Clinical Factors Associated With Pneumocystis Pneumonia Despite Its Primary Prophylaxis: When to Stop Prophylaxis?

Area of Science:

• Rheumatology
• Infectious Diseases
• Pharmacology

Background:

• Primary prophylaxis against Pneumocystis jirovecii pneumonia (PJP) is recommended for rheumatic disease patients on immunosuppressants.
• Optimal timing for discontinuing PJP prophylaxis remains unclear, posing a risk for patients.

Purpose of the Study:

• To identify risk factors for PJP in rheumatic disease patients despite prophylaxis.
• To provide evidence-based recommendations for an optimal PJP prophylaxis schedule.

Main Methods:

• A case-control study involving 1,294 prophylactic episodes in 1,148 rheumatic disease patients.
• Trimethoprim-sulfamethoxazole (TMP-SMX) was used for prophylaxis.
• Cox proportional hazards model with LASSO was employed to assess clinical factors.

Main Results:

• PJP occurred in 10 patients (0.85 per 100 person-years), primarily after TMP-SMX discontinuation.
• Higher glucocorticoid doses (>12.5 mg prednisone equivalent) at prophylaxis withdrawal significantly increased PJP risk (aHR: 13.84).
• Adverse events from TMP-SMX were observed in 15.9% of cases.

Conclusions:

• Initiating PJP prophylaxis withdrawal when glucocorticoid doses are tapered to 12.5 mg/day of prednisone equivalent is a reasonable strategy.
• This approach may help mitigate the risk of PJP in patients with rheumatic diseases.