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Sauvat L, Denis L, Nourrisson C, Poirier P, Ruivard M, Le Guenno G. Pneumocystis jirovecii pneumonia in non-HIV patients: need for a more extended prophylaxis. Front Med (Lausanne) 2024; 11:1414092. [PMID: 38988362 PMCID: PMC11233525 DOI: 10.3389/fmed.2024.1414092] [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] [Received: 04/08/2024] [Accepted: 06/14/2024] [Indexed: 07/12/2024] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PCP) has a significant mortality rate for non-HIV immunocompromised patients. Prevention is primarily based on combined trimethoprim and sulfamethoxazole (TMP-SMX) but guidelines on pneumocystosis prophylaxis are scattered and not consensual. Objectives This study aims to describe PCP in non-HIV patients and to review case by case the prior indication of prophylaxis according to specific guidelines.We included patients with confirmed diagnosis of PCP admitted to one university hospital from 2007 to 2020. Prior indication for pneumocystis prophylaxis was assessed according to the specific guidelines for the underlying pathology or treatment. Results Of 150 patients with a medical diagnosis of PCP, 78 were included. Four groups of underlying pathologies were identified: hematological pathologies (42%), autoimmune diseases (27%), organ transplantation (17%), and other pathologies at risk of PCP (14%). A small subgroup of 14 patients (18%) had received a prior prescription of pneumocystis prophylaxis but none at the time of the episode. Transfer to intensive care was necessary for 33 (42%) patients, and the mortality rate at 3 months was 20%. According to international disease society guidelines, 52 patients (59%) should have been on prophylaxis at the time of the pneumocystis episode. Lowest compliance with guidelines was observed in the hematological disease group for 24 patients (72%) without prescription of indicated prophylaxis. Conclusion Infectious disease specialists should draw up specific prophylactic guidelines against pneumocystis to promote a better prevention of the disease and include additional criteria in their recommendations according to individual characteristics to prevent fatal cases.
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Affiliation(s)
- Léo Sauvat
- Infection Control Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laure Denis
- Department of Internal Medicine, CH Alpes - Lemans, Contamine sur Arve, France
| | - Céline Nourrisson
- Laboratory of Mycology and Parasitology, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 3IHP, Clermont-Ferrand, France
| | - Philippe Poirier
- Laboratory of Mycology and Parasitology, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 3IHP, Clermont-Ferrand, France
| | - Marc Ruivard
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
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Miyake K, Senoo S, Shiiba R, Itano J, Kimura G, Kawahara T, Tamura T, Kudo K, Kawamura T, Nakahara Y, Higo H, Himeji D, Takigawa N, Miyahara N. Pneumocystis jirovecii pneumonia mortality risk associated with preceding long-term steroid use for the underlying disease: A multicenter, retrospective cohort study. PLoS One 2024; 19:e0292507. [PMID: 38330061 PMCID: PMC10852346 DOI: 10.1371/journal.pone.0292507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVE Long-term steroid use increases the risk of developing Pneumocystis pneumonia (PcP), but there are limited reports on the relation of long-term steroid and PcP mortality. METHODS Retrospective multicenter study to identify risk factors for PcP mortality, including average steroid dose before the first visit for PcP in non-human immunodeficiency virus (HIV)-PcP patients. We generated receiver operating characteristic (ROC) curves for 90-day all-cause mortality and the mean daily steroid dose per unit body weight in the preceding 10 to 90 days in 10-day increments. Patients were dichotomized by 90-day mortality and propensity score-based stabilized inverse probability of treatment weighting (IPTW) adjusted covariates of age, sex, and underlying disease. Multivariate analysis with logistic regression assessed whether long-term corticosteroid use affected outcome. RESULTS Of 133 patients with non-HIV-PcP, 37 died within 90 days of initial diagnosis. The area under the ROC curve for 1-40 days was highest, and the optimal cutoff point of median adjunctive corticosteroid dosage was 0.34 mg/kg/day. Past steroid dose, underlying interstitial lung disease and emphysema, lower serum albumin and lower lymphocyte count, higher lactate dehydrogenase, use of therapeutic pentamidine and therapeutic high-dose steroids were all significantly associated with mortality. Underlying autoimmune disease, past immunosuppressant use, and a longer time from onset to start of treatment, were associated lower mortality. Logistic regression analysis after adjusting for age, sex, and underlying disease with IPTW revealed that steroid dose 1-40 days before the first visit for PcP (per 0.1 mg/kg/day increment, odds ratio 1.36 [95% confidence interval = 1.16-1.66], P<0.001), low lymphocyte counts, and high lactate dehydrogenase revel were independent mortality risk factor, while respiratory failure, early steroid, and sulfamethoxazole/trimethoprim for PcP treatment did not. CONCLUSION A steroid dose before PcP onset was strongly associated with 90-day mortality in non-HIV-PcP patients, emphasizing the importance of appropriate prophylaxis especially in this population.
