{"id":3318,"date":"2019-09-20T12:45:20","date_gmt":"2019-09-20T12:45:20","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=3318"},"modified":"2019-10-03T13:13:55","modified_gmt":"2019-10-03T13:13:55","slug":"pneumocytis-jirovecii-pneumonia-pcp-treatment","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/infection-prophylaxis-and-treatment\/pneumocytis-jirovecii-pneumonia-pcp-treatment\/","title":{"rendered":"Pneumocytis jirovecii pneumonia (PCP) treatment"},"content":{"rendered":"<p style=\"text-align: center;\"><span style=\"font-size: 36pt;\"><strong><span style=\"color: #993300;\">Solid organ transplant guidance<br \/>\n<\/span><\/strong><span style=\"color: #993300;\"><span style=\"font-size: 24pt;\"><span style=\"color: #993300;\">Royal Infirmary of Edinburgh<\/span><\/span><\/span><\/span><\/p>\n<h3><span style=\"color: #993300;\"><strong><span style=\"color: #993300;\">Initiating treatment:<\/span><\/strong><\/span><\/h3>\n<ul style=\"list-style-type: circle;\">\n<li>Oral: if Pa02 &gt; 10 kPa on room air<\/li>\n<li>IV Otherwise:<\/li>\n<li><strong><span style=\"color: #993300;\">Consider:<\/span><\/strong>\n<ul style=\"list-style-type: circle;\">\n<li>Steroids: if Sa02 &lt;92% or PaO2 &lt;9.3 kPa<\/li>\n<li><strong><span style=\"color: #993300;\">Check G6PD status early on as second line therapy is often required<\/span><\/strong><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">First line treatment: co-trimoxazole<\/span><\/strong><\/h3>\n<ul style=\"list-style-type: circle;\">\n<li>Dose: 120mg\/kg in 2-4 divided doses (round to nearest 480mg), reduce by 25% after 3 days\n<ul style=\"list-style-type: circle;\">\n<li>Duration: 3 weeks<\/li>\n<li>IVOS: After a minimum 4 days of IV therapy, but beware of nausea<\/li>\n<\/ul>\n<\/li>\n<li>Renal dosing: Only if CrCl &lt;30ml\/min:<\/li>\n<\/ul>\n<table style=\"width: 90%; border-collapse: collapse;\" border=\"2\">\n<tbody>\n<tr>\n<td style=\"width: 33.3333%; background-color: #e6f7ed; border-color: #993300; border-style: solid;\"><strong><span style=\"color: #993300;\">Creatinine Clearance<\/span><\/strong><\/td>\n<td style=\"width: 33.3333%; background-color: #e6f7ed; border-color: #993300; border-style: solid;\"><strong><span style=\"color: #993300;\">First 72h<\/span><\/strong><\/td>\n<td style=\"width: 33.3333%; background-color: #e6f7ed; border-color: #993300; border-style: solid;\"><strong><span style=\"color: #993300;\">Subsequently<\/span><\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%; border-color: #993300; border-style: solid;\">15-30 ml\/min<\/td>\n<td style=\"width: 33.3333%; border-color: #993300; border-style: solid;\">60mg\/kg twice daily<\/td>\n<td style=\"width: 33.3333%; border-color: #993300; border-style: solid;\">30mg\/kg twice daily<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%; border-color: #993300; border-style: solid;\">&lt;15 ml\/min<\/td>\n<td style=\"width: 33.3333%; border-color: #993300; border-style: solid;\">30mg\/kg twice daily<\/td>\n<td style=\"width: 33.3333%; border-color: #993300; border-style: solid;\">~23mg\/kg twice daily<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>NB: can be given centrally in concentrated form if fluid overload is a concern.<\/p>\n<ul style=\"list-style-type: circle;\">\n<li>Monitoring: FBC, U&amp;E \u2013 daily<\/li>\n<li>Adverse Effects:\n<ul style=\"list-style-type: circle;\">\n<li>Common: nephrotoxicity, electrolyte abnormalities (esp. Renal SOT)<\/li>\n<li>Less common: haematological abnormalities, neurological symptoms, headache, GI upset, skin reactions<\/li>\n<li>If there are concerns about side effects, then consider switching to second line treatment<\/li>\n<\/ul>\n<\/li>\n<li>Monitoring co-trimoxazole levels is impractical due to turnaround times and has been found to be non contributory.<\/li>\n<\/ul>\n<p>NB: It is important that the patient receives ~ 2 litres of 0.9% NaCl over 24 hrs, but with careful attention to fluid balance and potential overload.<\/p>\n<h3><strong><span style=\"color: #993300;\">Adjunctive Steroid Therapy<\/span><\/strong><\/h3>\n<p>Steroids improve survival and shorten duration of illness in HIV patients with PCP, but clear evidence for this benefit is not available in non-HIV patients.