Consult expert advice.
All patients suspected of having Pneumocystis pneumonia (PCP) should be treated, as early treatment improves outcome, without impairing diagnostic tests.
Treatment should match the patient's clinical condition, with the patient managed as an out-patient if possible.
First-line treatment:
- All patients with PCP are treated with antibiotics, but this treatment may be modified according to the severity of the disease. (1) In adults and children, the severity of PCP may be graded as follows: (1)
- Mild-to-moderate PCP: arterial blood gas room air pO₂ ≥70 mmHg or an alveolar-arterial (A-a) gradient ≤35 mmHg.
- The treatment of choice in mild-to-moderate PCP is trimethoprim/sulfamethoxazole (TMP/SMX), given either intravenously or orally. The recommended duration of therapy is 21 days (1).
- Moderate-to-severe PCP: arterial blood gas room air pO₂ <70 mmHg or an alveolar-arterial (A-a) gradient >35 mmHg.
- Treatment of choice in moderate-to-severe PCP is intravenous TMP/SMX combined with a corticosteroid (2).
Alternative treatment regimens include either clindamycin plus primaquine, or intravenous pentamidine, both with an adjuvant corticosteroid. Clindamycin plus primaquine may be more effective and less toxic than intravenous pentamidine (3).
Notes:
- IV co-trimoxazole
- side-effects are, however, severe: most experience nausea and some develop intractable vomiting; there may also be skin rashes, neutropenia, thrombocytopenia and hepatitis
- 25% of patients will require alternative therapy
- pentamidine IV
- note that pentamidine however has serious adverse effects including cardiac arrhythmias, hypotension, pancreatitis, thrombocytopenia, neutropenia, hypoglycaemia, hypocalcaemia and acute renal failure and should be monitored carefully
- atovaquone (BW566 C80 - a hydroxy naphthoquinone)
- side-effects: fever, vomiting, diarrhoea, insomnia, rash, abnormal LFTs; interactions include: rifampicin, zidovudine, metoclopramide
References:
- National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication].
- Ewald H, Raatz H, Boscacci R, et al. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV infection. Cochrane Database Syst Rev. 2015 Apr 2;(4):CD006150.
- Benfield T, Atzori C, Miller RF, et al. Second-line salvage treatment of AIDS-associated Pneumocystis jiroveci pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008 May 1;48(1):63-7.