eMedicine Specialties > Infectious Diseases > Fungal Infections

Pneumocystis (carinii) jiroveci Pneumonia: Follow-up

Author: Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Coauthor(s): Shelley A Gilroy, MD, Clinical Professor of Medicine, State University of New York Upstate; Medical Director, Infection Control, University Hospital and Crouse Hospital, Syracuse; Frederick Burton Rose, MD, FACP, Professor, Department of Medicine, University Hospital Epidemiologist, State University of New York Upstate Medical University; Joseph C McLean, MD, Staff Physician, Department of Internal Medicine, William Beaumont Army Medical Center; Clinton Murray, MD, Program Director, Infectious Disease Fellowship, San Antonio Uniformed Services Health Education Consortium; Tanya S Schreibman, MD, Consulting Staff, Department of Internal Medicine, Bach and Godofsky; Michael Rigsby, MD, Director of HIV Care Program, VA Connecticut Healthcare System, West Haven Campus; Associate Professor, Department of Internal Medicine, Yale University School of Medicine
Contributor Information and Disclosures

Updated: Nov 20, 2009

Follow-up

Further Inpatient Care

  • All patients who require corticosteroids should be admitted to the hospital because of the risk of progressive respiratory compromise.
  • Treatment of P carinii pneumonia (PCP) may be initiated before the workup is complete in severely ill high-risk patients.
  • Appropriate histopathologic testing may still be used to confirm a diagnosis of PCP after treatment is initiated.
  • Endotracheal tube aspirates from severely ill patients on mechanical ventilation may be submitted for diagnosis.
  • Because of increasing evidence of possible human transmission (see Pathophysiology), the CDC Hospital Infection Control Practice Advisory Committee has recommended that patients with PCP not have direct contact with other immunocompromised patients.

Further Outpatient Care

  • Arranging close medical follow-up with a primary care provider upon hospital discharge is essential to monitor resolution of disease and to initiate prophylactic medication.

Inpatient & Outpatient Medications

  • Oral therapy with TMP-SMX has been shown to be very effective in the outpatient setting. However, oral therapy should be considered only in patients with mild-to-moderate PCP who have reliable outpatient follow-up care.

Deterrence/Prevention

  • Smoking cessation is strongly recommended in patients with HIV infection, as studies have shown that, in addition to the common deleterious effects of tobacco use, smokers are at an increased risk of PCP and have a more complicated treatment course.
  • An expert panel overseen by the US Public Health Service and Infectious Disease Society of America has published guidelines on PCP prophylaxis in adult and pediatric patients with HIV infection. Chemoprophylaxis is recommended for the following groups:
    • Adults, adolescents, and pregnant patients with a CD4 count of less than 200/µL, oropharyngeal candidiasis, unexplained fever exceeding 100°F (37.7° C) for more than 2 weeks, and a prior episode of PCP regardless of CD4 count should receive prophylaxis.
    • Children born to mothers with HIV infection should receive prophylaxis with TMP-SMX beginning at age 4-6 weeks. The drug should be discontinued if they are subsequently determined not to be infected with HIV.
    • Children who are determined to be HIV positive through the first year of life, then as determined by age-specific CD4 levels, should receive prophylaxis.
  • Two types of outpatient chemoprophylactic therapies exist, as follows:
    • Primary prophylaxis is used in immunocompromised patients without a history of PCP.
    • Secondary prophylaxis is used in patients with a prior bout of PCP.
  • Prophylaxis may be discontinued in patients with HIV infection whose CD4 count exceeds 200/µL for 3 consecutive months while on HAART. Prophylaxis should be restarted if the CD4 count drops below 200/µL. Prophylaxis should be continued for life in patients who developed PCP while their CD4 level exceeded 200/µL.
  • Unlike in patients with HIV infection, no specific PCP prophylaxis guidelines exist for immunocompromised patients without HIV infection. In general, chemoprophylaxis should be considered in any of the following patients:
    • Patients with an underlying primary immune deficiency (eg, SCID or hypogammaglobulinemia)
    • Patients with a persistent CD4 count less than 200/µL
    • Solid organ transplant recipients
    • Hematopoietic stem cell transplant (HSCT) recipients, with prophylaxis administered (1) for 6 months after engraftment months or (2) for more than 6 months after HSCT in those who are still receiving immunosuppressive therapy (eg, prednisone, cyclosporine) or who have chronic graft versus host disease
    • Patients receiving daily systemic corticosteroid therapy (at least 20 mg daily for at least 1 mo)
    • Patients with cancer, vasculitides, or collagen vascular disorders and others receiving cytotoxic or immunosuppressive treatments such as cyclosporine or the purine analogs fludarabine or cladribine
  • TMP-SMX is the agent of choice for PCP prophylaxis in the absence of a contraindication. In patients who cannot tolerate TMP-SMX, other options include dapsone, dapsone plus pyrimethamine, atovaquone, and aerosolized pentamidine.
  • Prophylactic regimens include the following (see Medication for complete details on individual agents):
    • Trimethoprim-sulfamethoxazole
      • Dose is one double-strength tablet (160 mg TMP to 800 mg SMX) daily.
      • One single-strength tablet (80 mg TMP to 400 mg SMX) daily is also effective.
      • Another alternative is one double-strength tablet 3 times per week.
      • Daily-dosing regimen provides an additional benefit of cross protection against Toxoplasma gondii infection and other bacterial infections.
    • Dapsone: Dose is 100 mg by mouth daily if administered alone.
    • Dapsone with pyrimethamine (plus leucovorin)
      • Dose is 50 mg of dapsone by mouth daily with 50 mg of pyrimethamine weekly and 25 mg of leucovorin weekly.
      • Dapsone with pyrimethamine (plus leucovorin) provides protection against T gondii infection but not other bacterial infections.
    • Atovaquone
      • Dose is 1500 mg by mouth once daily given with food.
      • Atovaquone is an alternative if the patient cannot tolerate TMP-SMX or dapsone.
      • Atovaquone has a low toxicity profile.
      • This is a very expensive regimen.
    • Aerosolized pentamidine
      • Dose is 300 mg in 6 mL sterile water via Respirgard nebulizer every 4 weeks.
      • Aerosolized pentamidine is better tolerated than dapsone or TMP-SMX.
      • Side effects include cough and bronchospasm.
      • This treatment is much more expensive and less effective than other prophylactic regimens.
      • The potential for extrapulmonary Pneumocystis manifestations and apical lung disease exists.
      • This treatment may diminish the diagnostic sensitivity of sputum induction/BAL.

