Pneumocystis jiroveci pneumonia (PJP) (formerly PCP)

Treatment of Pneumocystis jirovecii pneumonia (PJP) (Formerly PCP)

Treatment of PJP in both HIV and non-HIV infected patients.

Always consult Micro/ID.
Start treatment on suspicion of PJP.
Suggested investigations:
- CXR (if normal and PJP still suspected, advise High Resolution CT)
- PCR of induced sputum or BAL (if induced sputum PCR negative and PJP still suspected, advise repeat PCR with BAL sample)
- Plasma beta-D-glucan
  - Pooled sensitivity of 95% and specificity of 86%. Negative predictive value of over 95%
Check glucose-6 phosphate dehydrogenase (G6PD) level when diagnosis is made.

Treat for 14-21 days.

Review empirical treatment within 48-72 hours

Severity assessment

	Mild-to- moderate PJP	Moderate-to- severe PJP
Symptoms and signs	SOBOE, cough, fever	SOB at rest, cough, fever
ABG PaO₂ (room air)	more than 9.3 kPa	9.3 kPa or less
SaO₂ (room air)	more than 92% at rest OR Falling on exercise by less than 3%	92% or less at rest OR Falling on exercise by 3% or more
CXR	Normal diffuse interstitial shadowing	diffuse interstitial and alveolar shadowing

Definition from British HIV Association guidelines on the management of opportunisitic infection in people living with HIV (2024)

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Preferred: co-trimoxazole po

Patient weight	co-trimoxazole oral dose
less than 48kg	90mg/kg/day given in 3 divided doses
48kg- 59kg	1440mg TDS
60kg or over	1920mg TDS

Alternative:

If allergic/intolerant to co-trimoxazole discuss alternatives with Micro/ID. The following may be recommended by Micro/ID:

trimethoprim 15mg/kg/day po in 3 divided doses (round to the nearest 100mg) + dapsone 100mg po od (use with caution in G6PD deficiency)
atovaquone 750mg po bd
clindamycin 600mg po/iv (iv only if NBM) tds AND primaquine 30mg po od (use with caution in G6PD deficiency)

Preferred: co-trimoxazole 120mg/kg/day iv in 3-4 divided doses

If toxicity is encountered, consider dose reduction to 60mg/kg/day or to mild to moderate PJP dosing before switching to another regimen.

For obese patients (BMI 30 or more) use adjusted bodyweight (AdjBW).

Round each dose to the nearest 480mg, see table below for suggested dosing.

After 3 days step down to mild to moderate PJP dosing as seen in section above. Switch to oral therapy where possible as co-trimoxazole has excellent oral bioavailability.

Table for suggested co-trimoxazole iv dosing:

Patient weight (AdjBW if obese)	Total daily co-trimoxazole iv dose	Suggested split dosing for four times daily administration
Patient weight (AdjBW if obese)	Total daily co-trimoxazole iv dose	06:00	12:00	18:00	00:00
40 – 44kg	4800mg	1440mg	1440mg	960mg	960mg
45 - 49 kg	5280 mg	1440 mg	1440 mg	1440 mg	960 mg
50 - 54 kg	5760mg	1440 mg	1440 mg	1440 mg	1440 mg
55 - 59 kg	6240mg	1920 mg	1440 mg	1440 mg	1440 mg
60 - 64 kg	7200 mg	1920 mg	1920 mg	1920 mg	1440 mg
65 - 69 kg	7680 mg	1920 mg	1920 mg	1920 mg	1920 mg
70 - 74 kg	8160 mg	2400 mg	1920 mg	1920 mg	1920 mg
75 - 79 kg	8640 mg	2400 mg	2400 mg	1920 mg	1920 mg
80 - 84 kg	9600 mg	2400 mg	2400 mg	2400 mg	2400 mg
85 - 89 kg	10,080 mg	2880 mg	2400 mg	2400 mg	2400 mg
90 – 94 kg	10,560 mg	2880 mg	2880 mg	2400 mg	2400 mg
95 – 99 kg	11,040 mg	2880 mg	2880 mg	2880 mg	2400 mg
100 kg and over	11,520 mg	2880 mg	2880 mg	2880 mg	2880 mg

Alternative:

If allergic/intolerant to co-trimoxazole: clindamycin 600mg po/iv (iv only if NBM) tds AND primaquine 30mg po od (use with caution in G6PD deficiency)
If clindamycin/primaquine therapy is inappropriate or not tolerated: pentamidine 4mg/kg iv od*

*NB: IV pentamidine is not available from the hospital pharmacy and must be ordered from an aseptic service unit. Contact the ward pharmacist to order as soon as a decision to treat with pentamidine is made.

Prednisolone doses (beginning as soon as possible and within 72 hours of PJP therapy)

Days 1–5: 40 mg po BD
Days 6–10: 40 mg po OD
Days 11–21: 20 mg po OD

IV methylprednisolone can be given as 75% of prednisolone dose.

References

British HIV Association guidelines on the management of opportunisitic infection in people living with HIV (2024)
Sanford. Adult treatment "PJP". On-line. Last updated November 2024. Accessed January 2025

Mild to Moderate PJP

Moderate to Severe PJP

Adjunctive corticosteroids (for moderate to severe PJP)

References

Editorial Information