Pneumocystis jirovecii Pneumonia
Last Updated: November 6, 2013; Last Reviewed: November 6, 2013
Panel's Recommendations for Pneumocystis jirovecii Pneumonia
Prevention of Primary Exposure
- Some experts recommend that consideration be given to not placing a patient with Pneumocystis jirovecii pneumonia (PCP) in a hospital room with another patient and not placing an at-risk immunocompromised patient in a room with a patient who has a respiratory tract infection (BIII).
- Chemoprophylaxis is highly effective in preventing PCP. Prophylaxis is recommended for all HIV-infected children aged ≥6 years who have CD4 T lymphocyte (CD4) cell counts <200 cells/mm3 or CD4 percentage <15%, for children aged 1 to <6 years with CD4 counts <500 cells/mm3 or CD4 percentage <15%, and for all HIV-infected infants aged <12 months regardless of CD4 count or percentage (AII).
- Infants with indeterminate HIV infection status should receive prophylaxis until they are determined to be HIV-uninfected or presumptively HIV-uninfected (AIII). HIV-infected infants should be administered prophylaxis until age 1 year, at which time they should be reassessed on the basis of the age-specific CD4 count or percentage thresholds mentioned above (AII).
- Trimethoprim–sulfamethoxazole (TMP–SMX; cotrimoxazole), administered either on 3 consecutive days/week or daily, is the drug of choice for prophylaxis because of its high efficacy, relative safety, low cost, and broad antimicrobial spectrum (AI).
- Other effective and safe prophylaxis regimens are available for patients unable to take TMP-SMX. A second choice would be either atovaquone (AI) or dapsone (BI*).
- Aerosolized pentamidine is recommended for children who cannot take TMP-SMX, atovaquone, or dapsone and who are old enough to use nebulization with a Respirgard II® nebulizer (Marquest; Englewood, CO) (BI*).
- Intravenous (IV) pentamidine is not recommended for prophylaxis unless no other options are available (BII).
- Discontinuation of PCP prophylaxis should be considered for HIV-infected children when, after receiving combination antiretroviral therapy for ≥6 months, CD4 percentage is ≥15% or CD4 count is ≥200 cells/mm3 for patients aged ≥ 6 years (BII) and CD4 percentage is ≥15% or CD4 count is ≥500 cells/mm3 for patients aged 1 to <6 years (BII) for >3 consecutive months. Thereafter, CD4 percentage and CD4 count should be reevaluated at least every 3 months and prophylaxis reinstituted if the age-specific criteria for prophylaxis are reached (BIII).
- TMP-SMX, administered IV, is the recommended treatment for PCP (AI). As the acute pneumonitis subsides, children with mild-to-moderate disease who do not have malabsorption or diarrhea can be transitioned to oral treatment with the same total daily dose of TMP-SMX administered in 3 or 4 divided doses to complete a 21-day course (AII).
- IV pentamidine isethionate once daily is recommended for patients who cannot tolerate TMP-SMX or who demonstrate clinical treatment failure after 5 to 7 days of TMP-SMX therapy (AI*).
- Atovaquone is an alternative for treatment of mild-to-moderately severe PCP (BI*).
- Dapsone/TMP is effective in treating mild-to-moderate PCP (BI*).
- Clindamycin/primaquine has been used to treat mild-to-moderate PCP; data in children are unavailable (BIII).
- A short course of corticosteroids is recommended in cases of moderate or severe PCP, starting within 72 hours of diagnosis (AI*).
- Patients who have experienced an episode of PCP should continue on PCP prophylaxis after completion of treatment until CD4 counts exceed the threshold for initiating prophylaxis (AI).
- Children who present with clinical signs and symptoms compatible with PCP after discontinuation of prophylaxis should be evaluated thoroughly despite normal or high CD4 counts or percentages (BI*).
Dosing Recommendations for Prevention and Treatment of Pneumocystis Pneumonia
- TMP-SMX (Cotrimoxazole): TMP 2.5–5 mg/kg body weight/dose with SMX 12.5–25 mg/kg body weight/dose twice per day. Dosing based on TMP component.
