Pneumocystis Jirovecii Pneumonia Treatment and Prophylaxis

Treatment of Active PCP

The American College of Physicians recommends Trimethoprim-sulfamethoxazole (TMP-SMX) as the first-line treatment for documented Pneumocystis jirovecii pneumonia (PCP), administered at 75-100 mg/kg/day of sulfamethoxazole and 15-20 mg/kg/day of trimethoprim, divided every 6 hours for 14-21 days, according to the European Society for Medical Oncology 1
The European Society for Medical Oncology recommends Clindamycin plus primaquine as the preferred alternative for patients who cannot tolerate TMP-SMX or experience treatment failure after 5-7 days 1
The CDC recommends Pentamidine isethionate 4 mg/kg/day IV once daily over 60-90 minutes for TMP-SMX-intolerant patients 1

The CDC recommends prophylaxis initiation in HIV-infected patients with CD4+ counts <200 cells/μL or <20% of total T-lymphocytes, according to the MMWR Recommendations and Reports 2, 3, 1
The European Society for Medical Oncology recommends prophylaxis initiation in allogeneic transplant recipients from engraftment until end of immunosuppressive therapy or resolution of chronic GVHD, for at least 6 months 4, 5
The American College of Physicians recommends TMP-SMX as the preferred prophylactic agent, with a standard dose of one double-strength tablet (800 mg SMX/160 mg TMP) daily, according to the MMWR Recommendations and Reports 6, 4, 5, 1

The American Thoracic Society recommends fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) as the preferred diagnostic method, with 87-95% sensitivity, according to the Praxis Medical Insights 1
The Infectious Diseases Society of America recommends positive quantitative PCR (>1450 copies/ml) from BAL to trigger treatment, according to the Praxis Medical Insights 1

The CDC recommends that after successful treatment of breakthrough PCP, TMP-SMX remains preferred for secondary prophylaxis if the patient can tolerate it, according to the MMWR Recommendations and Reports 6

The CDC recommends patients be monitored closely for PCP development, as no regimen is 100% effective, according to the MMWR Recommendations and Reports 6
The American College of Physicians recommends being alert for extrapulmonary pneumocystosis and unusual radiologic presentations (upper-lobe infiltrates, pneumothorax) during aerosolized pentamidine prophylaxis, according to the MMWR Recommendations and Reports 6

The American College of Clinical Pharmacy recommends that erythromycin should be used cautiously with mefloquine or halofantrine due to arrhythmia risk, according to The Lancet Infectious Diseases 7
The CDC recommends that TMP-SMX provides dual coverage against both PCP and encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae), according to the MMWR Recommendations and Reports 8