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Masaki T, Ishikawa K, Fujino T, Koyamada R, Kawai F, Ota E, Mori S. Intermittent Versus Daily Trimethoprim/Sulfamethoxazole Regimens for Pneumocystis Pneumonia Prophylaxis: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2024; 11:ofae499. [PMID: 39296342 PMCID: PMC11409865 DOI: 10.1093/ofid/ofae499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/30/2024] [Indexed: 09/21/2024] Open
Abstract
Background In immunocompromised individuals, trimethoprim/sulfamethoxazole (TMP/SMX) for Pneumocystis pneumonia (PCP) prophylaxis has adverse events, and the optimal dosage is unclear. The objective of this study was to assess efficacy and safety of intermittent versus daily TMP/SMX for PCP prophylaxis. Methods This systematic review included randomized controlled trials (RCTs) indexed in the Cochrane Central Register of Controlled Trials, PubMed, Ichushi, or Embase databases, published from database inception to September 2023. The inclusion criteria were adults taking intermittent or daily TMP/SMX for PCP prophylaxis. Risk of bias was assessed using the Cochrane risk-of-bias tool. The primary outcomes were PCP incidence, PCP-related mortality, and adverse events requiring temporary or permanent TMP/SMX discontinuation. Results Four RCTs (N = 2808 patients) were included. PCP incidence did not differ significantly between the intermittent and daily regimen groups (risk ratio [RR], 1.17 [95% confidence interval {CI}, .89-1.53]; certainty: very low). There was no PCP-related mortality in the 3 RCTs reporting its outcome. Compared with the daily regimen group, the intermittent regimen group experienced significantly fewer adverse events requiring temporary or permanent TMP/SMX discontinuation (RR, 0.51 [95% CI, .42-.61]; certainty: low). Conclusions This systematic review and meta-analysis suggests that intermittent TMP/SMX regimens for PCP prophylaxis may be more tolerable than daily regimens and may have similar efficacy. Further RCTs are needed to apply this to current practice. Clinical Trials Registration. PROSPERO (CRD42022359102).
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Affiliation(s)
- Tetsuhiro Masaki
- Department of Haematology, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Kazuhiro Ishikawa
- Department of Infectious Diseases, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Takahisa Fujino
- Department of Haematology, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Ryosuke Koyamada
- Department of Haematology, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Fujimi Kawai
- Library, Department of Academic Resources, St Luke's International University, Chuo-ku, Tokyo, Japan
| | - Erika Ota
- Graduate School of Nursing Sciences, St Luke's International University, Chuo-ku, Tokyo, Japan
| | - Shinichiro Mori
- Department of Haematology, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
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Scherger SJ, Kalil AC. Changes in the Mortality Rate and Epidemiology of Pneumocystis Pneumonia Require Novel Approaches to Clinical Care. Chest 2024; 165:1273-1275. [PMID: 38852956 DOI: 10.1016/j.chest.2024.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 06/11/2024] Open
Affiliation(s)
- Sias J Scherger
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE.
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Rhoads S, Maloney J, Mantha A, Van Hook R, Henao-Martínez AF. Pneumocystis jirovecii Pneumonia in HIV-Negative, Non-transplant Patients: Epidemiology, Clinical Manifestations, Diagnosis, Treatment, and Prevention. CURRENT FUNGAL INFECTION REPORTS 2024; 18:125-135. [PMID: 38948111 PMCID: PMC11213562 DOI: 10.1007/s12281-024-00482-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 07/02/2024]
Abstract
Purpose of Review Pneumocystis jirovecii pneumonia (PJP) is an opportunistic fungal infection that is increasingly seen in HIV-negative patients with immune compromise due to other etiologies. We lack comprehensive clinical recommendations for this population. Recent Findings In non-HIV cases, PJP has a mortality rate of up to 50%, which is unacceptable despite the presence of safe and effective prophylaxis and therapy. Steroid use is one of the most common risk factors for disease development. New data suggests that lower doses of the preferred treatment regimen, TMP-SMX, may be equally effective for treatment while limiting side effects. While commonly used, the benefit of corticosteroids for the treatment of PJP has recently been called into question, with a recent multicenter cohort demonstrating no benefit among solid organ transplant recipients. Summary A high suspicion of PJP in individuals with pneumonia during immunosuppressant use is crucial. Therapeutic options are evolving to decrease potential side effects while maintaining efficacy in this highly morbid disease.
