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Low-Dose Sulfamethoxazole-Trimethoprim Could Prevent Pneumocystis jiroveci Pneumonia in Kidney Transplant Recipients:
Rongrong Wang1, Xiuhua Wu1, Xishao Xie2
1Department of Clinical Pharmacy, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China.
Objective:
Emerging evidence suggests that low doses of sulfamethoxazole-trimethoprim (TMP-SMX) may offer protection against Pneumocystis jiroveci pneumonia (PJP) in kidney transplant recipients. However, cases of PJP following the withdrawal of prophylaxis have been documented. This study aimed to investigate the relationship between the occurrence of PJP and different regimes of low-dose TMP-SMX prophylaxis.
Methods:
This retrospective observational study was conducted in the First Affiliated Hospital of Zhejiang University in China. Recipients diagnosed with PJP were included, and four controls were matched for each case based on transplantation time, age, and sex. Multivariate conditional logistic regression was employed to compare the odds of PJP occurrence among different TMP-SMX regimens.
Results:
From January 1, 2017, to December 31, 2020, 1763 patients underwent kidney transplantation at our center. Thirty-one patients developed PJP post-transplantation, and 124 patients without PJP were included as controls. One patient developed PJP during the prophylaxis period, and the others occurred after TMP-SMX discontinuation, resulting in a PJP incidence rate of 1.36% over the follow-up period. Compared to controls, the PJP group received a significantly lower cumulative TMP-SMX dose (median: 57 single-strength dose [SSD] tablets vs 100 tablets; p = 0.001) and had a shorter prophylaxis duration (median: 6.00 months vs 10.00 months; p = 0.004). They also exhibited higher CMV infection rates (29.0% vs 4.8%, p < 0.001), elevated serum creatinine levels at discharge (174.80μmol/L vs 134.58 μmol/L, p = 0.018), and reduced CD 4+ cell counts (354.12/L vs 542.58/L, p = 0.05). Multivariate analysis revealed that a higher cumulative TMP-SMX dose was significantly associated with a lower risk of PJP (p = 0.005). Subgroup analysis indicated that at least 6 months of TMP-SMX prophylaxis is necessary for PJP prevention in recipients on quarter-strength daily (SMX/TMP 100/20 mg, p = 0.022) or half-single strength daily (SMX/TMP 200/40 to 400/80 mg, p = 0.005) regimens.
Conclusion:
An adequate prophylactic duration of either quarter-strength daily TMP-SMX or half-single strength daily TMP-SMX may protect kidney transplant recipients from PJP.
Insights
Low-dose sulfamethoxazole-trimethoprim (TMP-SMX) prophylaxis is crucial for preventing Pneumocystis jiroveci pneumonia (PJP) in kidney transplant recipients. Maintaining adequate prophylaxis duration, particularly for at least six months, significantly reduces PJP risk.
Area of Science:
- Nephrology
- Infectious Diseases
- Pharmacology
Background:
- Kidney transplant recipients are at high risk for Pneumocystis jiroveci pneumonia (PJP).
- Low-dose sulfamethoxazole-trimethoprim (TMP-SMX) is commonly used for PJP prophylaxis.
- PJP cases have been reported after TMP-SMX prophylaxis withdrawal.
Purpose of the Study:
- To investigate the relationship between PJP occurrence and different low-dose TMP-SMX prophylaxis regimens in kidney transplant recipients.
- To determine optimal TMP-SMX prophylaxis duration and dosage for PJP prevention.
Main Methods:
- Retrospective observational study of 1763 kidney transplant recipients from 2017-2020.
- 31 PJP cases were matched with 124 controls.
- Multivariate conditional logistic regression analyzed TMP-SMX regimens and PJP risk.
Main Results:
- PJP occurred more frequently in patients with lower cumulative TMP-SMX doses and shorter prophylaxis durations.
- Higher cumulative TMP-SMX dose was significantly associated with lower PJP risk (p = 0.005).
- At least 6 months of quarter-strength or half-single strength daily TMP-SMX was necessary for PJP prevention.
Conclusions:
- Adequate prophylactic duration of TMP-SMX is essential for PJP prevention in kidney transplant recipients.
- Quarter-strength or half-single strength daily TMP-SMX for at least six months may protect against PJP.
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