From the Guidelines
PJP prophylaxis is recommended for all patients, with trimethoprim-sulfamethoxazole, dapsone, or atovaquone as the preferred agents, according to the most recent evidence from 2024 1. The first-line agent for PJP prophylaxis is trimethoprim-sulfamethoxazole (TMP-SMX), given as one double-strength tablet (160mg/800mg) daily or three times weekly.
- For patients who cannot tolerate TMP-SMX due to allergies or side effects, alternatives include:
- Dapsone 100mg daily
- Atovaquone 1500mg daily with food
- Aerosolized pentamidine 300mg monthly Prophylaxis should continue until immune reconstitution occurs, typically when CD4 counts remain above 200 cells/μL for at least 3-6 months on effective antiretroviral therapy for HIV patients, or when immunosuppressive therapy is discontinued for other conditions.
- TMP-SMX is preferred because it also provides protection against toxoplasmosis and some bacterial infections, as noted in the 2024 study 1. Monitoring for side effects is important, particularly bone marrow suppression, rash, and kidney injury.
- For patients starting prophylaxis who have a history of mild TMP-SMX allergy, desensitization protocols can be considered rather than immediately switching to alternative agents, as suggested in the 2023 study 1. It is also important to note that PJP prophylaxis should be used in allogeneic HCT recipients, patients receiving CAR T-cell therapy, and patients with ALL, throughout antileukemic therapy, as recommended in the 2024 study 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 recommended oral dosage is 1,500 mg (10 mL) once daily administered with food.
The recommended dosage for PJP prophylaxis is 1,500 mg of atovaquone oral suspension once daily, administered with food 2.
- Key points:
- Indicated for adults and adolescents (aged 13 years and older) who cannot tolerate TMP-SMX.
- Administer with food to avoid lower plasma atovaquone concentrations.
From the Research
PJP Prophylaxis Options
- Trimethoprim-sulfamethoxazole (TMP-SMX) is a broad spectrum antibiotic and the first line agent for PJP prophylaxis in immunosuppressed patients 3
- Alternative options for PJP prophylaxis include pentamidine, dapsone, and atovaquone, which may be used in patients with a history of allergy or severe intolerance to TMP-SMX 3, 4, 5
Efficacy and Safety of PJP Prophylaxis Options
- TMP-SMX offers superior coverage for PJP, toxoplasmosis, and nocardiosis compared to pentamidine 3
- Atovaquone is well-tolerated and has a high rate of continuation compared to TMP-SMX and pentamidine 4
- Intravenous pentamidine is effective and well-tolerated for PJP prophylaxis in adult HSCT recipients 5
- Low-dose TMP-SMX regimens may reduce the risk of mortality and adverse events in PJP patients 6
Clinical Considerations for PJP Prophylaxis
- The use of alternative prophylactic agents (APAs) such as pentamidine, atovaquone, and dapsone may be unnecessary in some cases and can result in excess cost and potential side effects 7
- Evaluation and removal of TMP-SMX allergy labels can enable the use of TMP-SMX for prophylaxis against opportunistic infections 3
- Desensitization to TMP-SMX may be possible in some patients with a history of allergy or intolerance 3