From the Guidelines
PJP prophylaxis is indicated for patients with certain underlying conditions, including allogeneic hematopoietic cell transplant (HCT) recipients, those with acute lymphoblastic leukemia (ALL), and individuals at high risk for Pneumocystis jirovecii infection, such as those receiving select PI3K inhibitors or rituximab, as well as patients on prolonged high-dose corticosteroids (equivalent to prednisone ≥20 mg daily for ≥4 weeks) 1. The primary goal of PJP prophylaxis is to prevent this opportunistic infection in immunocompromised patients, thereby reducing morbidity, mortality, and improving quality of life.
Key Indications for PJP Prophylaxis
- Allogeneic HCT recipients: for at least 6 months and while receiving immunosuppressive therapy (IST) 1
- Acute lymphoblastic leukemia (ALL) patients: for a minimum of 2 months, especially those receiving alemtuzumab 1
- High-risk patients: including those on select PI3K inhibitors +/- rituximab, for at least through active treatment 1
- Patients on prolonged high-dose corticosteroids: equivalent to prednisone ≥20 mg daily for ≥4 weeks 1
Recommended Prophylactic Agents
- Trimethoprim/sulfamethoxazole (TMP/SMX) is the preferred agent for PJP prophylaxis, due to its efficacy and broad-spectrum activity against other pathogens, including Nocardia, Toxoplasma, and Listeria 1
- Alternative options for patients intolerant to TMP/SMX include atovaquone, dapsone, or pentamidine (aerosolized or IV) 1
Duration of Prophylaxis
- PJP prophylaxis should be continued until recovery from lymphocytopenia or until the patient is no longer at high risk for Pneumocystis jirovecii infection 1
- For HIV patients, prophylaxis can be discontinued when CD4 counts are above 200 cells/μL for at least 3-6 months on antiretroviral therapy, but this is not directly applicable to the provided evidence 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 Pneumocystis jirovecii pneumonia (PJP) prophylaxis are:
- Prevention of PJP in adults and adolescents (aged 13 years and older) who cannot tolerate trimethoprim-sulfamethoxazole (TMP-SMX) 2. Key points:
- The recommended oral dosage for PJP prophylaxis is 1,500 mg (10 mL) once daily administered with food.
- Atovaquone oral suspension is contraindicated in patients with a history of hypersensitivity reactions to atovaquone or any of its components.
From the Research
Indications for PJP Prophylaxis
The following groups are at high risk of developing Pneumocystis jirovecii pneumonia (PJP) and may require prophylaxis:
- HIV-infected patients with a low CD4 count 3
- Haematopoietic stem cell and solid organ transplant recipients 3, 4
- Patients with cancer, particularly haematologic malignancies 3, 4
- Patients receiving glucocorticoids, chemotherapeutic agents, and other immunosuppressive medications 3, 4
- Patients with certain autoimmune diseases, such as Wegener granulomatosis 5
Special Considerations
- Patients on high-dose, chronic corticosteroid therapy without AIDS may also be at risk of PJP, although the benefit of prophylaxis in this group is still controversial 6
- Patients with immunosuppressive diseases, such as sarcoidosis, cryptogenic organizing pneumonia, interstitial lung disease, asthma, and chronic obstructive pulmonary disease, may require PJP prophylaxis if they are on immunosuppressive therapy 6, 7
Prophylaxis Recommendations
- Trimethoprim-sulfamethoxazole is the established first-line agent for prevention and treatment of PJP 3, 5, 4, 7
- Dapsone is considered a suitable second-line agent for PJP prophylaxis in patients who cannot tolerate trimethoprim-sulfamethoxazole 3
- Prophylaxis is highly effective and should be given to all patients at moderate to high risk of PJP 4