Pneumocystis Jirovecii Pneumonia

GENERAL PRINCIPLES

Pneumocystis jirovecii pneumonia is the most common OI in patients with AIDS characterized by subacute progressive dyspnea.

DIAGNOSIS

Positive direct immunofluorescent stain from induced sputum samples or bronchoalveolar lavage fluid.

TREATMENT

• Trimethoprim-Sulfamethoxazole (TMP-SMX) is the treatment of choice. The dosage is 15-20 mg/kg of the TMP component IV daily, divided q6-8h for severe cases, with a switch to oral therapy when the patient's condition improves. Total duration of therapy is 21 days. Prednisone should be added with severe disease as defined below. For patients who cannot receive TMP-SMX, the following alternatives are available:

î For mild to moderately severe disease (arterial oxygen tension [PaO₂] gt;70 mm Hg or alveolar arterial oxygen gradient [P(A-a)O₂] lt;35 mm Hg):

#9632; TMP, 15 mg/kg PO q8h, and dapsone, 100 mg PO daily. G6PD deficiency should be ruled out before dapsone is used.

#9632; Clindamycin, 600 mg IV or PO q8h, plus primaquine, 30 mg PO daily. G6PD deficiency should be ruled out before primaquine is used.

#9632; Atovaquone, 750 mg PO q12h. This drug should be administered with meals to increase absorption.

î For severe disease (PaO₂ lt;70 mm Hg or P[A-a]O₂ #8805;35 mm Hg):

#9632; Prednisone taper should be added. The most frequently prescribed prednisone regimen is 40 mg PO bid on days 1-5 and 40 mg daily on days 6-10, followed by 20 mg on days 11-21.

#9632; IV pentamidine is used in cases when all other options are exhausted and requires close monitoring for side effects.

Primary prophylaxis is indicated (see Table 16-2). Secondary PCP prophylaxis can be discontinued if the CD4 count is gt;200 cells#8725;#956;L for more than 3 months in patients responding to ART.