- The total daily dose should not exceed 320 mg TMP and 1600 mg SMX. Several dosing schemes have been used successfully—
- Given 3 days per week on consecutive days or on alternate days
- Given 2 days per week on consecutive days or on alternate days
- Given every day (total daily dose of TMP 5–10 mg/kg body weight given as a single dose each day)
Children aged ≥1 months:
- 2 mg/kg body weight (maximum 100 mg) by mouth once daily or 4 mg/kg body weight (maximum 200 mg) by mouth once weekly
Children Aged 1–3 Months and >24 Months–12 Years:
Children Aged 4–24 Months:
- 30-40 mg/kg body weight/dose by mouth once daily with food
Children Aged ≥13 Years:
- 45 mg/kg body weight/dose by mouth once daily with food
- 1500 mg (10 cc oral yellow suspension) per dose by mouth once daily
Children Aged ≥5 Years:
- 300 mg every month via Respirgard II™ nebulizer (manufactured by Marquest; Englewood, Colorado)
|Primary Prophylaxis Indicated For:
Criteria for Discontinuing Primary Prophylaxis:
- All HIV-infected or HIV-indeterminate infants from aged 4–6 weeks to 12 months regardless of CD4 cell count/percentage
- HIV-infected children aged 1 to <6 years with CD4 count <500 cells/mm3 or CD4 percentage <15%; HIV-infected children aged 6–12 years with CD4 count <200 cells/mm3 or CD4 percentage <15%
Note: Do not discontinue in HIV-infected children aged <1 year
After ≥6 Months of cART:
Criteria for Restarting Primary Prophylaxis:
- Aged 1 to <6 years; CD4 percentage ≥15% or CD4 count is ≥500 cells/mm3 for >3 consecutive months, or
- Aged ≥6 years, CD4 percentage ≥15% or CD4 count is ≥200 cells/mm3 for >3 consecutive months
- Aged 1 to < 6 years with CD4 percentage <15 or CD4 count <500 cells/mm3
- Aged ≥6 years with CD4 percentage <15% or CD4 count <200 cells/mm3
|Same as for primary prophylaxis.
||Same as for primary prophylaxis.
||Secondary Prophylaxis Indicated For:
Criteria for Discontinuing Secondary Prophylaxis:
- Children with prior episode of PCP
Criteria for Restarting Secondary Prophylaxis:
- Same as for primary prophylaxis
- Same as for primary prophylaxis
||TMP-SMX 3.75–5 mg/kg body weight/dose TMP (based on TMP component) every 6 hours IV or orally given for 21 days (followed by secondary prophylaxis dosing)
||If TMP-SMX-Intolerant or Clinical Treatment Failure After 5–7 Days of TMP-SMX Therapy
- 4 mg/kg body weight/dose IV/IM once daily is the first choice alternative regimen. Note: Pentamidine can be changed to atovaquone after 7–10 days IV therapy.
- Children aged 1–3 months and >24 months–12 years: 30-40 mg/kg body weight/dose by mouth once daily with food
- Children aged 4–24 months: 45 mg/kg body weight/dose by mouth once daily with food
- Children aged ≥13 years: 750 mg/dose by mouth twice daily
|After acute pneumonitis resolved in mild-moderate disease, IV TMP-SMX can be changed to oral. For oral administration, total daily dose of TMP-SMX can also be administered in 3 divided doses (every 8 hours).
Dapsone 2 mg/kg body weight by mouth once daily (maximum 100 mg/day) plus trimethoprim 5 mg/kg body weight by mouth every 8 hours has been used in adults but data in children are limited.
Primaquine base 0.3 mg/kg body weight by mouth once daily (maximum 30 mg/day) plus clindamycin 10 mg/kg body weight/dose IV or by mouth (maximum 600 mg given IV and 300–450 mg given orally) every 6 hours has been used in adults, but data in children are not available.
Indications for Corticosteroids:
- PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >35 mm Hg
Alternative Corticosteroid Regimens Include:
- 1 mg/kg body weight/dose by mouth twice daily for 5 days, then
- 0.5–1 mg/kg body weight/dose by mouth twice daily for 5 days, then
- 0.5 mg/kg body weight by mouth once daily for days 11 to 21.
Chronic suppressive therapy (secondary prophylaxis) with TMP/SMX is recommended in children and adults following initial therapy (see Secondary Prophylaxis).
- Adult dosage of prednisone: 40 mg/dose twice daily on days 1–5, 40 mg/dose once daily on days 6–10, 20 mg/dose once daily on days 11–21, and
- Methylprednisolone IV 1 mg/kg/dose every 6 hours on days 1–7, 1 mg/kg/dose twice daily on days 8–9, 0.5 mg/kg/dose twice daily on days 10 and 11, and 1 mg/kg/dose once daily on days 12–16.