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Pneumocystis pneumonia guidelines – in haematology patients

May 23 2016

Pneumocystis pneumonia (PCP) remains a rather enigmatic condition outwith AIDS. Uncommon, acute, non-specific and often fatal, it represents a real challenge to those caring for immunocompromised patients. In a series of 4 articles just published in the Journal of Antimicrobial Chemotherapy, multiple authors from Europe have reviewed the burden, diagnosis, therapy and prevention of PCP in haematology patients, including those undergoing allogeneic stem cell transplantation. It is a generally increasing problem, despite effective prophylaxis.

The presentation differs substantially between HIV and non-HIV patients:

Key recommendations of these articles are that:

1. Effective prevention with oral cotrimoxazole (TMP/SMX) reduces rates by 90%, with a number needed to treat of 15:1, and a greatly reduced mortality.

2. Alternative regimens for prophylaxis are graded and assessed.

3. Immunofluorescence assays and real-time PCR are recommended for diagnosis and bronchoalveolar lavage the best specimen as it yields good negative predictive value.

4. Non-invasive specimens tested with PCR or b-D-glucan and are useful if positive but PCP cannot be ruled out if negative.

5. Optimal therapy is cotrimoxazole (TMP/SMX) 15 – 20 mg/kg (TMP) 75 – 100 mg/kg (SMX) per day for ≥14 days, without corticosteroid boosting.

6. ICU care with non-invasive or mechanical ventilation is indicated, if exhaustion and/or respiratory failure occur, which is is common (~50%).

These detailed and updated guidelines are welcome, as the only other guidelines for PCP were published 5 years and were less detailed, especially with regard to prophylaxis (Limper, 2011). Prophylaxis in the context of possible outbreaks is not addressed but is very rare in haematology patients.

Pneumocystis pneumonia in an HIV-negative patient - bilateral reticular markings with no pleural effusions

Articles

1. Alanio et al. 2016

2. Cordonnier et al. 2016

3. Maertens et al. 2016

4. Maschmeyer et al. 2016