Treatment and prevention of Pneumocystis pneumonia in HIV-uninfected patients
- Charles F Thomas, Jr, MD
Charles F Thomas, Jr, MD
- Associate Professor of Medicine
- Mayo Clinic College of Medicine
- Andrew H Limper, MD
Andrew H Limper, MD
- Professor of Pulmonary Medicine
- Mayo Clinic College of Medicine
Pneumocystis pneumonia (PCP) is a potentially life-threatening infection that occurs in immunocompromised individuals. The nomenclature for the species of Pneumocystis that infects humans has been changed from Pneumocystis carinii to Pneumocystis jirovecii; this was done to distinguish it from the species that infects rats.
HIV-infected patients with a low CD4 count are at the highest risk of PCP. Others at substantial risk include hematopoietic stem cell and solid organ transplant recipients, those with cancer (particularly hematologic malignancies), and those receiving glucocorticoids, chemotherapeutic agents, and other immunosuppressive medications.
The treatment and prophylaxis of PCP in patients without HIV infection will be reviewed here. PCP in HIV-infected patients and the epidemiology, clinical manifestations, and diagnosis of PCP in HIV-uninfected patients are discussed separately. (See "Treatment and prevention of Pneumocystis infection in HIV-infected patients" and "Epidemiology, clinical manifestations, and diagnosis of Pneumocystis pneumonia in HIV-uninfected patients".)
Trimethoprim-sulfamethoxazole — We recommend trimethoprim-sulfamethoxazole (TMP-SMX) as the treatment of choice for Pneumocystis pneumonia (PCP) of any severity in HIV-uninfected patients (table 1) . The dose of TMP-SMX for patients with normal renal function is 15 to 20 mg/kg (dosing is based upon the TMP component and expressed as mg/kg per day of TMP) intravenously or orally daily in three or four divided doses. For renal dose adjustment recommendations, see trimethoprim-sulfamethoxazole drug information. Because TMP-SMX has excellent bioavailability, oral administration is appropriate for all patients who have a functioning gastrointestinal tract.
For patients with allergy to TMP-SMX, desensitization should ideally be performed since TMP-SMX is the most effective regimen. However, if the patient has a history of a severe allergy (eg, Stevens-Johnson syndrome, toxic epidermal necrolysis), TMP-SMX should be avoided and desensitization should not be performed. (See "Treatment and prevention of Pneumocystis infection in HIV-infected patients", section on 'Desensitization for patients with a sulfa allergy' and "Sulfonamide allergy in HIV-uninfected patients".)
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- Alternative agents
- Duration of therapy
- Adjunctive glucocorticoids
- INFECTION CONTROL
- - Trimethoprim-sulfamethoxazole
- - Other drugs
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- PCP treatment
- Infection control
- PCP prophylaxis