What is the management of Pneumocystis jiroveci (Pneumocystis jirovecii) pneumonia?

From the Guidelines

The management of Pneumocystis jirovecii pneumonia (PJP) primarily involves trimethoprim-sulfamethoxazole (TMP-SMX) as first-line therapy, with a recommended dose of TMP 15-20 mg/kg/day and SMX 75-100 mg/kg/day, divided into 3-4 doses daily for 21 days, as supported by the most recent study 1. For moderate to severe cases, adjunctive corticosteroids (prednisone 40 mg twice daily for 5 days, then 40 mg daily for 5 days, followed by 20 mg daily for 11 days) should be added for patients with moderate to severe disease (PaO2 <70 mmHg or A-a gradient >35 mmHg). Some key points to consider in the management of PJP include:

• Alternative treatments for patients who cannot tolerate TMP-SMX include intravenous pentamidine (4 mg/kg once daily), clindamycin (600 mg IV every 8 hours) plus primaquine (30 mg oral daily), or atovaquone (750 mg oral twice daily) 1.
• Supportive care including oxygen supplementation and ventilatory support may be necessary.
• Treatment should be continued for the full 21-day course regardless of clinical improvement.
• PJP is caused by the fungus Pneumocystis jirovecii, which primarily affects immunocompromised individuals, particularly those with HIV/AIDS with CD4 counts below 200 cells/μL, and the treatment aims to eliminate the organism while managing inflammatory responses that can worsen lung injury. The most recent and highest quality study 1 provides the best evidence for the management of PJP, and its recommendations should be followed in clinical practice. Other studies, such as 1, 1, 1, 1, and 1, also provide relevant information on the management of PJP, but the study 1 is the most recent and highest quality, and its recommendations should be prioritized.

From the FDA Drug Label

The recommended dosage for treatment of patients with documented Pneumocystis jirovecii pneumonia is 75 mg/kg to 100 mg/kg sulfamethoxazole and 15 mg/kg to 20 mg/kg trimethoprim per 24 hours given in equally divided doses every 6 hours for 14 to 21 days Atovaquone oral suspension is indicated for the acute oral treatment of mild-to-moderate PCP in adults and adolescents (aged 13 years and older) who cannot tolerate TMP-SMX

The management of Pneumocystis jirovecii pneumonia includes:

• Treatment with sulfamethoxazole and trimethoprim: 75 mg/kg to 100 mg/kg sulfamethoxazole and 15 mg/kg to 20 mg/kg trimethoprim per 24 hours given in equally divided doses every 6 hours for 14 to 21 days 2
• Treatment with atovaquone: for mild-to-moderate PCP in adults and adolescents (aged 13 years and older) who cannot tolerate trimethoprim-sulfamethoxazole (TMP-SMX) 3 Key considerations:
• Sulfamethoxazole and trimethoprim is the recommended treatment for PCP
• Atovaquone is an alternative treatment for mild-to-moderate PCP in patients who cannot tolerate TMP-SMX

From the Research

Management of Pneumocystis jiroveci Pneumonia

The management of Pneumocystis jiroveci pneumonia (PCP) involves the use of antimicrobial therapy, with trimethoprim-sulfamethoxazole (TMP-SMX) being the first-line treatment 4, 5, 6, 7, 8.

• The recommended dose of TMP-SMX is 15-20 mg/kg/day of trimethoprim and 75-100 mg/kg/day of sulfamethoxazole for 2 or 3 weeks 4.
• However, studies have shown that lower doses of TMP-SMX, such as 10-15 mg/kg/day of trimethoprim, can be effective and may reduce the risk of adverse events 4, 8.
• In patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency, low-dose TMP-SMX can be used with caution, and enzyme activity detection is recommended before treatment 6.
• Alternative treatments, such as pentamidine, atovaquone, clindamycin, and primaquine, can be used in patients who are intolerant to TMP-SMX or have failed first-line treatment 5, 7.
• The treatment duration is typically 3 weeks, and secondary anti-PCP prophylaxis is indicated in all patients thereafter 7.
• In patients with critical respiratory failure, non-invasive ventilation and intubation with mechanical ventilation can be used, and the administration of glucocorticoids should be decided on a case-by-case basis 7.

Treatment Outcomes

• Studies have shown that treatment with TMP-SMX can result in high cure rates of PCP, with a 30-day mortality rate of 13% 4.
• The use of low-dose TMP-SMX has been associated with similar rates of mortality compared to standard doses, but with significantly fewer treatment-emergent severe adverse events 8.
• The relapse rate of PCP is low, with one study reporting a relapse rate of 4% in patients who were switched to low-dose TMP-SMX 4.

Special Considerations

• In patients with haematological malignancies, PCP can present with severe symptoms, and antimicrobial therapy should be started intravenously 7.
• In patients with G6PD deficiency, treatment with oxidizing drugs, such as sulfonamides, should be used with caution, and enzyme activity detection is recommended before treatment 6.