What are the US Public Health Service-IDSA guidelines for chemoprophylaxis guidelines prophylaxis against Pneumocystis jiroveci pneumonia (PJP)?

Updated: Apr 24, 2019
  • Author: Shelley A Gilroy, MD, FACP, FIDSA; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Answer

Answer

Two types of outpatient chemoprophylactic therapies exist. Primary prophylaxis is used in immunocompromised patients without a history of PJP. Secondary prophylaxis is used in patients with a prior bout of PJP.

An expert panel overseen by the US Public Health Service and Infectious Disease Society of America has published guidelines on prophylaxis against P jiroveci pneumonia (PJP) in adult and pediatric patients with HIV infection. Chemoprophylaxis is recommended for the following groups:

  • Adults, adolescents, and pregnant patients with a CD4 count of less than 200/µL, oropharyngeal candidiasis, unexplained fever exceeding 100°F (37.7° C) for more than 2 weeks, and a prior episode of PJP regardless of CD4 count should receive prophylaxis.

  • Children born to mothers with HIV infection should receive prophylaxis with TMP-SMX beginning at age 4-6 weeks, if HIV infection has not been "presumptively ruled out" by two negative HIV DNA PCRs (typically one at birth, with another after age 4 weeks). Many HIV-exposed newborns in the developed world with access to this kind of testing therefore may never need to start PJP prophylaxis.

  • Children born to mothers with HIV infection who have had 4 negative HIV DNA PCRs (with one after at least age 4 months) or a negative HIV antibody test after age 6 months can be definitively said to be HIV-uninfected, and PJP prophylaxis can be safely discontinued.

  • All children who are determined to be HIV-infected should receive prophylaxis through the first year of life, then as determined by age-specific CD4 levels.

  • Prophylaxis may be discontinued in patients with HIV infection whose CD4 count exceeds 200/µL for 3 consecutive months while on HAART. Prophylaxis should be restarted if the CD4 count drops below 200/µL. Prophylaxis should be continued for life in patients who developed PJP while their CD4 level exceeded 200/µL.

One study suggests that discontinuation of prophylaxis may be safe in patients with HIV and CD4 counts of 101-200 cells/μL and suppressed viral load. [42]


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