Complications

  • Hypoxemia and respiratory failure
    • A pathophysiologic process similar to acute respiratory distress syndrome (ARDS) may occur in patients with severe PCP.
    • These patients may require intubation.
    • This greatly diminishes the prognosis.

Prognosis

  • The prognosis of PCP is worse in patients who present with concurrent pulmonary disease, in patients who develop pneumothorax, and in patients who require mechanical ventilation.
  • Other factors that affect prognosis include a delay in diagnosis that leads to to delayed treatment.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The diagnosis of P carinii pneumonia (PCP) should prompt consideration for HIV testing.
  • If HIV testing is performed, appropriate pretest and posttest counseling guidelines must be followed.
 


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References
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Further Reading

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Keywords

Pneumocystis carinii pneumonia, PCP, P carinii pneumonia, Pneumocystis jiroveci pneumonia, P jiroveci pneumonia, Pneumocystis pneumonia, PCP prophylaxis, PCP prevention, opportunistic respiratory infection, opportunistic pneumonia, HIV, AIDS

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Contributor Information and Disclosures

Author

Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Nicholas John Bennett, MB, BCh, PhD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Shelley A Gilroy, MD, Clinical Professor of Medicine, State University of New York Upstate; Medical Director, Infection Control, University Hospital and Crouse Hospital, Syracuse
Shelley A Gilroy, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Frederick Burton Rose, MD, FACP, Professor, Department of Medicine, University Hospital Epidemiologist, State University of New York Upstate Medical University
Frederick Burton Rose, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Joseph C McLean, MD, Staff Physician, Department of Internal Medicine, William Beaumont Army Medical Center
Joseph C McLean, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Clinton Murray, MD, Program Director, Infectious Disease Fellowship, San Antonio Uniformed Services Health Education Consortium
Clinton Murray, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Association of Military Surgeons of the US, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Tanya S Schreibman, MD, Consulting Staff, Department of Internal Medicine, Bach and Godofsky
Disclosure: Nothing to disclose.

Michael Rigsby, MD, Director of HIV Care Program, VA Connecticut Healthcare System, West Haven Campus; Associate Professor, Department of Internal Medicine, Yale University School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: sepracor Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Harold L Manning, MD, Associate Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School
Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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