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
400/80 mg qd po or
800/160 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
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
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

 

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
30 mg (base) qd po

Check for G6PD deficiency

+ clindamycin
600-900 mg tid po

or
atovaquone suspension
750 mg bid po (with food)
 

or
dapsone

100 mg qd po

Check for G6PD deficiency.

In case of rash: reduce dose of TMP (50%), antihistamines

+ trimethoprim
5 mg/kg tid po

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