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Affiliation(s)
- Kohei Miyake
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Satoru Senoo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Ritsuya Shiiba
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Junko Itano
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Goro Kimura
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Tatsuyuki Kawahara
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Tomoki Tamura
- Department of Respiratory Medicine, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Kenichiro Kudo
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Hisao Higo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Daisuke Himeji
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Nagio Takigawa
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Nobuaki Miyahara
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Guo HJ, Ye YL, Cao R, Liu ZH, He Q. Association between the cumulative dose of glucocorticoids before the development of pneumonia and death in patients receiving long-term glucocorticoids: a secondary analysis based on a Chinese cohort study. Front Med (Lausanne) 2023; 10:1175855. [PMID: 37547616 PMCID: PMC10399627 DOI: 10.3389/fmed.2023.1175855] [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] [Received: 03/01/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Background The present study aimed to evaluate the association between the cumulative dose of glucocorticoids (GCs) and case fatality in hospitalized patients who developed pneumonia while receiving glucocorticoid therapy. Methods This retrospective cohort study included 625 patients receiving long-term GC treatment who were hospitalized with pneumonia (322 male and 303 female). Data were obtained from the Dryad Digital Repository and were used to perform secondary analysis. Multivariable Cox proportional hazard regression model and restricted cubic splines (RCS) were used to evaluate the association between the cumulative dose of GCs and case fatality. Sensitivity analyses and subgroup analyses were performed. Results The 30-day and 90-day death rates were 22.9 and 26.2%, respectively. After adjusting for potential confounders, compared with those in the lowest quintile (≤ 1.5 g), the Cox proportional hazard regression model analysis showed that patients with different cumulative doses of GCs (1.5 to 2.95, 2.95 to 5, 5 to 11.5, and > 11.5 g) had lower risks for 30-day death, with respective hazard ratios of 0.86 (95% CI, 0.52 to 1.42), 0.81 (0.49 to 1.33), 0.29 (0.15 to 0.55), and 0.42 (0.22 to 0.79). The multivariable-adjusted RCS analysis suggested a statistically significant N-shaped association between the cumulative dose of GCs and 30-day death. A higher cumulative dose of GC tended to first lead to an increase in 30-day death within 1.8 g, then to a statistically significant decrease until around 8 g [HR for 1 g = 0.82 (0.69 to 0.97)], and again to an increase afterward. Similar results were found in the subgroup analyses and sensitivity analyses. Conclusion N-shaped association between the cumulative dose of GCs and case fatality was observed in patients receiving long-term GC treatment who were hospitalized with pneumonia. Our findings may help physicians manage these patients.
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Affiliation(s)
- Hui-Jie Guo
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Yi-Lu Ye
- Department of Rehabilitation Medicine, Key Laboratory of Biological Targeting Diagnosis, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rong Cao
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Zhi-Hua Liu
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qun He
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
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Lang Q, Li L, Zhang Y, He X, Liu Y, Liu Z, Yan H. Development and Validation of a Diagnostic Nomogram for Pneumocystis jirovecii Pneumonia in Non-HIV-Infected Pneumonia Patients Undergoing Oral Glucocorticoid Treatment. Infect Drug Resist 2023; 16:755-767. [PMID: 36760781 PMCID: PMC9907006 DOI: 10.2147/idr.s398850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023] Open
Abstract
Purpose Pneumocystis jirovecii pneumonia (PJP) is an opportunistic but potentially fatal infection with increasing prevalence in HIV-free patients. Glucocorticoid therapy is one of the most important risk factors for PJP. The delay in diagnosis contributes to poor outcomes. Hence, the aim of this study was to develop and validate a nomogram for the diagnosis of PJP in patients with non-HIV-infected pneumonia who are undergoing oral glucocorticoid treatment. Patients and Methods This study was a retrospective, cross-sectional research. The development group included 434 patients who were admitted with pneumonia from 6 hospitals. Demographics, symptomatic features, laboratory and computed tomography data were analyzed using the least absolute shrinkage and selection operator (LASSO) to select potential diagnostic indicators. Binary logistic regression was used to develop a diagnostic nomogram. Another 119 patients with pneumonia admitted at Sichuan Provincial People's Hospital was used as the validation group. The diagnostic performance of the nomogram was measured by area under the receiver-operating-characteristics curve (AUC), calibration curves, and the net benefit by decision curve. Results PJP prevalence was 25.3% in the development group. LASSO regression revealed that age, lymphocyte count, fever, dry cough, respiratory failure, ground-glass opacity in lungs, glucocorticoid therapy duration, and immunosuppressive therapy were indicators of PJP. The nomogram showed robust discrimination, with an AUC of 0.82 (95% CI 0.77-0.86) in the development group and an AUC of 0.87 (95% CI 0.80-0.94) in the validation group, both showing acceptable calibration. In the decision curve analysis, our model consistently achieved a greater net benefit across almost all ranges of clinical thresholds. Conclusion We developed a nomogram with good diagnostic power for PJP diagnosis in pneumonia patients receiving oral glucocorticoids. This nomogram may help promote timely treatment of PJP and thus reduce the mortality rate in these patients.
