Pneumocystis jirovecii Pneumonia

Suspect PJP in an immunocompromised patient with progressive dyspnea, nonproductive cough, fever, chest discomfort, and new pulmonary infiltrates. In HIV, illness is usually subacute over days to weeks; non-HIV immunosuppressed patients may deteriorate more fulminantly. Document the immune condition, current and recent immunosuppressive drugs, prior PJP, and TMP-SMX prophylaxis at presentation because these findings alter pretest probability and the urgency of treatment. clinicalinfo hiv+1clinicalinfo hivPneumocystis Pneumonia: Adult and Adolescent OIs | NIHWolters KluwerThe Saudi Thoracic Society evidence-based... : Annals of Thoracic Medicine

Assess respiratory severity immediately with room-air pulse oximetry and arterial blood gas when hypoxemia is present or corticosteroid eligibility is being considered. In HIV-associated PJP, oxygen saturation below 92% on room air, PaO2 below 70 mm Hg, or A-a oxygen gradient at least 35 mm Hg identifies hypoxemia relevant to adjunctive corticosteroid treatment. Escalate oxygen support and pursue monitored or intensive care management when oxygen requirements are increasing or respiratory failure is evolving. ccjmccjmWhen should I give corticosteroids to my patient with Pneumocystis pneumonia? | Cleveland Clinic Journal of medicine

Obtain chest imaging and send organism-directed testing early, but do not postpone TMP-SMX in a patient with high clinical probability and clinically important hypoxemia. In immunocompromised patients with pulmonary infiltrates, high-resolution chest CT, bronchoalveolar lavage (BAL), and molecular diagnostics may be required because bacterial, viral, fungal, atypical, and noninfectious processes can coexist or mimic PJP. Wolters KluwerWolters KluwerThe Saudi Thoracic Society evidence-based... : Annals of Thoracic Medicine

BAL PCR is the preferred high-yield respiratory test when a definitive diagnosis is needed and bronchoscopy is safe. In a cohort of immunocompromised patients undergoing BAL for pulmonary infiltrates, PCR diagnosed PJP in 42 of 56 cases compared with 8 of 56 by conventional stains, increasing diagnostic yield 5.4-fold. Direct microscopic identification remains a diagnostic standard, while BAL PCR has become more sensitive than microscopy. ScienceDirect+1ScienceDirectPolymerase Chain Reaction-Based Detection of Pneumocystis jirovecii in Bronchoalveolar Lavage Fluid for the Diagnosis of Pneumocystis PneumoniaPubMedPositive Pneumocystis jirovecii Sputum PCR Results with Negative Bronchoscopic PCR Results in Suspected Pneumocystis Pneumonia - PubMed

Interpret a positive respiratory PCR as PJP only when the host is susceptible and the pulmonary syndrome is compatible. Low-level DNA detection can reflect colonization, whereas higher quantitative PCR burdens support disease. In one study, BAL qPCR of 1,300 copies/mL discriminated definite PJP from colonization with 100% sensitivity and 80% specificity; the threshold for probable PJP versus colonization was lower at 340 copies/mL but less discriminating. These cutoffs are assay- and population-dependent and should not be transferred uncritically between laboratories. ScienceDirectScienceDirectQuantitative real-time PCR and the (1 → 3)-β-d-glucan assay for differentiation between Pneumocystis jirovecii pneumonia and colonization - ScienceDirect

Use serum β-D-glucan as an adjunct rather than a stand-alone PJP test. β-D-glucan concentrations were higher in PJP than colonization in a cohort of immunocompromised patients with pulmonary infiltrates, and combining noninvasive β-D-glucan testing with oral wash PCR has been evaluated in non-HIV immunosuppressed patients. A positive β-D-glucan supports a fungal process in the appropriate clinical setting but does not independently establish Pneumocystis as the cause. NEJM+1NEJMA New Noninvasive Testing Strategy for Pneumocystis jirovecii Pneumonia | NEJM ClinicianScienceDirectQuantitative real-time PCR and the (1 → 3)-β-d-glucan assay for differentiation between Pneumocystis jirovecii pneumonia and colonization - ScienceDirect

Noninvasive sputum or oral-wash PCR can help when BAL is not immediately feasible, but a negative noninvasive result should not exclude PJP in a high-risk patient. In paired-sample prospective data, noninvasive specimens had high specificity but lower ability to exclude disease than invasive samples. Discordant sputum-positive/BAL-negative results also occur; therefore, resolve discordance using specimen quality, timing, fungal burden, imaging, β-D-glucan, and trajectory rather than treating either result as definitive in isolation. ScienceDirect+1ScienceDirectA prospective comparison of fungal load in paired sputum and bronchoalveolar lavage fluid for Pneumocystis pneumonia diagnosis: Clinical thresholds and diagnostic accuracyPubMedPositive Pneumocystis jirovecii Sputum PCR Results with Negative Bronchoscopic PCR Results in Suspected Pneumocystis Pneumonia - PubMed

