From the Guidelines
The recommended prophylaxis regimen for Pneumocystis jirovecii pneumonia (PJP) is trimethoprim-sulfamethoxazole (TMP-SMX) as the first-line agent, due to its high efficacy in preventing PJP and broad antimicrobial coverage, as supported by the most recent guidelines 1.
Key Points
- The standard adult dosage of TMP-SMX is one double-strength tablet (160 mg TMP/800 mg SMX) daily or three times weekly.
- For patients who cannot tolerate TMP-SMX, alternative options include dapsone 100 mg daily, aerosolized pentamidine 300 mg monthly via nebulizer, or atovaquone 1500 mg daily with food, as recommended by the NCCN guidelines 1.
- PJP prophylaxis is indicated for immunocompromised patients, including those with HIV infection with CD4 counts below 200 cells/μL, patients on prolonged high-dose corticosteroids, those receiving certain immunosuppressive medications for cancer or transplantation, and patients with primary immunodeficiency disorders.
- Prophylaxis should continue until immune function is adequately restored, such as sustained CD4 counts above 200 cells/μL for at least 3-6 months in HIV patients on antiretroviral therapy.
Patient Groups Requiring PJP Prophylaxis
- Allogeneic HCT recipients
- Patients receiving CAR T-cell therapy for at least 6 months and while receiving IST
- Patients with ALL throughout antileukemic therapy
- Patients receiving treatment with select phosphatidylinositol-3-kinase inhibitors + rituximab
- Patients with neoplastic diseases receiving intensive corticosteroid treatment
- Patients receiving temozolomide, as outlined in the NCCN guidelines 1.
Important Considerations
- TMP-SMX has the potential advantage of activity against other infectious complications, such as common bacterial infections, listeriosis, nocardiosis, and toxoplasmosis.
- Atovaquone appears to be equivalent to dapsone in HIV patients who cannot tolerate TMP-SMX, as reported in the guidelines 1.
- Measurement of G6PD levels is recommended before the start of dapsone therapy to avoid hemolytic adverse reactions.
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 recommended oral dosage is 1,500 mg (10 mL) once daily administered with food.
The recommended prophylaxis regimen for Pneumocystis jirovecii pneumonia (PJP) with atovaquone is 1,500 mg (10 mL) once daily administered with food, for adults and adolescents (aged 13 years and older) who cannot tolerate trimethoprim-sulfamethoxazole (TMP-SMX) 2.
- Key points:
- Atovaquone is used for PJP prophylaxis in patients who cannot tolerate TMP-SMX.
- The dosage is 1,500 mg (10 mL) once daily.
- It should be administered with food to ensure adequate absorption.
From the Research
PJP Prophylaxis Regimens
The recommended prophylaxis regimen for Pneumocystis jirovecii pneumonia (PJP) includes:
- Trimethoprim-sulfamethoxazole (TMP-SMX) as the first-line agent 3, 4, 5, 6
- Alternative options for patients with a history of allergy or severe intolerance to TMP-SMX: pentamidine, dapsone, or atovaquone 3, 5, 7
TMP-SMX Dosage
- The conventional dose of TMP-SMX is 15-20 mg/kg/d of trimethoprim 4, 6
- Reduced doses of TMP-SMX (≤10 mg/kg/d of trimethoprim) may be effective and carry an improved safety profile 4, 6
Alternative Prophylaxis Options
- Intravenous pentamidine (IV PEN) has been shown to be effective and well-tolerated for PJP prophylaxis in adult HSCT recipients 7
- Other alternative options include dapsone, atovaquone, and clindamycin 3, 5