Primary Care Guidelines for the Management of Persons Infected ...

Table 1. Standard and Alternative PCP Therapy
Drugs Dosages Notes
Standard Therapy
Trimethoprim +
sulfamethoxazole
(TMP-SMX)
Alternative Therapies
TMP: 15-20 mg/kg
plus
SMX: 75-100 mg/kg
divided into 3
or 4 doses daily
intravenously (IV) or
orally for 21 days
Pentamidine 4 mg/kg IV daily for
21 days
Dapsone +
trimethoprim
Clindamycin +
primaquine
Dapsone* 100 mg
orally daily plus
trimethoprim 15 mg/
kg orally daily
for 21 days
Clindamycin 600-900
mg IV every 6-8 hours
(or 300-450 mg orally
every 6-8 hours)
plus
Primaquine* base
15-30 mg orally once
daily for 21 days
Atovaquone 750 mg orally twice
daily for 21 days
Trimetrexate
(+ leucovorin)
Trimetrexate 45
mg/m 2
(or 1.2 mg/kg) IV daily
plus
Leucovorin 25 mg
orally every 6 hours
for 21 days
Patients who have
had previous reactions
to sulfa drugs may
be successfully
desensitized.
Adjust dose in renal
insufficiency.
Similar efficacy to
TMP-SMX but greater
toxicity (nephrotoxicity,
pancreatitis, glucose
dysregulation,
cardiac arrhythmias).
Usually reserved for
patients with severe
disease who require
intravenous therapy.
Appropriate for mildto-moderate
disease
Appropriate for mildto-moderate
disease.
For mild-to-moderate
PCP only; not as potent
as TMP-SMX
Not as potent as TMP-
SMX. Leucovorin must
be continued for 3 days
beyond completion of
trimetrexate
* Screen for G6PD deficiency (most common in patients of African or Mediterranean descent).
Section 6—Disease-Specific Treatment | 6–91
Other therapy notes
♦ Patients started on intravenous therapy can be
switched to an oral treatment regimen to complete
the 3-week course when they are afebrile, have
improved oxygenation, and are able to take oral
medications.
♦
♦
Paradoxical worsening of PCP due to presumed
immune reconstitution inflammatory syndrome (see
chapter) has been reported in patients who initiated
ART close to the time of diagnosis and treatment
for PCP. At present, there is no consensus on
whether initiation of ART during an acute episode
of PCP is preferable to delaying ART, and clinical
trials are under way to explore this question.
Many providers prefer to wait until completion of
PCP therapy and clinical stabilization of the patient
before initiating ART. Consultation with HIV
experts is advisable when considering starting ART
in the setting of PCP.
Treatment failures
The average time to clinical improvement in
hospitalized patients is 4-8 days, so avoid premature
change in therapy. In patients who fail to improve
on appropriate therapy, it is important to exclude
other diagnoses, rule out fluid overload, and consult
an infectious disease specialist. Some patients do
not respond to any therapy, and the mortality rate of
hospitalized patients is about 15%.