<\/p>\n<ul style=\"list-style-type: circle;\">\n<li>Indication: PaO2 &lt;9.3 kPa (or SaO2 &lt;92%) on room air, and still within 72h of antimicrobials being started<\/li>\n<li>Dose: oral prednisolone\n<ul style=\"list-style-type: circle;\">\n<li>40mg twice daily for 5 days, then<\/li>\n<li>40mg daily for 5 days, then<\/li>\n<li>20mg daily for 11 days then stop<\/li>\n<\/ul>\n<\/li>\n<li>Alternative: IV methylprednisolone (use 0.75x Prednisolone dose at all time points)<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">Second line treatment: clindamycin &amp; primaquine<\/span><\/strong><\/h3>\n<ul style=\"list-style-type: circle;\">\n<li>Doses:\n<ul style=\"list-style-type: circle;\">\n<li>IV clindamycin (600mg 3 times daily)<\/li>\n<li>Oral primaquine (30mg once daily)<\/li>\n<\/ul>\n<\/li>\n<li>Monitoring: check G6PD status prior to starting<\/li>\n<li>Adverse Effects: Nausea &amp; vomiting, diarrhoea (inc. C difficile infection), abdominal pain, rash, methaemaglobinaemia and haemolytic anaemia (with primaquine in G6PD deficient patients)\n<ul style=\"list-style-type: circle;\">\n<li>Methaemoglobinaemia may present as increased SOB or an apparent worsening of the PCP. If this occurs check levels with haematology<\/li>\n<li>If diarrhoea occurs test for C. difficile; start oral vancomycin empirically if high suspicion of infection (250mg 4 times daily)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">Alternative second line treatment:<\/span><\/strong><\/h3>\n<ul style=\"list-style-type: circle;\">\n<li>Discuss with microbiology\/infectious diseases if alternative regimen is required.<\/li>\n<li>Mild-moderate disease: oral atovaquone (750mg twice daily)<\/li>\n<li>Severe disease: IV pentamidine (4mg\/kg once daily)<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">Infection Control<\/span><\/strong><\/h3>\n<ul style=\"list-style-type: circle;\">\n<li>There is evidence of spread amongst immunocompromised patients<\/li>\n<li>Patients with PCP should be isolated in a single ensuite room (negative pressure if possible) in high risk patient areas<\/li>\n<li>There is no need for health care worker RPE (i.e. masks)<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">References<\/span><\/strong><\/h3>\n<p>Treatment recommendations are adapted for solid organ transplant unit from: Microguide, National IPCM, discussions with Infection specialists and local Transplant unit experience, and <a href=\"https:\/\/www.bhiva.org\/OI-guidelines\">British HIV Association Opportunistic Infections Guidance<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>Version 1.0 2013; I Laurenson, K Helgason, S Watson and K Davidson.<\/p>\n<p>V1.2 2014; Updated without Dr Helgason.<\/p>\n<p>V1.3 August 2019; I Laurenson, L Henderson, D Dockrell, D O\u2019Shea, P Phelan, C Hannah, P Lalonde, D Shaw, A Munro, C Hannah, J McCrae<\/p>\n<p>Review date by August 2021<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Solid organ transplant guidance Royal Infirmary of Edinburgh Initiating treatment: Oral: if Pa02 &gt; 10 kPa on room air IV Otherwise: Consider: Steroids: if Sa02 &lt;92% or PaO2 &lt;9.3 kPa Check G6PD status early on as second line therapy is often required First line treatment: co-trimoxazole Dose: 120mg\/kg in 2-4\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/infection-prophylaxis-and-treatment\/pneumocytis-jirovecii-pneumonia-pcp-treatment\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":1628,"menu_order":106,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-3318","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/3318","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=3318"}],"version-history":[{"count":10,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/3318\/revisions"}],"predecessor-version":[{"id":3336,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/3318\/revisions\/3336"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1628"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=3318"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}