From the Guidelines
Pneumocystis pneumonia (PCP) prophylaxis is strongly recommended for renal transplant recipients receiving prednisone, with trimethoprim-sulfamethoxazole (TMP-SMX) as the first-line agent, typically dosed at one single-strength tablet (80mg/400mg) daily or one double-strength tablet (160mg/800mg) three times weekly, as supported by the most recent evidence 1. The recommended duration of prophylaxis is at least 6-12 months post-transplant, but many centers recommend lifelong prophylaxis while patients remain on immunosuppression, especially with prednisone doses above 7.5-10mg daily. Key points to consider include:
- The risk of PCP infection is significantly increased in patients receiving high doses of glucocorticoids, especially in combination with immunosuppressants 1.
- Alternative prophylactic medications include atovaquone, dapsone, or nebulised pentamidine, which may be considered in patients with sulfa allergies or significant renal dysfunction 1.
- Dose adjustments may be necessary based on renal function, as transplant recipients often have varying degrees of allograft function.
- Regular monitoring of renal function and medication side effects is essential while on prophylaxis. The evidence from 1 suggests that prophylaxis for PCP has been mostly examined in patients treated with glucocorticoids, and the minimum dose and duration of glucocorticoid treatment above which prophylaxis is recommended is not defined, but evidence suggests that in daily doses >15–30 mg of prednisolone or equivalent for >2–4 weeks, prophylaxis is beneficial. In the context of renal transplant recipients, the guidelines from 1 recommend that all kidney transplant recipients receive PCP prophylaxis with daily trimethoprim-sulfamethoxazole for 3–6 months after transplantation, and for at least 6 weeks during and after treatment for acute rejection. However, the most recent evidence from 1 takes precedence, and trimethoprim-sulfamethoxazole (TMP-SMX) is the recommended first-line agent for PCP prophylaxis in renal transplant recipients receiving prednisone.
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 PCP prophylaxis for a patient with a renal transplant who is currently taking prednisone (a corticosteroid) is atovaquone 1,500 mg (10 mL) once daily with food if they cannot tolerate trimethoprim-sulfamethoxazole (TMP-SMX) 2.
- Key points:
- Atovaquone is used for PCP prevention in patients who cannot tolerate TMP-SMX.
- The recommended dosage is 1,500 mg (10 mL) once daily with food.
- Food administration is crucial to avoid lower plasma atovaquone concentrations.
From the Research
Pneumocystis jirovecii Pneumonia Prophylaxis
The recommended prophylaxis for Pneumocystis jirovecii pneumonia (PCP) in patients with a renal transplant who are taking prednisone (a corticosteroid) is trimethoprim-sulfamethoxazole (TMP-SMX) 3, 4, 5.
Dosage and Duration
- The dosage of TMP-SMX can be 80/400 mg/day or 160/800 mg every other day, for at least 4 months 3.
- A low-dose prophylactic regimen of 1 single-strength tablet 3 times weekly is also well tolerated 6.
- Extending the duration of TMP-SMX prophylaxis from 3 to 6 months after transplant may be beneficial in preventing PCP without increasing adverse events 5.
Alternative Prophylaxis
- In cases of TMP-SMX intolerance, aerosolized pentamidine (300 mg once or twice per month) is an alternative for prophylaxis 3.
- Atovaquone is also an effective alternative for PCP prophylaxis in renal transplant recipients, with comparable rates of infections and lower rates of leukopenia and hyperkalemia compared to TMP-SMX 7.