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Alternative Pneumocystis Pneumonia Prophylaxis in Solid Organ Transplants.
Kevin D He1, Linh Nguyen2,3, Maxwell Norris2,3
1Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Summary
Alternative prophylaxis for Pneumocystis pneumonia (PJP) in solid organ transplant (SOT) recipients has risks and barriers. Re-trying trimethoprim-sulfamethoxazole (TMP-SMX) is often feasible after adverse events resolve.
Area of Science:
- Transplant medicine
- Infectious disease prevention
- Pharmacology
Background:
- Limited data supports Pneumocystis pneumonia (PJP) prophylaxis with atovaquone or dapsone in solid organ transplant (SOT) recipients.
- Trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred agent, but alternatives are sometimes used.
Purpose of the Study:
- To evaluate the safety and efficacy of alternative PJP prophylaxis in SOT recipients.
- To identify barriers to initiating and continuing PJP prophylaxis.
Main Methods:
- Retrospective cohort study of adult SOT recipients receiving non-TMP-SMX PJP prophylaxis.
- Included patients with over one year of follow-up.
Main Results:
- 34.9% of SOT recipients received alternative PJP prophylaxis, primarily atovaquone.
- Common reasons for switching from TMP-SMX included hyperkalemia and leukopenia.
- Breakthrough infections occurred (toxoplasmosis, Nocardia), but no PJP cases were reported. Barriers included cost and prior authorization.
Conclusions:
- Alternative PJP prophylaxis is associated with risks and initiation barriers.
- Most patients tolerated TMP-SMX after adverse events resolved, suggesting re-trial is feasible.
- Re-challenging with TMP-SMX should be considered when clinically appropriate.
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