Preferred maintenance therapy for PJP
After an episode of Pneumocystis jirovecii pneumonia (PJP), patients with immune compromise (eg patients with HIV infection or cancer, transplant recipients) may require maintenance therapy (secondary prophylaxis) – seek expert advice on the need for maintenance therapy.
Trimethoprim+sulfamethoxazole is preferred for prophylaxis against PJP because it is the most effective. For patients who report hypersensitivity to trimethoprim+sulfamethoxazole, see Maintenance therapy for PJP in patients with hypersensitivity to trimethoprim+sulfamethoxazole.
The optimal trimethoprim+sulfamethoxazole dosage regimen is not clear. The strongest evidence is for daily and 3-times weekly regimensStern 2014, but observational data suggest that other regimens (eg once weekly, twice weekly) may be effectiveCooley 2014Lindemulder 2007. The choice of regimen depends on patient preference, adherence and tolerability. However, only the daily regimens are appropriate for patients who have undergone desensitisation for trimethoprim+sulfamethoxazole hypersensitivity.
For maintenance therapy (secondary prophylaxis) for PJP in adults, useCooley 2014European AIDS Clinical Society (EACS) 2022Panel on Opportunistic infections in HIV-exposed and HIV-infected children 2022Stern 2014:
1trimethoprim+sulfamethoxazole 80+400 mg orally, daily; see below for advice on duration of therapy. For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole PJP prophylaxis dosage adjustment trimethoprim + sulfamethoxazole trimethoprim+sulfamethoxazole trimethoprim+sulfamethoxazole
OR
1trimethoprim+sulfamethoxazole 160+800 mg orally, daily; see below for advice on duration of therapy. For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole PJP prophylaxis dosage adjustment
OR
1trimethoprim+sulfamethoxazole 160+800 mg orally, 3 times weekly; see below for advice on duration of therapy1. For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole PJP prophylaxis dosage adjustment.
For maintenance therapy (secondary prophylaxis) for PJP in children 1 month or older, twice- or 3-times-weekly regimens are used more commonly than daily regimens; useCooley 2014Paediatric European Network for Treatment of AIDS (PENTA) 2022Panel on Opportunistic infections in HIV-exposed and HIV-infected children 2022:
1trimethoprim+sulfamethoxazole 5+25 mg/kg up to 160+800 mg orally, daily; see below for advice on duration of therapy trimethoprim + sulfamethoxazole
OR
1trimethoprim+sulfamethoxazole 5+25 mg/kg up to 160+800 mg orally, twice weekly; see below for advice on duration of therapy2
OR
1trimethoprim+sulfamethoxazole 5+25 mg/kg up to 160+800 mg orally, 3 times weekly; see below for advice on duration of therapy1.
The duration of therapy depends on whether the patient has HIV infection:
- For adults with HIV infection taking combination antiretroviral therapy with a suppressed HIV viral load, stop maintenance therapy if CD4 count is greater than 200 cells/microlitre for 3 months. Continue maintenance therapy indefinitely if an episode of PJP occurred when CD4 count was more than 200 cells/microlitre.
- For children with HIV infection, see the Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children.
- For adults and children who do not have HIV infection, the duration of maintenance therapy depends on the type of immune compromise, the duration of immunosuppression and patient factors such as comorbidities – seek expert advice.