Use TMP-SMX as initial treatment unless a severe contraindication prevents its use. Dose the trimethoprim component at 15–20 mg/kg/day with sulfamethoxazole 75–100 mg/kg/day in three or four divided doses; oral and IV formulations have equivalent bioavailability. Treat for 21 days. For mild-to-moderate disease with intact gastrointestinal absorption, oral TMP-SMX is reasonable; TMP-SMX double-strength, two tablets orally three times daily, is a cited oral regimen. PubMed+2PubMedPneumocystis jiroveci Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised PatientsccjmWhen should I give corticosteroids to my patient with Pneumocystis pneumonia? | Cleveland Clinic Journal of medicinePubMedPneumocystis jirovecii Pneumonia - StatPearls - NCBI Bookshelf

Use IV TMP-SMX for moderate-to-severe illness, then convert to oral therapy after clinical improvement. Monitor for myelosuppression, hyperkalemia, acute kidney injury, increased creatinine, transaminase elevation, rash including severe cutaneous reactions, neutropenia, and thrombocytopenia. Follow oxygenation and vital signs for response or early treatment failure while checking renal function, serum potassium, and blood counts during therapy. ccjm+2ccjmWhen should I give corticosteroids to my patient with Pneumocystis pneumonia? | Cleveland Clinic Journal of medicinePubMedPneumocystis jirovecii Pneumonia - StatPearls - NCBI BookshelfPubMedPneumocystis jirovecii pneumonia in people living with HIV: a review - PMC

For TMP-SMX intolerance, select an alternative based on severity and contraindications. For mild-to-moderate PJP, options include dapsone plus trimethoprim, clindamycin plus primaquine, or atovaquone; atovaquone is less effective than TMP-SMX. For moderate-to-severe disease, clindamycin-primaquine or IV pentamidine are alternatives. Do not use aerosolized pentamidine to treat active PJP. ccjm+1ccjmWhen should I give corticosteroids to my patient with Pneumocystis pneumonia? | Cleveland Clinic Journal of medicinePubMedTherapy and Management of Pneumocystis jirovecii Infection

Before primaquine, screen for G6PD deficiency because primaquine can cause hemolysis and methemoglobinemia in deficient patients. A cited regimen is primaquine 30 mg orally daily plus clindamycin 900 mg IV every 8 hours or 600 mg orally every 8 hours. IV pentamidine is dosed at 4 mg/kg once daily, with reduction to 3 mg/kg once daily if toxicity develops. PubMed+2PubMedPneumocystis jiroveci Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised PatientsPubMedManagement of Pneumocystis Jirovecii pneumonia in HIV infected patients: current options, challenges and future directionsPubMedPneumocystis jirovecii pneumonia in people living with HIV: a review - PMC

For nonpregnant adults with HIV-associated PJP, add corticosteroids when room-air PaO2 is below 70 mm Hg or the A-a oxygen gradient is at least 35 mm Hg. Oxygen saturation below 92% on room air is also a practical marker of hypoxemia requiring ABG-based severity assessment. Start prednisone within 72 hours of beginning anti-Pneumocystis therapy, or as soon as possible thereafter. PubMed+1PubMedPneumocystis jiroveci Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised PatientsccjmWhen should I give corticosteroids to my patient with Pneumocystis pneumonia? | Cleveland Clinic Journal of medicine

Use prednisone 40 mg orally twice daily on days 1–5, 40 mg once daily on days 6–10, then 20 mg once daily on days 11–21. IV methylprednisolone is an alternative when oral administration is not feasible. PubMedPubMedPneumocystis jiroveci Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised Patients

For non-HIV PJP, do not prescribe adjunctive corticosteroids routinely solely by extrapolation from HIV trials. Select hypoxemic patients may benefit, but the evidence base does not establish a universal indication; weigh the potential pulmonary benefit against competing infection risks and the patient’s existing immunosuppressive regimen. ccjmccjmWhen should I give corticosteroids to my patient with Pneumocystis pneumonia? | Cleveland Clinic Journal of medicine

In adults with HIV, initiate PJP prophylaxis for CD4 count below 200 cells/µL, CD4 percentage below 14%, or oropharyngeal candidiasis. Consider prophylaxis at CD4 200–250 cells/µL when antiretroviral therapy cannot be initiated promptly or CD4 monitoring every three months is not feasible. TMP-SMX is the preferred preventive agent. PubMedPubMedPneumocystis jirovecii Pneumonia - StatPearls - NCBI Bookshelf

A cited TMP-SMX prophylaxis regimen is one single-strength or double-strength tablet orally daily, or one double-strength tablet three times weekly. Daily double-strength TMP-SMX may be preferred when prophylaxis is also intended to cover toxoplasmosis or selected bacterial infections. Review concurrent ACE inhibitor, ARB, or spironolactone use because of hyperkalemia risk. PubMedPubMedPneumocystis jirovecii pneumonia in people living with HIV: a review - PMC

After acute PJP therapy, reassess immune recovery strategy and the continuing indication for prophylaxis. In patients receiving TMP-SMX treatment or prophylaxis, use serial CBC, creatinine, and potassium measurements to identify cytopenias, renal toxicity, and hyperkalemia before they force an unplanned regimen change. ccjm+2ccjmWhen should I give corticosteroids to my patient with Pneumocystis pneumonia? | Cleveland Clinic Journal of medicinePubMedPneumocystis jirovecii Pneumonia - StatPearls - NCBI BookshelfPubMedPneumocystis jirovecii pneumonia in people living with HIV: a review - PMC