What are the indications for Pneumocystis jirovecii pneumonia (PJP) prophylaxis?

From the Guidelines

Pneumocystis jirovecii pneumonia (PJP) prophylaxis is recommended for immunocompromised patients at high risk for developing this opportunistic infection, including HIV-infected individuals with CD4 counts below 200 cells/μL, those with a history of oropharyngeal candidiasis, or those with an AIDS-defining illness regardless of CD4 count, as well as non-HIV immunocompromised patients such as solid organ transplant recipients, hematopoietic stem cell transplant recipients, and patients receiving prolonged high-dose corticosteroids or specific immunosuppressive medications 1.

Indications for PJP Prophylaxis

• HIV-infected individuals with CD4 counts below 200 cells/μL
• Those with a history of oropharyngeal candidiasis
• Those with an AIDS-defining illness regardless of CD4 count
• Non-HIV immunocompromised patients, including:
  • Solid organ transplant recipients
  • Hematopoietic stem cell transplant recipients
  • Patients receiving prolonged high-dose corticosteroids (equivalent to prednisone ≥20 mg daily for ≥3 weeks)
  • Patients on specific immunosuppressive medications like TNF-alpha inhibitors
  • Those with certain hematologic malignancies, particularly during intensive chemotherapy

First-Line Prophylactic Agent

• Trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of one double-strength tablet daily or one single-strength tablet daily 1

Alternative Options for Patients with Sulfa Allergies

• Dapsone 100 mg daily
• Aerosolized pentamidine 300 mg monthly
• Atovaquone 1500 mg daily

Duration of Prophylaxis

• Prophylaxis should continue until immune reconstitution occurs, typically when CD4 counts remain above 200 cells/μL for at least 3-6 months in HIV patients, or until immunosuppressive therapy is significantly reduced in other patients 1

Importance of PJP Prophylaxis

• PJP prophylaxis is critical because the mortality rate of PJP infection in immunocompromised patients can exceed 30-50%, and prevention is more effective than treatment once infection occurs 1

From the FDA Drug Label

Atovaquone oral suspension is indicated for the prevention of Pneumocystis jirovecii pneumonia (PCP) in adults and adolescents (aged 13 years and older) who cannot tolerate trimethoprim-sulfamethoxazole (TMP-SMX). The indications for PJP prophylaxis are:

• Prevention of Pneumocystis jirovecii pneumonia (PCP) in adults and adolescents (aged 13 years and older) who cannot tolerate trimethoprim-sulfamethoxazole (TMP-SMX) 2. Key points:
• Atovaquone oral suspension is used for PJP prophylaxis in patients who cannot tolerate TMP-SMX.
• The recommended oral dosage for PJP prophylaxis is 1,500 mg (10 mL) once daily administered with food 2.

From the Research

Indications for PJP Prophylaxis

The indications for Pneumocystis jirovecii pneumonia (PJP) prophylaxis are as follows:

• HIV-infected patients with a CD4 count <200 cells/mm3 3
• Persons with CD4 percentage (CD4%) below 14% should also be considered for prophylaxis 3
• Patients with oropharyngeal candidiasis 3
• Virally suppressed patients on antiretroviral therapy (ART) with a CD4 count >100 cells/µL may not require secondary PJP prophylaxis 4, 5, 6

Special Considerations

• Discordance between CD4 count and CD4% occurs in 16% to 25% of HIV-infected patients, and provider compliance with current PJP prophylaxis guidelines when such discordance is present should be assessed 3
• The incidence of PJP among HIV-infected patients who discontinued primary PJP prophylaxis and were well controlled on ART is low 5, 6
• Decisions to discontinue PJP prophylaxis in patients with a CD4 count <200 cells/mm3 should be done on an individual patient basis, taking into consideration clinical factors, including ongoing adherence to ART 5

Guidelines and Recommendations

• Current guidelines suggest that primary prophylaxis for PJP can be safely stopped in HIV-infected patients who are receiving combined antiretroviral therapy (cART) and who have a CD4 cell count >200 cells/microL 6
• The US treatment guidelines recommend PJP prophylaxis for all HIV-infected persons with a CD4 count <200 cells/mm3, but some studies suggest PJP prophylaxis may be unnecessary in virally suppressed patients 7
• European guidelines recommend discontinuing secondary PJP prophylaxis only if CD4 counts rise above 200 cells/mL, while the latest US Guidelines consider secondary prophylaxis discontinuation even in patients with a CD4 count above 100 cells/µL and suppressed viral load 4