Overview
Pneumocystis jirovecii pneumonia (PcP) poses a substantial risk for patients with hematologic malignancies and solid tumors who are undergoing chemo- or immunotherapy-related immunosuppression 1. Most non-HIV-infected hematology patients present with severe PcP 2.Diagnosis
Diagnosis is triggered by clinical signs and symptoms, typical radiological findings, and occasionally laboratory findings in at-risk patients 2.
Diagnostic proof by bronchoalveolar lavage (BAL) should not delay the initiation of treatment 2.Management
For most hematological malignancy patients presenting with severe PcP, intravenous antimicrobial therapy should be started 2.
First-line treatment: High-dose trimethoprim/sulfamethoxazole (TMP/SMX) 2.
Alternative treatment (for TMP/SMX intolerance): Combination of primaquine plus clindamycin 2.
Treatment duration: Typically 3 weeks 2.
Treatment evaluation: First assessment after 1 week. If no clinical response, repeat pulmonary CT scan and bronchoalveolar lavage to check for secondary or co-infections 2.
Adjunctive therapy: Glucocorticoid administration must be decided on a case-by-case basis 2.
Ventilatory support: Non-invasive ventilation is not significantly superior to intubation and mechanical ventilation for patients with critical respiratory failure 2.Special Populations
Guidelines address PcP prophylaxis in hematologic and oncologic patients with chemo- or immunotherapy-related immunosuppression 1.
Treatment guidelines are specifically for non-HIV-infected hematology patients 2.Key Recommendations
PcP prophylaxis is recommended for cancer patients with chemo- or immunotherapy-related immunosuppression 1. (Evidence: Expert opinion)
High-dose trimethoprim/sulfamethoxazole is the treatment of choice for PcP in non-HIV-infected hematology patients 2. (Evidence: Expert opinion)
In patients with documented intolerance to trimethoprim/sulfamethoxazole, the preferred alternative treatment is the combination of primaquine plus clindamycin 2. (Evidence: Expert opinion)
Treatment for PcP typically lasts 3 weeks 2. (Evidence: Expert opinion)
Secondary anti-PCP prophylaxis is indicated in all non-HIV-infected hematology patients after completing treatment 2. (Evidence: Expert opinion)
Diagnostic proof by bronchoalveolar lavage should not delay the start of PcP treatment 2. (Evidence: Expert opinion)References
1 Classen AY, Henze L, von Lilienfeld-Toal M, Maschmeyer G, Sandherr M, Graeff LD et al.. Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors: 2020 updated guidelines of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO/DGHO). Annals of hematology 2021. link
2 Maschmeyer G, Helweg-Larsen J, Pagano L, Robin C, Cordonnier C, Schellongowski P. ECIL guidelines for treatment of Pneumocystis jirovecii pneumonia in non-HIV-infected haematology patients. The Journal of antimicrobial chemotherapy 2016. link