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Observational Study
. 2016 Jun;44(3):291-9.
doi: 10.1007/s15010-015-0851-1. Epub 2015 Oct 15.

Treatment of Pneumocystis pneumonia with intermediate-dose and step-down to low-dose trimethoprim-sulfamethoxazole: lessons from an observational cohort study

Dina Creemers-Schild  1 , Frank P Kroon  1 , Ed J Kuijper  2 , Mark G J de Boer  3
Affiliations
Observational Study

Treatment of Pneumocystis pneumonia with intermediate-dose and step-down to low-dose trimethoprim-sulfamethoxazole: lessons from an observational cohort study

Dina Creemers-Schild et al. Infection. 2016 Jun.

Abstract

Background: The recommended treatment of Pneumocystis jirovecii pneumonia (PCP) is high-dose trimethoprim-sulfamethoxazole (TMP-SMX) in an equivalent of TMP 15-20 mg/kg/day and SMX 75-100 mg/kg/day for 2 or 3 weeks. High rates of adverse events are reported with this dose, which raises the question if lower doses are possible.

Methods: All adult patients diagnosed with PCP in various immune dysfunctions and treated with TMP-SMX between January 1, 2003 and July 1, 2013 in a tertiary university hospital were included. Per institutional protocol, patients initiated treatment on intermediate-dose TMP-SMX (TMP 10-15 mg/kg/day) and could be stepped down to low-dose TMP-SMX (TMP 4-6 mg/kg/day) during treatment. Clinical variables at presentation, relapse rate and mortality rates were compared between intermediate- and step-down treatment groups by uni- and multivariate analyses.

Results: A total of 104 patients were included. Twenty-four patients (23 %) were switched to low-dose TMP-SMX after a median of 4.5 days (IQR 2.8-7.0 days). One relapse (4 %) occurred in the step-down group versus none in the intermediate-dose group. The overall 30-day mortality was 13 %. There was 1 death in the step-down group (4 %) compared to 13 deaths (16 %) in the intermediate-dose group.

Conclusions: We observed high cure rates of PCP by treatment with intermediate-dose TMP-SMX. In addition, a step-down strategy to low-dose TMP-SMX during treatment in selected patients appears to be safe and does not compromise the outcome of treatment.

Keywords: Antibiotic stewardship; Cotrimoxazole; Low dose; Pneumocystis jirovecii; Treatment; Trimethoprim–sulfamethoxazole.

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The study cohort
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