Preferred antimicrobial therapy for high-severity PJP
Trimethoprim+sulfamethoxazole is the most effective treatment for PJP and is recommended in all patients unless contraindicated (eg in patients hypersensitive to trimethoprim+sulfamethoxazole). For patients who report hypersensitivity to trimethoprim+sulfamethoxazole, see Treatment for high-severity PJP in patients with hypersensitivity to trimethoprim+sulfamethoxazole.
For high-severity PJP in adults and children, useCooley 2014European AIDS Clinical Society (EACS) 2022Panel on Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV 2022Panel on Opportunistic infections in HIV-exposed and HIV-infected children 2022:
trimethoprim+sulfamethoxazole (adult and child 1 month or older) 5+25 mg/kg up to 480+2400 mg intravenously, 6- to 8-hourly. For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole PJP treatment dosage adjustment trimethoprim + sulfamethoxazole trimethoprim+sulfamethoxazole trimethoprim+sulfamethoxazole
For clinically unstable patients, 6-hourly dosing is preferred for initial therapy.
Once the patient improves, switch to oral therapy. For guidance on when to switch to oral therapy, see Guidance for intravenous to oral switch. For oral continuation therapy for high-severity PJP in adults and children, useCooley 2014Panel on Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV 2022Panel on Opportunistic infections in HIV-exposed and HIV-infected children 2022:
trimethoprim+sulfamethoxazole (adult and child 1 month or older) 5+25 mg/kg up to 480+2400 mg orally or enterally, 8-hourly to complete 21 days total duration of therapy (intravenous + oral). For adults, see Calculated dose and number of tablets of trimethoprim+sulfamethoxazole to achieve a 5+25 mg/kg dose in adults for calculated weight-banded doses in number of double-strength tablets. For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole PJP treatment dosage adjustment.
If the dosages above are not tolerated, consider giving the same total daily dose more frequently (eg divided into 4 daily doses and given 6-hourly).
In patients with PJP who do not have HIV infection, emerging evidence suggests a lower dose of trimethoprim+sulfamethoxazole may be as effective as the standard dosage. In these patients, if the standard dosage is not tolerated, it may be safe to reduce the total daily dose once the patient is stable – seek expert adviceNagai 2023.
Consider if adjunctive corticosteroid therapy is required.
After completing 21 days of therapy, maintenance therapy (secondary prophylaxis) for PJP may be required for patients with immune compromise (eg patients with HIV infection or cancer, organ transplant recipients).