Treatment of Pneumocystis infection in HIV-infected patients
- Paul E Sax, MD
Paul E Sax, MD
- Clinical Director, Division of Infectious Diseases
- Brigham and Women's Hospital
- Professor of Medicine
- Harvard Medical School
Pneumocystis jirovecii (formerly carinii) pneumonia (PCP) is the most common opportunistic respiratory infection in patients infected with HIV .
This topic will review the treatment of PCP in patients with HIV infection. Treatment of PCP (and other opportunistic infections) has been reviewed in a summary document from the CDC, NIH, and IDSA entitled, "Treating opportunistic infections among HIV-infected Adults and Adolescents" .
The treatment of PCP in patients without HIV infection, the clinical presentation and diagnosis of PCP, and prophylactic therapy to prevent PCP infection are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of Pneumocystis pneumonia in non-HIV-infected patients" and "Clinical presentation and diagnosis of Pneumocystis pulmonary infection in HIV-infected patients" and "Prophylaxis against Pneumocystis infection in HIV-infected patients".)
The choice of an initial regimen for treatment of PCP is influenced by the efficacy and toxicity of the treatment, disease severity (which may dictate intravenous therapy), patient intolerances and allergies, and ease of administration. The recommended doses and duration of therapy for the different regimens are shown in the table (table 1).
In patients who can tolerate the regimen, treatment with trimethoprim-sulfamethoxazole (TMP-SMX) is the initial drug of choice for both intravenous and oral therapy. As the oral formulation is well absorbed, patients can be treated with oral TMP-SMX unless concomitant gastrointestinal disease or the severity of the respiratory symptoms make administration of oral medications difficult.
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- ANTI-PNEUMOCYSTIS REGIMENS
- Prior prophylaxis
- Oral versus intravenous therapy
- Oral regimens
- - Oral TMP-SMX
- - TMP-dapsone
- - Oral clindamycin-primaquine
- - Atovaquone
- Intravenous regimens
- - TMP-SMX
- - Pentamidine
- - Clindamycin-primaquine
- - Trimetrexate
- OTHER MANAGEMENT ISSUES
- Inpatient versus outpatient therapy
- Use of corticosteroids
- - Efficacy
- - Selection of patients
- - Regimen
- - Complications
- Respiratory failure
- CLINICAL COURSE
- Treatment failure
- - Concurrent infections
- TIMING OF ART
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS