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McDonald EG, Afshar A, Assiri B, Boyles T, Hsu JM, Khuong N, Prosty C, So M, Sohani ZN, Butler-Laporte G, Lee TC. Pneumocystis jirovecii pneumonia in people living with HIV: a review. Clin Microbiol Rev 2024; 37:e0010122. [PMID: 38235979 PMCID: PMC10938896 DOI: 10.1128/cmr.00101-22] [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] [Indexed: 01/19/2024] Open
Abstract
Pneumocystis jirovecii is a ubiquitous opportunistic fungus that can cause life-threatening pneumonia. People with HIV (PWH) who have low CD4 counts are one of the populations at the greatest risk of Pneumocystis jirovecii pneumonia (PCP). While guidelines have approached the diagnosis, prophylaxis, and management of PCP, the numerous studies of PCP in PWH are dominated by the 1980s and 1990s. As such, most studies have included younger male populations, despite PCP affecting both sexes and a broad age range. Many studies have been small and observational in nature, with an overall lack of randomized controlled trials. In many jurisdictions, and especially in low- and middle-income countries, the diagnosis can be challenging due to lack of access to advanced and/or invasive diagnostics. Worldwide, most patients will be treated with 21 days of high-dose trimethoprim sulfamethoxazole, although both the dose and the duration are primarily based on historical practice. Whether treatment with a lower dose is as effective and less toxic is gaining interest based on observational studies. Similarly, a 21-day tapering regimen of prednisone is used for patients with more severe disease, yet other doses, other steroids, or shorter durations of treatment with corticosteroids have not been evaluated. Now with the widespread availability of antiretroviral therapy, improved and less invasive PCP diagnostic techniques, and interest in novel treatment strategies, this review consolidates the scientific body of literature on the diagnosis and management of PCP in PWH, as well as identifies areas in need of more study and thoughtfully designed clinical trials.
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Affiliation(s)
- Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Avideh Afshar
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Bander Assiri
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tom Boyles
- Right to Care, NPC, Centurion, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jimmy M. Hsu
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Connor Prosty
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University of Toronto, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Zahra N. Sohani
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Liao TY, Huang YT, Lee TF, Hsueh PR, Yu CJ, Chien JY. Clinical significance of mutations in dihydropteroate synthase in Pneumocystis jirovecii pneumonia among non-HIV-infected patients. Int J Antimicrob Agents 2024; 63:107019. [PMID: 37925109 DOI: 10.1016/j.ijantimicag.2023.107019] [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: 03/23/2023] [Revised: 07/17/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Dihydropteroate synthase (DHPS) mutations may be associated with trimethoprim-sulfamethoxazole resistance in Pneumocystis jirovecii pneumonia (PCP) and worse clinical outcomes. However, the clinical significance of DHPS mutations in PCP among non-human immunodeficiency virus (HIV)-infected patients remains unclear. METHODS Patients with PCP in three tertiary referral hospitals in Taiwan between 2016 and 2020 were retrospectively enrolled. Two point mutations, Thr55Ala and Pro57Ser, in the DHPS protein were analysed. Patients with invalid DHPS mutations in the respiratory specimen, chronic respiratory failure, receiving endotracheal intubation for surgical intervention, HIV infection, Pneumocystis jirovecii colonisation, and no lactate dehydrogenase (LDH) data were excluded. The primary outcome was 30-day survival. RESULTS A total of 215 patients were analysed. Mutants inside DHPS were found in 78 patients (36.3%) and 68 patients (31.6%) died within 30 days. A total of 214 patients (99.5%) received trimethoprim-sulfamethoxazole as the first-line treatment. The rates of mechanical ventilation, 30-day, and in-hospital mortality were similar between wild-type and mutant DHPS PCP. After adjusting for important confounders, LDH > 500 µ/L (adjusted hazard ratio [aHR] = 2.448, P = 0.001), pneumonia severity index > 135 mg/dL (aHR = 1.689, P = 0.049), and having solid tumours (aHR = 1.832, P = 0.034) were independently associated with higher mortality. In subgroup analysis, mutant DHPS PCP patients had less 30-day mortality among patients aged > 65 years (P = 0.049), with lymphopenia (P = 0.040), and those without solid tumour (P = 0.045). CONCLUSIONS In non-HIV-infected PCP, point mutants inside DHPS may not be associated with trimethoprim-sulfamethoxazole treatment outcomes. Further prospective large-scale studies are warranted.
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Affiliation(s)
- Ting-Yu Liao
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Tsung Huang
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tai-Fen Lee
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Qi H, Dong D, Liu N, Xu Y, Qi M, Gu Q. Efficacy of initial caspofungin plus trimethoprim/sulfamethoxazole for severe PCP in patients without human immunodeficiency virus infection. BMC Infect Dis 2023; 23:409. [PMID: 37328748 PMCID: PMC10273704 DOI: 10.1186/s12879-023-08372-z] [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: 04/07/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND The number of pneumocystis pneumonia (PCP) cases is increasing in immunocompromised patients without human immunodeficiency virus infection (HIV), causing serious morbidity with high mortality. Trimethoprim/sulfamethoxazole (TMP/SMZ) monotherapy has limited effectiveness in the treatment of PCP. Clinical data on whether initial caspofungin plus TMP/SMZ for this disease is superior to monotherapy in non-HIV-infected patients are limited. We aimed to compare the clinical effectiveness of these regimens for severe PCP in non-HIV patients. METHODS A retrospective study reviewed 104 non-HIV-infected patients with confirmed PCP in the intensive care unit between January 2016 and December 2021. Eleven patients were excluded from the study because TMP/SMZ could not be used due to severe hematologic disorders or clinical data were missing. All enrolled patients were divided into three groups according to different treatment strategies: Group 1 received TMP/SMZ monotherapy, Group 2 received caspofungin combined with TMP/SMZ as first-line therapy, and Group 3 initially received TMP/SMZ monotherapy and later received caspofungin as salvage therapy. The clinical characteristics and outcomes were compared among the groups. RESULTS A total of 93 patients met the criteria. The overall positive response rate of anti-PCP treatment was 58.06%, and the overall 90-day all-cause mortality rate was 49.46%. The median APACHE II score was 21.44. The concurrent infection rate was 74.19%, among whom 15.05% (n = 14) of those patients had pulmonary aspergillosis, 21.05% (n = 20) had bacteremia, and 23.65% (n = 22) had CMV infections. The patients who received initial caspofungin combination with TMP/SMZ had the best positive response rate (76.74%) compared to others (p = 0.001). Furthermore, the group that received initial caspofungin combined with TMP/SMZ had a 90-day all-cause mortality rate (39.53%) that was significantly different from that of the shift group (65.51%, p = 0.024), but this rate showed no statistically significant difference compared with that in the monotherapy group (48.62%, p = 0.322). None of the patients had serious adverse events from caspofungin therapy. CONCLUSIONS For non-HIV-infected patients with severe PCP, initial combination therapy with caspofungin and TMP/SMZ is a promising first-line treatment option compared with TMP/SMZ monotherapy and combination therapy as salvage therapy.
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Affiliation(s)
- Hui Qi
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Danjiang Dong
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Ning Liu
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Ying Xu
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Mengzhi Qi
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Qin Gu
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China.
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Trubin PA, Azar MM. Current Concepts in the Diagnosis and Management of Pneumocystis Pneumonia in Solid Organ Transplantation. Infect Dis Clin North Am 2023:S0891-5520(23)00026-0. [PMID: 37142510 DOI: 10.1016/j.idc.2023.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Pneumocystis infection manifests predominantly as an interstitial pneumonia in immunocompromised patients. Diagnostic testing in the appropriate clinical context can be highly sensitive and specific and involves radiographic imaging, fungal biomarkers, nucleic acid amplification, histopathology, and lung fluid or tissue sampling. Trimethoprim-sulfamethoxazole remains the first-choice agent for treatment and prophylaxis. Investigation continues to promote a deeper understanding of the pathogen's ecology, epidemiology, host susceptibility, and optimal treatment and prevention strategies in solid organ transplant recipients.
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Affiliation(s)
- Paul A Trubin
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, 135 College Street, New Haven, CT 06510, USA.
| | - Marwan M Azar
- Department of Medicine, Section of Infectious Diseases; Department of Laboratory Medicine; Yale School of Medicine, 135 College Street, New Haven, CT 06510, USA
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Huang YM, Lu CH, Cheng CF, Shen CY, Hsieh SC, Li KJ, Chien JY, Hsueh PR. Clinical features and prognostic predictors in patients with rheumatic diseases complicated by Pneumocystis pneumonia. Int J Infect Dis 2022; 122:1018-1025. [DOI: 10.1016/j.ijid.2022.07.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/19/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022] Open
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Efficacy of Trimethoprim–Sulfamethoxazole in Combination with an Echinocandin as a First-Line Treatment Option for Pneumocystis Pneumonia: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11060719. [PMID: 35740126 PMCID: PMC9220274 DOI: 10.3390/antibiotics11060719] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/19/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
Although combination therapy using trimethoprim–sulfamethoxazole (TMP–SMX) plus echinocandins has been reported to reduce the mortality of patients with pneumocystis pneumonia (PCP), it remains unclear whether it is more effective than TMP–SMX monotherapy, the current first-line treatment for this disease. Hence, we performed a systematic review and meta-analysis to compare the efficacies of these treatment options for PCP. The Scopus, EMBASE, PubMed, CINAHL, and Ichushi databases were searched for studies (up to January 2022) reporting the mortality and positive response rates (fewer clinical symptoms, improved partial pressure of arterial oxygen, and resolution of pneumonitis on chest imaging) of PCP patients receiving monotherapy or combination therapy. Four studies met the inclusion criteria. All four presented mortality data and one had positive response rates. Compared with the monotherapy, the combination therapy resulted in significantly lower mortality and higher positive response rates (mortality: odds ratio (OR) 2.20, 95% confidence interval (CI) 1.46–3.31; positive response rate: OR 2.13, 95%CI 1.41–3.23), suggesting it to be an effective and promising first-line therapy for PCP. However, further safety evaluations are needed to establish this as a fact.
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Szymański M, Chmielewska S, Czyżewska U, Malinowska M, Tylicki A. Echinocandins - structure, mechanism of action and use in antifungal therapy. J Enzyme Inhib Med Chem 2022; 37:876-894. [PMID: 35296203 PMCID: PMC8933026 DOI: 10.1080/14756366.2022.2050224] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
With increasing number of immunocompromised patients as well as drug resistance in fungi, the risk of fatal fungal infections in humans increases as well. The action of echinocandins is based on the inhibition of β-(1,3)-d-glucan synthesis that builds the fungal cell wall. Caspofungin, micafungin, anidulafungin and rezafungin are semi-synthetic cyclic lipopeptides. Their specific chemical structure possess a potential to obtain novel derivatives with better pharmacological properties resulting in more effective treatment, especially in infections caused by Candida and Aspergillus species. In this review we summarise information about echinocandins with closer look on their chemical structure, mechanism of action, drug resistance and usage in clinical practice. We also introduce actual trends in modification of this antifungals as well as new methods of their administration, and additional use in viral and bacterial infections.
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Affiliation(s)
- Mateusz Szymański
- Department of Microbiology and Biotechnology, Laboratory of Cytobiochemistry, University of Bialystok, Bialystok, Poland
| | - Sandra Chmielewska
- Doctoral School of Exact and Natural Sciences, University of Bialystok, Bialystok, Poland
| | - Urszula Czyżewska
- Department of Microbiology and Biotechnology, Laboratory of Cytobiochemistry, University of Bialystok, Bialystok, Poland
| | - Marta Malinowska
- Department of Organic Chemistry, Laboratory of Natural Product Chemistry, University of Bialystok, Bialystok, Poland
| | - Adam Tylicki
- Department of Microbiology and Biotechnology, Laboratory of Cytobiochemistry, University of Bialystok, Bialystok, Poland
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