Pneumocystis pneumonia

B20.6

DESCRIPTION

Interstitial pneumonitis due to Pneumocystis jirovecii (formerly carinii). AIDS-defining illness (WHO clinical stage 4).

MEDICINE TREATMENT

All patients:

  • Cotrimoxazole 80/400 mg, oral, 6 hourly for 21 days.
    • <60 kg three tablets
    • ≥60 kg four tablets

Monitor FBC and potassium when on high dose therapy.

OR

If vomiting:

  • Cotrimoxazole, IV, 6 hourly for 21 days.
    • <60 kg 240/1200 mg
    • ≥60 kg 320/1600 mg

For hypoxic patients:

  • Oxygen by face mask or CPAP as necessary.

AND

  • Corticosteroids (intermediate-acting) e.g.:
  • Prednisone, oral, 80 mg daily for 5 days, then taper over 14 days.(Refer to PREDNISONE, ORAL for an example of a dose reduction regimen).

Cotrimoxazole intolerance and desensitisation

Attempt desensitisation in patients with a history of cotrimoxazole intolerance, unless this was life-threatening, e.g. Stevens-Johnson syndrome. See Erythema Multiforme, Stevens Johnson Syndrome, Toxic Epidermal Necrolysis. Unless rash is severe or associated with systemic symptoms, continue treatment with careful observation for deterioration.

Desensitisation should be attempted using cotrimoxazole suspension 240 mg/5ml. Dilute the suspension appropriately and consult with your pharmacist if necessary. DO NOT administer antihistamines or steroids.

Time (hours) Cotrimoxazole dose (mL of 240mg/5mL suspension
0 0.0005
1 0.005
2 0.05
3 0.5
4 5
5 Two single strength tablets (each tablet = 80/400 mg) followed by full dose

Alternatively, in case of intolerance and unsuccessful desensitisation:

  • Clindamycin, oral, 600 mg 8 hourly for 21 days.

AND

  • Primaquine, oral, 15 mg daily for 21 days.
    • Exclude G6PD deficiency before initiating therapy.

OR

If primaquine is not available, consider:

  • Clindamycin, oral, 600 mg 8 hourly for 21 days.

AND

  • Dapsone, oral, 100 mg daily for 21 days.

Secondary prophylaxis

Continue for at least 6 months and until CD4 count increases to >200 cells/mm3 on ART.

  • Cotrimoxazole 160/800 mg, oral daily.

Alternatively, in case of intolerance to cotrimoxazole:

  • Dapsone, oral, 100 mg daily.

REFERRAL/CONSULTATION

Specialist or tertiary

Intolerance to second line regimen.