PCP Pneumonia Prophylaxis for Pediatric Solid Organ Transplant Patients

Post-transplant prophylaxis protocol for Pneumocystis jirovecii for solid organ transplant recipients.

Pneumocystis jirovecii is a ubiquitous fungus that causes PCP pneumonia. Primary infection occurs in infants and young children1 and is typically characterized by mild upper respiratory tract symptoms or is asymptomatic in an immunocompetent host. Fulminant pneumonia can occur in immunocompromised hosts and is likely from re-infection, not reactivation. P. jirovecii has not been shown to be latent in animal models. The most important risk factors for PCP pneumonia are prolonged corticosteroids2 (e.g. >20 mg/day for >2 weeks or 30mg/day for 12 weeks) and intensity of the immune suppression (e.g. during induction with ATG or during allograft rejection).

Recommendations:

  1. PCP prophylaxis should be given to all pediatric solid organ transplant patients after transplantation.
  2. First-line medication for prophylaxis is Trimethoprim/Sulfamethoxazole (TMP/SMX). Studies have shown this medication to be the most effective prophylaxis against PCP in pediatric oncology patients3,4 and in adult HIV patients5. These data are used as the basis for solid organ transplant patients2.
  3. Any of the second-line medications for prophylaxis can be used, if there are problems with using TMP/SMZ. There is little data to recommend one medication over another among the choices of second-line medications. All of the second-line medications are associated with an increased risk of “breakthrough” episodes of PCP pneumonia, so close monitoring is warranted.
  4. Duration of prophylaxis is around 6 months. Longer durations may be considered for lung and small bowel transplantation2.
  5. Prophylaxis should be re-started during periods of enhance immunosuppression (e.g. allograft rejection episode).

Specific medications and doses are listed in attached table.

References

  1. Gigliotti F. PLOS Pathogens 2012, 8:e1003025
  2. Martin SI. Am J Transpl 2013, 13:272 (SOT Guidelines)
  3. Hughes WT. NEJM 1977, 297:1419
  4. Hughes WT. NEJM 1987, 316:1627
  5. Ioannidis JPA. Arch Intern Med 1996, 156:177

Name Dose Infants/Children Dose Adults Formulations Details
Drug of choice
(First-line agent)

Trimethophrim-sulfamethoxazole 75 mg/m2/dose BIDa
Equivalent to 2.5-5 mg/kg/dose BID

2.5 – 5mg/kg/dose BID for 3 consecutive days in a weekb

Dosing based on Trimethoprim
1 single or double strength tablet once a day

1 double strength tablet once a day for 3 days in a week
Suspension 8mg/ml (TMP)
Tablets

Single strength 80mg (TMP)

Double strength 160mg (TMP)
Added benefit of prophylaxis to other organisms, if given daily: Toxoplasma, Listeria, Nocardia, Salmonella, Haemophilus, Staphylococcus
Alternative
(Second-line agent)
Atovaquone (1-3 months) 30mg/kg/day once a day

(4-24 months)
45 mg/kg/day once a day

(>24 months)
30 mg/kg/day once a day

(Max: 1500 mg/day)
(13-16 years)
1500 mg once a day
Mepron
750mg/5ml
(5ml, 210ml)

Generic
750mg/5ml
(210ml)
Administer with food, especially high-fat meal

Expensive

Mepron contains benzyl alcohol; citrus flavor
Alternative
(Second-line agent)
Dapsone (≥ 1 month)
2 mg/kg/dose once a day
Max: 100mg/day

OR

4 mg/k/dose once a week
Max: 200mg/week
100 mg once a day
OR
50 mg BID
Tablet (scored)
25mg
Need to test for G6PD deficiency

Don’t use if severe Trimethoprim allergy
Alternative
(Second-line agent)
Pentamidine <5 years
150mg every 4 weeks

≥5 years
300 mg every 4 weeks
300 mg every 4 weeks Powder for nebulization 300mg Breakthrough infection more common compared to all other prophylaxis regimens

a Hughes WT. NEJM 1977, 297:1419, b Hughes WT. NEJM 1987, 316:1627, Based on HIV OI guidelines and AST ID guidelines


The PDF version of this page can be found here:
PCP Prophylaxis Guidelines