Alternative maintenance therapy for adults with PJP

For maintenance therapy of PJP in adults with nonsevere hypersensitivity to trimethoprim+sulfamethoxazole, useCooley 2014 European AIDS Clinical Society (EACS) 2022 Panel on Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV 2022:

1dapsone 100 mg orally, daily; see below for advice on duration of therapy¹ ² ³. For dosage adjustment in adults with kidney impairment, see dapsone dosage adjustment dapsone dapsone dapsone

2pentamidine 300 mg via nebuliser, every 4 weeks; see below for advice on duration of therapy⁴ ⁵. For dosage adjustment in adults with kidney impairment, seek expert advice. pentamidine pentamidine pentamidine

3atovaquone 1500 mg orally with fatty food or full-fat milk, daily; see below for advice on duration of therapy. atovaquone atovaquone atovaquone

For adults with severe⁶ hypersensitivity to trimethoprim+sulfamethoxazole, use pentamidine or atovaquone (see dosages above). Do not give dapsone because there is a possibility of cross-reactivity between dapsone and sulfamethoxazole.

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 monthsPanel on Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV 2022. Continue maintenance therapy indefinitely if an episode of PJP occurred when CD4 count was greater than 200 cells/microlitre.
For adults 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.

¹ Test for glucose-6-phosphate dehydrogenase (G6PD) deficiency before starting treatment with dapsone – seek expert advice if the patient is G6PD deficient.Return

² Reduce dapsone dosage to 50 mg daily in adults who develop toxicity (methaemoglobinaemia, chemical haemolysis).Return

³ The cross-reactivity rate between dapsone and sulfamethoxazole is approximately 9 to 12%; do not use dapsone in patients with severe hypersensitivity (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN]; see Definition of commonly used antimicrobial hypersensitivity terms).Return

⁴ Administer pentamidine via a jet nebuliser producing a droplet size of 1 to 2 microns.Return

⁵ Use nebulised pentamidine with caution in patients with lung disease (eg asthma, chronic obstructive pulmonary disease [COPD]) because it may cause cough and bronchospasm.Return

⁶ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse. Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return