmed/31077616?tool=bestpractice.com [98]Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128. https://www.atsjournals.org/doi/10.1164/rccm.2008-740ST?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/21193785?tool=bestpractice.com Local guidelines should be consulted for information on suitable regimens.
Patients with respiratory compromise should be admitted to the hospital, possibly to the intensive care unit, and may require mechanical ventilation.
The 2019 American Society of Transplantation guidelines also recommend trimethoprim/sulfamethoxazole (TMP/SMX) as the preferred PCP treatment in children and adult solid-organ transplant recipients.[49]Fishman JA, Gans H, AST Infectious Diseases Community of Practice. Pneumocystis jiroveci in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13587. http://www.ncbi.nlm.nih.gov/pubmed/31077616?tool=bestpractice.com Oral dosing may be considered in mild infections. In severe infections, intravenous pentamidine is the preferred second-line agent after TMP/SMX; however, it should be avoided in pancreas recipients due to the potential for islet cell necrosis. Other options for mild-moderate PCP include atovaquone or clindamycin plus primaquine, and options for mild-moderate or moderate-severe PCP include dapsone plus trimethoprim, or pyrimethamine plus sulfadiazine; however, these combinations regimens have not been studied adequately in children.[49]Fishman JA, Gans H, AST Infectious Diseases Community of Practice. Pneumocystis jiroveci in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13587. http://www.ncbi.nlm.nih.gov/pubmed/31077616?tool=bestpractice.com
All patients should be checked for glucose-6-phosphate dehydrogenase (G6PD) deficiency prior to starting primaquine or dapsone, if possible.
Duration of therapy is 14-21 days.
Primary options
sulfamethoxazole/trimethoprim: children ≥2 months of age: 15-20 mg/kg/day intravenously/orally given in divided doses every 6-8 hours; adolescents and adults: 15-20 mg/kg/day intravenously/orally given in divided doses every 6-8 hours, or 320 mg orally three times daily
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
Secondary options
pentamidine: children, adolescents, and adults: 4 mg/kg intravenously every 24 hours
More pentamidineA dose reduction may be required if toxicities occur.
Tertiary options
atovaquone: children 1-3 months of age: 30-40 mg/kg/day orally given in 1-2 divided doses, maximum 1500 mg/day; children 4-24 months of age: 45 mg/kg/day orally given in 1-2 divided doses, maximum 1500 mg/day; children >24 months of age: 30-40 mg/kg/day orally given in 1-2 divided doses, maximum 1500 mg/day; adolescents and adults: 750-1500 mg orally twice daily
OR
dapsone: 100 mg orally once daily
and
trimethoprim: 15 mg/kg/day orally given in 3 divided doses
OR
clindamycin: 600-900 mg intravenously/orally every 6-8 hours
and
primaquine phosphate: 15-30 mg orally once daily
OR
pyrimethamine: consult specialist for guidance on dose
and
sulfadiazine: consult specialist for guidance on dose
corticosteroid
Treatment recommended for SOME patients in selected patient group
The use of adjuvant corticosteroids in HIV-negative-associated severe PCP has been controversial, with meta-analyses of observational studies reporting conflicting findings regarding mortality, including in hypoxemic patients.[61]Pareja JGR, Garland R, Koziel H. Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia. Chest. 1998 May;113(5):1215-24. http://www.ncbi.nlm.nih.gov/pubmed/9596297?tool=bestpractice.com [103]Injean P, Eells SJ, Wu H, et al. A systematic review and meta-analysis of the data behind current recommendations for corticosteroids in non-HIV-related PCP: knowing when you are on shaky foundations. Transplant Direct. 2017 Feb 15;3(3):e137. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367754 http://www.ncbi.nlm.nih.gov/pubmed/28361121?tool=bestpractice.com [104]Wieruszewski PM, Barreto JN, Frazee E, et al. Early corticosteroids for Pneumocystis pneumonia in adults without HIV are not associated with better outcome. Chest. 2018 Sep;154(3):636-44. https://journal.chestnet.org/article/S0012-3692(18)30648-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29705221?tool=bestpractice.com [105]Inoue N, Fushimi K. Adjunctive corticosteroids decreased the risk of mortality of non-HIV Pneumocystis pneumonia. Int J Infect Dis. 2019 Feb;79:109-15. https://www.ijidonline.com/article/S1201-9712(18)34950-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/30529109?tool=bestpractice.com [106]Ding L, Huang H, Wang H, et al. Adjunctive corticosteroids may be associated with better outcome for non-HIV Pneumocystis pneumonia with respiratory failure: a systemic review and meta-analysis of observational studies. Ann Intensive Care. 2020 Mar 20;10(1):34. https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-020-00649-9 http://www.ncbi.nlm.nih.gov/pubmed/32198645?tool=bestpractice.com [107]Fujikura Y, Manabe T, Kawana A, et al. Adjunctive corticosteroids for Pneumocystis jirovecii pneumonia in non-HIV-infected patients: a systematic review and meta-analysis of observational studies [in Spanish]. Arch Bronconeumol. 2017 Feb;53(2):55-61. https://www.archbronconeumol.org/en-adjunctive-corticosteroids-for-pneumocystis-jirovecii-articulo-S1579212916301872 http://www.ncbi.nlm.nih.gov/pubmed/27616706?tool=bestpractice.com
Primary options
prednisone: children: 1 mg/kg orally twice daily for 5 days, followed by 0.5 mg/kg twice daily for 5 days, then 0.5 mg/kg once daily for 10 days; adults: 40-60 mg orally two to three times daily for 5-7 days, then taper over 1-2 weeks
completed successful treatment of PCP infection
secondary prophylaxis
Patients who have had PCP infection, who have been treated and are without symptoms receive secondary prophylaxis, which conforms to the same schedule as primary prophylaxis for each patient group.
Secondary prophylaxis is recommended for HIV-positive patients who have had PCP and should be started after completion of PCP treatment and continued until immune reconstitution occurs with antiretroviral therapy.[22]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/pediatric-opportunistic-infection/pneumocystis-jirovecii-pneumonia?view=full [32]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/pneumocystis-pneumonia
Secondary prophylaxis can be discontinued for most patients using the same criteria as for discontinuing primary prophylaxis. PCP prophylaxis should not be discontinued in HIV-infected infants ages <1 year. Prophylaxis should be continued for life in patients who develop PCP despite CD4 count >200 cells/microliter.
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