Single-day trimethoprim/sulfamethoxazole prophylaxis for Pneumocystis pneumonia in children with cancer
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Désirée Caselli1, Maria Grazia Petris2, Roberto Rondelli3
1Department of Pediatric Hematology-Oncology, Azienda Ospedaliero Universitaria Meyer Children Hospital, Florence, Italy.
Insights
A simplified 1-day/week regimen of trimethoprim/sulfamethoxazole may effectively prevent Pneumocystis pneumonia (PCP) in children with cancer. This approach could simplify prophylaxis for immunocompromised patients. Keywords: trimethoprim/sulfamethoxazole, Pneumocystis pneumonia, PCP prophylaxis, childhood cancer.
Area of Science:
- Pediatric Oncology
- Infectious Diseases
- Pharmacology
Background:
- Pneumocystis pneumonia (PCP) is a serious opportunistic infection in immunocompromised patients, particularly those undergoing chemotherapy.
- Current prophylaxis regimens for PCP vary, with recommendations ranging from daily to 3 days per week of trimethoprim/sulfamethoxazole.
- There is a need for simplified and effective PCP prophylaxis strategies in pediatric cancer patients.
Purpose of the Study:
- To evaluate the efficacy of a simplified 1-day/week regimen of trimethoprim/sulfamethoxazole for PCP prophylaxis in children with cancer.
- To compare the incidence of PCP across different prophylaxis frequencies (1-day, 2-day, and 3-day per week).
Main Methods:
- A prospective survey was conducted across pediatric hematology-oncology centers in Italy.
- Data were collected on 2466 patients treated for childhood cancer, analyzing their PCP prophylaxis regimens.
- Incidence of PCP was tracked and compared based on the adopted prophylaxis schedule.
Main Results:
- The study included 2466 patients, with varying prophylaxis regimens: 1-day/week (27.9%), 2-day/week (16.5%), and 3-day/week (55.6%).
- Only 2 cases of PCP (0.08%) were reported overall, both occurring in the 2-day/week prophylaxis group.
- The cumulative incidence of PCP at 3 years was very low (0.09% overall), with no cases reported in the 1-day/week or 3-day/week groups. Both patients who developed PCP had discontinued prophylaxis.
Conclusions:
- A 1-day/week trimethoprim/sulfamethoxazole prophylaxis regimen appears sufficient for preventing PCP in pediatric cancer patients receiving intensive chemotherapy.
- This simplified strategy offers a potential improvement in adherence and management.
- The findings may extend to other patient populations requiring PCP prophylaxis due to immune suppression from various therapies, including those with rheumatic diseases.
Objective:
To determine whether a simplified, 1-day/week regimen of trimethoprim/sulfamethoxazole is sufficient to prevent Pneumocystis (jirovecii [carinii]) pneumonia (PCP). Current recommended regimens for prophylaxis against PCP range from daily administration to 3 consecutive days per week dosing.
Study Design:
A prospective survey of the regimens adopted for the PCP prophylaxis in all patients treated for childhood cancer at pediatric hematology-oncology centers of the Associazione Italiana Ematologia Oncologia Pediatrica.
Results:
The 20 centers participating in the study reported a total of 2466 patients, including 1093 with solid tumor and 1373 with leukemia/lymphoma (or primary immunodeficiency; n = 2). Of these patients, 1371 (55.6%) received the 3-day/week prophylaxis regimen, 406 (16.5%) received the 2-day/week regimen, and 689 (27.9%), including 439 with leukemia/lymphoma, received the 1-day/week regimen. Overall, only 2 cases of PCP (0.08%) were reported, both in the 2-day/week group. By intention to treat, the cumulative incidence of PCP at 3 years was 0.09% overall (95% CI, 0.00-0.40%) and 0.51% for the 2-day/week group (95% CI, 0.10%-2.00%). Remarkably, both patients who failed had withdrawn from prophylaxis.
Conclusion:
A single-day course of prophylaxis with trimethoprim/sulfamethoxazole may be sufficient to prevent PCP in children with cancer undergoing intensive chemotherapy regimens. This simplified strategy might have implications for the emerging need for PCP prophylaxis in other patients subjected to the increased use of biological and nonbiological agents that induce higher levels of immune suppression, such as those with rheumatic diseases.
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