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

From the Guidelines

The treatment of Pneumocystis jirovecii pneumonia (PCP) typically involves the administration of trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 15-20 mg/kg/day of trimethoprim and 75-100 mg/kg/day of sulfamethoxazole, divided into 3-4 doses per day, for a duration of 14-21 days 1.

Key Considerations

• In mild-to-moderate cases, oral therapy can be discussed, otherwise it should be administered intravenously 1.
• Alternative regimens for patients intolerant to TMP-SMX include pentamidine isethionate at a dose of 4 mg/kg/day intravenously for 14-21 days, or clindamycin at a dose of 600 mg four times daily or 900 mg three times daily intravenously, in combination with primaquine at a dose of 30 mg daily orally, for 14-21 days 1.
• Glucose-6-phosphate dehydrogenase deficiency must be excluded before administration of dapsone or primaquine 1.
• Secondary prophylaxis using oral TMP-SMX at a daily dosage of 160/800 mg given on 3 days per week or with monthly pentamidine inhalation at a dose of 300 mg is recommended for patients who have been successfully treated for PCP 1.
• Oxygen therapy and supportive care are also essential components of treatment, particularly for patients with severe disease.

Special Considerations

• In patients with respiratory failure due to PCP, systemic corticosteroids may be beneficial in AIDS patients, but data are conflicting in non-HIV patients 1.
• Recent studies could not show a clinical benefit and were even associated with increased mortality 1.

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 The following table is a guideline for the upper limit of this dosage: Weight Dose – every 6 hours lb kg Tablets 18 8 - 35 16 1 53 24 1½ 70 32 2 or 1 DS tablet 88 40 2½ 106 48 3 or 1½ DS tablets 141 64 4 or 2 DS tablets 176 80 5 or 2½ DS tablets For the lower limit dose (75 mg/kg sulfamethoxazole and 15 mg/kg trimethoprim per 24 hours) administer 75% of the dose in the above table

The treatment for Pneumocystis jirovecii pneumonia (PCP) is sulfamethoxazole and trimethoprim. The recommended dosage 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 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
• For patients who cannot tolerate TMP-SMX, pentamidine isethionate is a suitable alternative 3, 4, 5
• The recommended dosage of pentamidine isethionate is 4 mg/kg/day, administered intramuscularly or intravenously 3, 5
• Aerosolized pentamidine is also effective for mild to moderate disease and as a prophylaxis regimen 4, 5

Alternative Therapies

• Clindamycin with primaquine is a reasonable alternative therapy for mild and moderately severe PCP 7
• Trimetrexate may be more effective in severe disease 4
• Dapsone in combination with trimethoprim is an investigational agent that has shown promise 5

Treatment Duration and Prophylaxis

• Treatment duration typically is 3 weeks 6
• Secondary anti-PCP prophylaxis is indicated in all patients after treatment 6
• TMP-SMX may be used to prevent recurrence of PCP or to prevent the initial occurrence of PCP in AIDS patients 5
• Aerosolized pentamidine is effective and safe for prophylaxis when administered correctly 4, 5