What is the treatment for Pneumocystis jirovecii pneumonia (PCP pneumonia)?

From the Guidelines

PCP pneumonia should be treated with high-dose trimethoprim-sulfamethoxazole (TMP-SMX) at a dosage of TMP 15–20 mg/kg plus SMX 75–100 mg/kg daily for at least 2 weeks. This treatment should be initiated immediately after obtaining representative samples, such as induced sputum or BAL, as treatment delay may enhance mortality 1. In mild-to-moderate cases, oral therapy can be discussed, otherwise, it should be administered intravenously.

Key Considerations

• Clinical improvement should develop within 8 days, otherwise, a second infection should be considered and diagnostic procedures repeated 1.
• In patients with proven PcP, treatment with TMP-SMX should be continued for at least 2 weeks 1.
• For patients who cannot tolerate TMP-SMX, alternatives include atovaquone oral suspension, intravenous pentamidine, or clindamycin plus primaquine 1.
• Glucose-6-phosphate dehydrogenase deficiency must be excluded before administration of dapsone or primaquine 1.

Prophylaxis and Adjunctive Therapy

• Patients who have been successfully treated for PcP should receive secondary oral prophylaxis to prevent PcP recurrence, with intermittent TMP/SMX or monthly aerosolized pentamidine being the drugs of choice 1.
• Adjunctive corticosteroids may be beneficial in AIDS patients with respiratory failure due to PcP, but their use in non-HIV patients is not generally recommended and should only be considered in individual patients 1.

Treatment Alternatives

• Atovaquone oral suspension, intravenous pentamidine, or clindamycin plus primaquine may be used as alternative treatments for PcP in patients who cannot tolerate TMP-SMX 1.
• Clindamycin plus primaquine is the preferred alternative for patients intolerant of or refractory to high-dose TMP/SMX 1.

From the FDA Drug Label

Pneumocystis Jiroveci Pneumonia Treatment: Adults and Children The recommended dosage for treatment of patients with documented Pneumocystis jiroveci pneumonia is 75 to 100 mg/kg sulfamethoxazole and 15 to 20 mg/kg trimethoprim per 24 hours given in equally divided doses every 6 hours for 14 to 21 days

The treatment for Pneumocystis jirovecii pneumonia (PCP pneumonia) is sulfamethoxazole and trimethoprim. The recommended dosage is 75 to 100 mg/kg sulfamethoxazole and 15 to 20 mg/kg trimethoprim per 24 hours, given in equally divided doses every 6 hours for 14 to 21 days 2.

From the Research

Treatment Options for Pneumocystis jirovecii Pneumonia (PCP)

• The primary treatment for PCP is trimethoprim-sulfamethoxazole (TMP-SMX) 3, 4, 5, 6, 7
• The recommended dose of TMP-SMX is 15-20 mg/kg/day of trimethoprim and 75-100 mg/kg/day of sulfamethoxazole 3, 6
• However, lower doses of TMP-SMX (10 mg/kg/day of trimethoprim and 50 mg/kg/day of sulfamethoxazole) have been shown to be effective and associated with fewer adverse effects 5, 6, 7
• Pentamidine isethionate is an alternative treatment for PCP, particularly for patients who are intolerant to TMP-SMX 3, 4
• The recommended dose of pentamidine isethionate is 4 mg/kg/day, administered intravenously or intramuscularly 3

Efficacy and Safety of Treatment Regimens

• A systematic review and network meta-analysis found that clindamycin/primaquine, intravenous pentamidine, and TMP-SMX were ranked as the best treatments for PCP in terms of treatment failure 4
• The same study found that TMP-SMX was superior to atovaquone in terms of all-cause mortality, but no treatment was superior in the full network analysis 4
• A retrospective cohort study found that low-dose TMP-SMX was associated with reduced adverse events and similar survival rates compared to conventional-dose TMP-SMX in patients with non-HIV PCP 7

Alternative Treatment Regimens

• Dapsone-TMP and inhaled pentamidine have been shown to be effective and well-tolerated alternative treatments for PCP 4
• Atovaquone and trimetrexate have also been used as alternative treatments for PCP, although their efficacy and safety are not as well established 3, 4
• Corticosteroids may be considered as a last resort for patients with severe PCP, although their use is not well established 3