Alternative maintenance therapy for children with PJP

For maintenance therapy of PJP in children with nonsevere hypersensitivity to trimethoprim+sulfamethoxazole, useCooley 2014 Panel on Opportunistic infections in HIV-exposed and HIV-infected children 2022:

1atovaquone; see below for advice on duration of therapy atovaquone

child younger than 3 months: 30 mg/kg orally with full-fat milk or feeds, daily

child 3 to 24 months: 45 mg/kg orally with fatty food or full-fat milk, daily

child older than 24 months: 30 mg/kg up to 1500 mg orally with fatty food or full-fat milk, daily

1dapsone 2 mg/kg up to 100 mg orally, daily; see below for advice on duration of therapy¹ ² ³ ⁴ dapsone

2pentamidine (child 5 years or older) 300 mg via nebuliser, every 4 weeks; see below for advice on duration of therapy⁵ ⁶. pentamidine

For children with severe⁷ 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 child has HIV infection:

For children with HIV infection, see the Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children.
For 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.

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 the maximum dapsone dosage to 50 mg daily in children 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 An oral liquid formulation of dapsone is not commercially available; for formulation options for children, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return

⁵ Administer pentamidine via a jet nebuliser producing a droplet size of 1 to 2 microns.Return

⁶ Use nebulised pentamidine with caution in patients with lung disease (eg asthma) because it may cause cough and bronchospasm.Return

⁷ 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