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Alternative pneumocystis prophylaxis in solid organ transplant recipients at two large transplant centers
Jessica Lum1, Ignacio Echenique2,3, Vasilios Athans4
1Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA.
Background:
Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for Pneumocystis jirovecii pneumonia (PJP) prophylaxis and has activity against other opportunistic infections (OIs) after solid organ transplant (SOT). We aimed to describe the incidence, reasons for and outcomes of use of alternative prophylactic agents (APAs) across SOT programs in our high volume centers.
Methods:
Solid organ transplant recipients (SOTRs) at our centers from 1/2015-12/2016 were identified. Pharmacy records identified APA (pentamidine, atovaquone, or dapsone) use within 1 year. Records were reviewed for allergies, laboratory values at APA initiation, diagnostic tests for TMP-SMX-preventable OIs, and APA side effects.
Results:
An APA was initiated in 105/1173 (8.9%) SOTRs. Of these, 51 (48.6%) were because of sulfonamide allergy recorded pre-SOT, mostly rash/hives (58.8%). The remaining 54 (51.4%) had TMP-SMX discontinued post-SOT, mostly for neutropenia (48%) and renal effects (34%). Differences occurred across programs, with kidney transplant never stopping TMP-SMX for renal issues. Of those changed to APAs post-transplant, 19 (35%) were later successfully re-challenged with TMP-SMX. With thresholds in mind, 67 (64%) received an APA unnecessarily, accounting for up to $100 000/y excess cost. Potential TMP-SMX-preventable OIs occurred in 7 (5 Nocardia; 2 PJP). APA side effects occurred in 14/105 (13.3%).
Conclusions:
Use of APAs for PJP prophylaxis after SOT is less than previously reported but often unwarranted. Such decisions require scrutiny to avoid TMP-SMX-preventable OIs, cost and important APA side effects. Use of reasonable thresholds for cessation of TMP-SMX and data-driven approaches to re-challenge would substantially reduce APA use.
Insights
Alternative prophylactic agents (APAs) for Pneumocystis pneumonia (PJP) are used less than expected after solid organ transplant (SOT). However, many APA uses are unwarranted, leading to increased costs and potential side effects.
Area of Science:
- Transplant medicine
- Infectious disease prophylaxis
- Pharmacology
Background:
- Trimethoprim-sulfamethoxazole (TMP-SMX) is the standard for Pneumocystis jirovecii pneumonia (PJP) prophylaxis post-solid organ transplant (SOT).
- Alternative prophylactic agents (APAs) are sometimes necessary due to intolerance or specific clinical scenarios.
Purpose of the Study:
- To determine the incidence, reasons for, and outcomes of using APAs in solid organ transplant recipients (SOTRs).
- To evaluate the appropriateness of APA use and associated costs and side effects.
Main Methods:
- Retrospective review of SOTRs from 1/2015-12/2016.
- Identification of APA use (pentamidine, atovaquone, dapsone) within one year post-transplant.
- Review of medical records for allergies, laboratory values, OI diagnoses, and side effects.
Main Results:
- APAs were used in 8.9% of SOTRs.
- Reasons included sulfonamide allergy (48.6%) and TMP-SMX discontinuation (neutropenia, renal effects) (51.4%).
- 64% of APA use was deemed unnecessary, incurring significant excess costs, with 13.3% experiencing APA side effects.
Conclusions:
- APA use for PJP prophylaxis post-SOT is less frequent than reported but often unwarranted.
- Scrutiny of APA decisions is crucial to prevent unnecessary costs, side effects, and TMP-SMX-preventable opportunistic infections.
- Implementing clear thresholds for TMP-SMX cessation and data-driven re-challenge strategies can reduce APA utilization.
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