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Drugs used in the treatment of Pneumocystis pneumonia (PCP) in adults and adolescents

Drugs used in the treatment of Pneumocystis pneumonia (PCP) in adults and adolescents
Drug Dose Major adverse reactions
Preferred regimen
TMP-SMX TMP-SMX (15 to 20 mg/kg/day of the trimethoprim component) orally or IV given in three or four divided doses* Rash (rarely SJS/TEN), fever, neutropenia, hyperkalemia, transaminase elevations, photosensitivity, increased serum creatinine
Alternative regimens
TMP plus dapsoneΔ TMP: 5 mg/kg orally three times daily Trimethoprim: Rash, gastrointestinal distress, transaminase elevation, neutropenia, hyperkalemia
Dapsone: 100 mg orally once per day Dapsone: Rash, fever, lymphadenopathy, transaminase elevations (sulfone hypersensitivity syndrome), gastrointestinal upset, methemoglobinemia, hemolytic anemia
PrimaquineΔ plus clindamycin* Primaquine: 30 mg (base) orally once per day Primaquine: Rash, fever, gastrointestinal distress, methemoglobinemia, hemolytic anemia, leukopenia, neutropenia
Clindamycin: 900 mg IV every eight hours OR 600 mg IV every six hours OR 600 mg orally three times daily OR 450 mg orally four times daily Clindamycin: Rash, diarrhea, Clostridioides difficile colitis, abdominal pain
Atovaquone suspension 750 mg orally twice daily (must be taken with food) Gastrointestinal distress, fever, transaminase elevation, rash (less frequently than with other regimens)
Pentamidine 4 mg/kg IV once daily

Nephrotoxicity, infusion reactions, hyperkalemia, hyperglycemia, pancreatitis, cardiac arrhythmias (including TdP), transaminase elevations, hypotension, hypoglycemia, hypokalemia, hypocalcemia

Certain adverse effects can be life threatening (eg, hypoglycemia and hypotension)§

Adjunctive glucocorticoids§
Prednisone

40 mg orally twice daily for five days, followed by

40 mg orally once daily for five days, followed by

20 mg orally once daily for 11 days
 
Patients should receive 21 days of therapy.
TMP-SMX: trimethoprim-sulfamethoxazole (cotrimoxazole); IV: intravenously; SJS/TEN: Stevens-Johnson syndrome and toxic epidermal necrolysis; TdP: torsades de pointes; G6PD: glucose-6-phosphate dehydrogenase.
* IV preferred in patients with PaO2 <60 mmHg, respiratory rate >25 or respiratory fatigue, unable to take oral medications.
¶ Dose shown in table is for patients with normal renal function. Dose modification for renal impairment may be needed.
Δ Check for G6PD deficiency.
◊ Pentamidine should only be used for patients with severe disease. Individuals requiring pentamidine should be admitted to the hospital and closely monitored with bedside telemetry and frequent measurement of blood pressure. Pentamidine dose may be reduced to 3 mg/kg IV daily due to toxicity. Refer to accompanying text.
§ Adjunctive glucocorticoids should be given to patients with a room air PaO2 <70 mmHg, an alveolar-arterial (A-a) oxygen gradient ≥35 mmHg, and/or evidence of hypoxemia (eg, room air O2 saturation <92 percent). IV methylprednisolone can be administered as 75 percent of prednisone dose.
Prepared with data from: DHHS Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. October 2014. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. (Updated April 22, 2015.)
Graphic 61052 Version 15.0

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