{"id":1631,"date":"2018-09-13T12:15:34","date_gmt":"2018-09-13T12:15:34","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=1631"},"modified":"2025-12-18T17:02:08","modified_gmt":"2025-12-18T17:02:08","slug":"pneumocystis-jirovecii","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/infection-prophylaxis-and-treatment\/pneumocystis-jirovecii\/","title":{"rendered":"Pneumocystis prophylaxis"},"content":{"rendered":"

First Line<\/span><\/strong><\/h3>\n

Co-trimoxazole 480mg daily for 3 months.<\/p>\n

On a case by case basis, individual patients (prior immunosuppression burden, persistent leucopaenia and previous opportunistic infection) may be judged to be higher risk of PJP and prophylaxis may be extended to 6 months or longer. This should also be considered for those receiving lymphocyte depleting induction (including ATG and alemtuzumab).<\/p>\n

If documented allergy to co-trimoxazole consider desensitisation regimen a soon as patient able to tolerate oral medicines post-transplant. This may be attempted in patients with a non-severe (grade 3 or less) co-trimoxazole reaction. It should not be attempted in patients with a grade 4 reaction to co-trimoxazole or other sulfa drugs. Toxicities can be graded as follows in Table 1.<\/p>\n

Table 1: Grade 1-4 Co-trimoxazole toxicity<\/span><\/strong><\/p>\n\n\n\n\n\n\n\n
Toxicity<\/span><\/td>\nClinical description<\/span><\/td>\n<\/tr>\n
Grade 1<\/span><\/td>\nErythema<\/span><\/td>\n<\/tr>\n
Grade 2<\/span><\/td>\nDiffuse maculopapular rash, dry desquamation<\/span><\/td>\n<\/tr>\n
Grade 3<\/span><\/td>\nVesiculation, mucosal ulceration<\/span><\/td>\n<\/tr>\n
Grade 4<\/span><\/td>\nExfoliatie dermatitis, Stevens-Johnson syndreome or erythema multiforms, moist desquamation<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

If a minor reaction occurs during the desensitisation regimen, repeat the same step for an additional day and progress to next step if the reaction subsides. If the reaction worsens, stop desensitisation. Consider giving concurrent antihistamine (i.e. cetirizine 10mg once daily), commenced 1 day prior to starting the desensitisation regimen.<\/p>\n

Table 2 – Co-trimoxazole desensitisation regimen<\/span><\/strong><\/p>\n\n\n\n\n\n\n\n\n
Step<\/span><\/td>\nDose<\/span><\/td>\n<\/tr>\n
Day 1<\/span><\/td>\n80mg sulfamethoxazole + 16mg trimethoprim (1ml oral suspension)<\/td>\n<\/tr>\n
Day 2<\/span><\/td>\n160mg sulfamethoxazole + 32mg trimethoprim (2ml oral suspension)<\/td>\n<\/tr>\n
Day 3<\/span><\/td>\n240mg sulfamethoxazole + 48mg trimethoprim (3ml oral suspension)<\/td>\n<\/tr>\n
Day 4<\/span><\/td>\n320mg sulfamethoxazole + 64mg trimethoprim (4ml oral suspension)<\/td>\n<\/tr>\n
Day 5<\/span><\/td>\n400mg sulfamethoxazole + 80mg trimethoprim ie 1 x 480mg tablet<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Co-trimoxazole oral suspension is 400mg sulfamethoxazole + 80mg trimethoprim\/5ml.\u00a0 There is an alternative protocol in which the dose is gradually escalated over 15 days (so that patients take each of the above doses for three days before increasing).<\/p>\n

Second Line<\/span><\/strong><\/h3>\n

Dapsone PO 100mg daily. Consider dose reduction to 50mg daily in severe renal dysfunction (creatinine clearance <10ml\/min). Alternatives such as atovaquone are also available. It is suggested to discuss with Microbiology if second line agents are required.<\/p>\n

After late treatment of Acute Rejection: Prophylaxis should be re-instigated for at least 3 months after late treatment with either pulsed IV methlyprednisolone or ATG.<\/p>\n","protected":false},"excerpt":{"rendered":"

First Line Co-trimoxazole 480mg daily for 3 months. On a case by case basis, individual patients (prior immunosuppression burden, persistent leucopaenia and previous opportunistic infection) may be judged to be higher risk of PJP and prophylaxis may be extended to 6 months or longer. This should also be considered for\u2026<\/p>\n

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