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Affiliation(s)
- Sarah Rhoads
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - James Maloney
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Aditya Mantha
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Reed Van Hook
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Andrés F. Henao-Martínez
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, 12700 E. 19Th Avenue, Mail Stop B168, Aurora, CO 80045, USA
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Ohmura SI, Matsui H, Miyamoto T, Shichi D, Masui T, Ichijo K, Homma Y, Fujioka H, Nagai T, Nakashima K. Comparison of the outcomes of Pneumocystis jirovecii pneumonia in rheumatoid arthritis patients treated with and without biologics. Respir Investig 2024; 62:377-383. [PMID: 38452442 DOI: 10.1016/j.resinv.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/29/2024] [Accepted: 02/22/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND To investigate the outcomes of Pneumocystis jirovecii pneumonia (PCP) between patients with rheumatoid arthritis (RA) treated with and without biologics before PCP onset. PATIENTS AND METHODS We retrospectively included rheumatoid arthritis (RA) patients with PCP treated with and without biologics before PCP onset. The primary endpoints were 30-day and 180-day survival rates, and the secondary endpoint was severe PCP, including in-hospital death, intensive care unit admission, and requirement of respiratory support during hospitalization. RESULTS Eighty-two patients were enrolled in this study, including the Biologics group (n = 39) and Non-Biologics group (n = 43). There were no significantly differences in the 30-day and 180-day survival rates and severe PCP rate in the Biologics group and the Non-Biologics group before and after adjusting the patient characteristics. Kaplan-Meier survival curves for death showed no significantly differences between the Biologics and Non-Biologics groups. Cox regression hazard analysis revealed that the average daily prednisolone dose within 90 days before PCP onset was weakly associated with mortality after PCP. CONCLUSIONS Biologic use before PCP onset did not increase the severity and mortality of PCP compared to non-biologics use in patients with RA.
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Affiliation(s)
- Shin-Ichiro Ohmura
- Department of Rheumatology, Seirei Hamamatsu General Hospital, 2-12-12 Chuo-ku, Sumiyoshi, Hamamatsu, Shizuoka, 430-8558, Japan.
| | - Hiroki Matsui
- Clinical Research Support Office, Kameda Medical Center, 929 Higashimachi, Kamogawa, Chiba, 296-0041, Japan
| | - Toshiaki Miyamoto
- Department of Rheumatology, Seirei Hamamatsu General Hospital, 2-12-12 Chuo-ku, Sumiyoshi, Hamamatsu, Shizuoka, 430-8558, Japan
| | - Daisuke Shichi
- Infectious Disease and Rheumatology, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Chuo-ku, Hamamatsu, Shizuoka, 433-8558, Japan
| | - Takayuki Masui
- Department of Radiology, Seirei Hamamatsu General Hospital, 2-12-12 Chuo-ku, Sumiyoshi, Hamamatsu, Shizuoka, 430-8558, Japan
| | - Katsutoshi Ichijo
- Department of Radiology, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Chuo-ku, Hamamatsu, Shizuoka, 433-8558, Japan
| | - Yuya Homma
- Department of Pulmonology, Kameda Medical Center, 929 Higashimachi, Kamogawa, Chiba, 296-0041, Japan
| | - Haruka Fujioka
- Department of Pulmonology, Kameda Medical Center, 929 Higashimachi, Kamogawa, Chiba, 296-0041, Japan
| | - Tatsuya Nagai
- Department of Pulmonology, Kameda Medical Center, 929 Higashimachi, Kamogawa, Chiba, 296-0041, Japan
| | - Kei Nakashima
- Department of Pulmonology, Kameda Medical Center, 929 Higashimachi, Kamogawa, Chiba, 296-0041, Japan
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Yanagihara T, Oka Y, Moriwaki A, Moriuchi Y, Ogata H, Ishimatsu A, Otsuka J, Taguchi K, Yoshida M. A Case of Pneumocystis Pneumonia Developed During Rheumatoid Arthritis Treatment With Methotrexate and Golimumab. Cureus 2024; 16:e52944. [PMID: 38406039 PMCID: PMC10894044 DOI: 10.7759/cureus.52944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
Here, we report a case of an 87-year-old female patient with rheumatoid arthritis (RA) treated with methotrexate (MTX) and golimumab who developed severe pneumocystis pneumonia (PCP), also known as Pneumocystis jirovecii pneumonia. The patient presented with chief complaints of dyspnea on exertion, dry cough, and fatigue. A high-resolution chest CT scan revealed diffuse, unevenly distributed ground-glass opacities throughout both lungs. The patient was clinically diagnosed with PCP based on the clinical settings, imaging, and a high level of serum β-D-glucan. While the patient required high-flow oxygen therapy, low-dose trimethoprim/sulfamethoxazole and corticosteroid therapy improved her condition, and the patient was discharged on day 25. Although to our knowledge no case report has been published regarding PCP in patients with RA treated with golimumab, this case emphasizes the importance of attention to opportunistic infections in elderly patients receiving immunosuppressive therapy. MTX use alongside tumor necrosis factor inhibitors like golimumab may increase the risk of serious infections such as PCP. The case underscores the necessity of prophylactic measures and early intervention for PCP, highlighting the delicate balance between immunosuppression benefits and infection risks in RA management.
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Affiliation(s)
- Toyoshi Yanagihara
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
| | - Yusuke Oka
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
| | - Atushi Moriwaki
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
| | - Yuki Moriuchi
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
| | - Hiroaki Ogata
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
| | - Akiko Ishimatsu
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
| | - Junji Otsuka
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
| | - Kazuhito Taguchi
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
| | - Makoto Yoshida
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, JPN
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