Guidelines
Pneumocystis jiroveci Pneumonia

Pneumocystis jiroveci Pneumonia

Clinical Considerations

  • [A-a] DO2: alveolar-arterial PO₂ gradient
  • PO2: room air arterial oxygen
  • PJP PCR has replaced DFA (no longer available at Scripps)
  • Bronchial wash/BAL samples are preferred over sputum given increased sensitivity
  • Pneumocystis can be a respiratory colonizer; PJP PCR interpretation must incorporate clinical judgment
    • Higher cycle threshold values may correlate with colonization
    • In patients with a compatible clinical syndrome for PJP, higher Beta-D-Glucan values (>200 pg/mL) are associated with clinically significant PJP infections among PCR-positive patients
  • Initiation of treatment should not be deferred by BAL/PCR results, since PJP remains detectable in bronchial secretions for many days after the start of systemic treatment
  • Testing for G6PD deficiency on all patients is recommended to prevent delays in therapy changes

TMP-SMX: GI distress, rash, fever, neutropenia, hyperkalemia, LFT elevation, photosensitivity, increased serum creatinine

Atovaquone: GI distress, fever, LFT elevation, rash

Clindamycin: Rash, diarrhea, C. difficile colitis

Primaquine: GI distress, rash, fever, methemoglobinemia, hemolytic anemia, leukopenia, neutropenia.

Pentamidine: Nephrotoxicity, infusion reactions, hypo/hyperkalemia, hyperglycemia, pancreatitis, arrhythmias (including Torsades de pointes), LFT elevation, hypotension, hypoglycemia, hypocalcemia

Treatment

  • [A-a] DO2 <35 mmHg and/or PO₂ ≥70 mmHg
  • Symptoms:
    • Increasing exertional dyspnea, with/without cough and sweats
  • [A-a] DO2 ≥35 to <45 mmHg and/or PO₂ ≥60 and <70 mmHg
  • Symptoms:
    • Dyspnea on minimal exertion
    • Occasional dyspnea at rest
    • Fever with/without sweats
  • [A-a] DO2 ≥45 and/or PO₂ <60 mmHg
  • Symptoms:
    • Dyspnea at rest
    • Tachypnea at rest
    • Persistent fever
    • Cough

Indication:

  • Moderate to Severe PJP and/or
  • Hypoxemia on pulse oximetry

More Information

  1. Respiration. 2016;92(3):144-9.
  2. J Clin Microbiol. 2016 Jun;54(6):1487-1495.
  3. Open Forum Infect Dis. 2020 Apr 2;7(5):ofaa112.
  4. Open Forum Infect Dis. 2021 Oct 29;8(12):ofab545.
  5. Clin Transplant. 2019 Sep;33(9):e13587.
  6. Antimicrob Agents Chemother. 1974 Mar;5(3):289-93.
  7. Antimicrob Agents Chemother. 2017 Nov 22;61(12):e01173-17.
  8. J. Microbiol Immunol Infect. 2018 Dec;51(6):810-820.
  9. Ann Pharmacother. 2016 Aug;50(8):673-9.
  10. J Infec Chemother. 2019 Apr;25(4):253-261
  11. Ann Intern Med. 1988 Aug 15;109(4):280-7.
  12. Scand J Infect Dis. 2009;41(11-12):862-8.
  13. PLoS One. 2014 Sep 3;9(9):e106141.
  14. J Antimicrob Chemother. 2016 Sep;71(9):2405-13.
  15. Ann Intensive Care. 2020 Mar 20;10(1):34.
  16. Clin Infect Dis. 2019 Sep 27;69(8):1303- 1309.
  17. Ann Intern Med 1988; 109:280–7.