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Incidence of Pneumocystis jirovecii Pneumonia and Prophylaxis-Associated Adverse Events Among Patients With Systemic
Yiran Jiang1, Alí A Duarte-García2, Michael S Putman3
1Y. Jiang, MD, M.S. Putman, MD, D.J. Gazeley, MD, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, Wisconsin.
Objective:
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that may affect patients with systemic lupus erythematosus (SLE). The objective of this project was to describe the incidence of PJP among patients with SLE.
Methods:
A retrospective cohort analysis of the TriNetX database was conducted. Included patients had ≥ 2 International Classification of Diseases, 9th or 10th revision, Clinical Modification (ICD-9-CM/ICD-10-CM) codes for SLE separated by at least 30 days and were new users of mycophenolate mofetil (MMF) and/or cyclophosphamide (CYC). The incidence of PJP over the first 6 months of therapy was calculated; adverse events were assessed using incidence rate ratios (IRR) and Cox proportional hazards regressions.
Results:
A total of 6017 patients with SLE were identified. Most were female (n = 5176, 86%) and Black or African American (n = 2138, 35.5%). Induction medications included MMF (n = 5208, 86.6%), CYC (n = 505, 8.4%), or both (n = 304, 5.1%); the most common PJP prophylaxis was trimethoprim-sulfamethoxazole (n = 1126, 18.7%). Five PJP cases were identified over 2752 person-years (PYs), one of whom received PJP prophylaxis, for an incidence rate of 1.8 cases/1000 PYs. In the adjusted analysis, patients who received prophylaxis had a higher risk of neutropenia (hazard ratio [HR] 2.5, 95% CI 1.4-4.4), leukopenia (HR 1.9, 95% CI 1.3-2.8), nephropathy (HR 1.7, 95% CI 1.4-2.1), and hyperkalemia (HR 1.4, 95% CI 0.9-2.0).
Conclusion:
PJP rarely affects patients with SLE undergoing therapy with MMF and/or CYC; prophylaxis against PJP is associated with adverse events. The majority of patients with SLE and PJP had structural lung disease. These data do not support universal prescribing of PJP prophylaxis for patients with SLE without lung disease.
Insights
Pneumocystis jirovecii pneumonia (PJP) is rare in systemic lupus erythematosus (SLE) patients treated with mycophenolate mofetil or cyclophosphamide. Prophylaxis for PJP is linked to adverse events and is not recommended for SLE patients without lung disease.
Area of Science:
- Immunology
- Infectious Diseases
- Rheumatology
Background:
- Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection.
- Patients with systemic lupus erythematosus (SLE) are susceptible to opportunistic infections.
- The incidence of PJP in SLE patients undergoing immunosuppressive therapy requires investigation.
Purpose of the Study:
- To determine the incidence of PJP in patients with SLE.
- To analyze risk factors and outcomes associated with PJP in SLE patients.
- To evaluate the association between PJP prophylaxis and adverse events in SLE patients.
Main Methods:
- Retrospective cohort analysis of the TriNetX database.
- Inclusion criteria: patients with SLE and new use of mycophenolate mofetil (MMF) and/or cyclophosphamide (CYC).
- Calculation of PJP incidence and assessment of adverse events using Cox proportional hazards regressions.
Main Results:
- A total of 6017 SLE patients were identified; most were female and Black or African American.
- Five cases of PJP were identified over 2752 person-years, yielding an incidence rate of 1.8 cases/1000 PYs.
- PJP prophylaxis was associated with increased risk of neutropenia, leukopenia, nephropathy, and hyperkalemia.
Conclusions:
- PJP is rare in SLE patients treated with MMF and/or CYC.
- PJP prophylaxis is associated with adverse events and is not supported for SLE patients without lung disease.
- Structural lung disease was common in SLE patients who developed PJP.
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