Pneumocystis jiroveci
PRIMARY PCP PROPHYLAXIS:
INDICATION: CD4 <200/mm3, prior PCP, thrush, CD4% <14 or CD4
count 200-250 /mm3 with monitoring < q 3 mo.
PREFERRED REGIMEN: TMP-SMX 1 DS/day or 1 SS/day
ALTERNATIVE REGIMENS
- TMP-SMX 1 DS 3x/week
- Dapsone 100 mg/day or 50 mg po bid
- Dapsone 50 mg/day plus pyrimethamine 50 mg/week plus
leucovorin 25 mg/week
- Dapsone 200 mg/week plus pyrimethamine 75 mg/week plus
leucovorin 25 mg/week
- Aerosolized pentamidine 300 mg/month by Respirgard II nebulizer
using 6 mL diluent delivered at 6L/min from a 50 psi compressed air
source until reservoir is dry (usually 45 min), with or without
albuterol (2 whiffs) to reduce cough and bronchospasm
- Atovaquone 1500 mg po qd with meals (NEJM 1998;339:1889)
- Atovaquone 1500 mg po + pyrimethamine 25 mg + leucovorin 10
mg/day.
- Other considerations for unusual circumstances: intermittent
parenteral pentamidine and oral clindamycin plus primaquine.
RISK: The risk of PCP without prophylaxis is 60% to 70% per year in
those with prior PCP and 40% to 50% per year for those with a CD4
count <100 cells/mm3. The mortality for patients hospitalized and
treated for PCP is 15% to 20%. PCP prophylaxis reduces the risk of
PCP 9-fold, and patients who get PCP despite prophylaxis have a lower
mortality rate (Am J Respir Crit Care Med 1997;155:60). The major
reasons for PCP prophylaxis failure are CD4 count <50 cells/mm3 and
non-adherence (JAMA 1995;273:1197; Arch Intern Med 1996;156:
177). Provider error in prescribing accounts for about 20% of failures
(Clin Infect Dis 2007;44:879).
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