Preferred PJP prophylaxis

Trimethoprim+sulfamethoxazole is the most effective prophylaxis against PJP and is recommended unless contraindicated (eg in patients hypersensitive to trimethoprim+sulfamethoxazole, patients taking high-dose methotrexate).

Note: Trimethoprim+sulfamethoxazole is the most effective prophylaxis against PJP.

The trimethoprim+sulfamethoxazole regimens below also provide protection against Toxoplasma gondii infection. For prophylaxis against both PJP and T. gondii in patients unable to take trimethoprim+sulfamethoxazole, see Toxoplasma gondii prophylaxis in immunocompromised adults without HIV infection.

Note: PJP prophylaxis with trimethoprim+sulfamethoxazole also provides prophylaxis against Toxoplasma gondii.

A Cochrane review1 found the regimens below to be effective for prevention of PJP. The choice of regimen depends on patient preference, adherence and tolerability. Use:

1 trimethoprim+sulfamethoxazole 80+400 mg orally, daily; for dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole PJP prophylaxis dosage adjustment. For duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection pneumonia, PJP: primary prophylaxis (immunocompromised adult without HIV) trimethoprim + sulfamethoxazole    

OR

1 trimethoprim+sulfamethoxazole 160+800 mg orally, daily; for dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole PJP prophylaxis dosage adjustment. For duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection trimethoprim + sulfamethoxazole    

OR

1 trimethoprim+sulfamethoxazole 160+800 mg orally, 3 times weekly; for dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole PJP prophylaxis dosage adjustment. For duration of prophylaxis, see Assessing the need for antimicrobial prophylaxis in immunocompromised adults without HIV infection2. trimethoprim + sulfamethoxazole    

Assess patients reporting hypersensitivity to trimethoprim+sulfamethoxazole. Desensitisation (see Principles of antimicrobial desensitisation) is an option for clinically stable patients; however, do not desensitise patients with severe hypersensitivity (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome / toxic epidermal necrolysis [SJS/TEN]) or if adherence to therapy is unlikely. If 1 day of therapy is missed, the patient’s hypersensitivity will return and desensitisation must be performed again. Seek expert advice if desensitisation is being considered. If desensitisation is not an option, see Alternative PJP prophylaxis.

Note: Assess patients reporting hypersensitivity to trimethoprim+sulfamethoxazole.
1 Stern A, Green H, Paul M, Vidal L, Leibovici L. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev 2014;(10):CD005590. [URL]Return
2 Do not use the 3-times weekly regimen if the patient has undergone desensitisation for trimethoprim+sulfamethoxazole hypersensitivity.Return