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Affiliation(s)
- Qin Lang
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China,Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610000, People’s Republic of China
| | - Lijuan Li
- National Clinical Research Centre for Respiratory Diseases, China-Japan Friendship Hospital, Capital Medical University, Beijing, 100000, People’s Republic of China
| | - Yue Zhang
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China
| | - Xing He
- School of Clinical Medicine, Chengdu Medical College, Chengdu, 610000, People’s Republic of China
| | - Yafeng Liu
- School of Medicine, Anhui University of Science and Technology, Huainan, 232000, People’s Republic of China,Anhui Province Engineering Laboratory of Occupational Health and Safety, Huainan, 232000, People’s Republic of China
| | - Zhen Liu
- The First Hospital of Liangshan Prefecture, Xichang, 615000, People’s Republic of China
| | - Haiying Yan
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China,Department of Pulmonary and Critical Care Medicine, Chengdu Qing Cheng Mt. Hospital, Chengdu, 610000, People’s Republic of China,Correspondence: Haiying Yan, Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Sec 2, 1st Ring Road, Chengdu, Sichuan, 610000, People’s Republic of China, Tel/Fax +86-18981838295, Email
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Park JW, Curtis JR, Jun KI, Kim TM, Heo DS, Ha J, Suh KS, Lee KW, Lee H, Yang J, Kim MJ, Choi Y, Lee EB. Primary prophylaxis for Pneumocystis jirovecii pneumonia in patients receiving rituximab. Chest 2021; 161:1201-1210. [PMID: 34788668 DOI: 10.1016/j.chest.2021.11.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/07/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Although previous studies suggested that rituximab increases the risk of Pneumocystis jirovecii pneumonia (PJP), it is uncertain whether its primary prophylaxis for PJP is justified. RESEARCH QUESTION Does the benefit of primary prophylaxis for PJP in patients receiving rituximab treatment outweigh the potential risk of the prophylaxis? STUDY DESIGN AND METHODS This retrospective study included 3524 patients (hematologic diseases=2500; rheumatic diseases=559; pre/post-solid organ transplantation=465) first exposed to rituximab between 2002 and 2018 in a tertiary referral center in South Korea. Patients were classified into a control group (n=2523) and a prophylaxis group (n=1001) according to the administration of prophylactic TMP-SMX during the first 28 days after the start of rituximab (intention-to-treat analysis). In addition, exposure to TMP-SMX was examined as a time-varying variable (time-varying analysis). Primary outcome was the prophylactic effect of TMP-SMX on the 1-year incidence of PJP. Inverse probability of treatment weights was applied to minimize the baseline imbalance. Secondary outcome included the incidence of adverse drug reactions (ADRs) related to TMP-SMX. RESULTS Over 2759.9 person-years, 92 PJP infections occurred, with a mortality rate of 27.2%. The prophylaxis group showed a significantly lower incidence of PJP (adjusted sub-distribution hazard ratio (aSHR), 0.20 [95% CI, 0.10-0.42]) than the control group. This result was consistent with the results of time-varying analysis, in which only one PJP infection occurred during TMP-SMX administration (aSHR, 0.01 [0.003-0.16]). The incidence of adverse drug reactions (ADRs) related to TMP-SMX was 18.1 (14.6-22.2)/100 person-years, and most were of mild-to-moderate severity. Based on ten severe ADRs, the number needed to harm was 101 (61.9-261.1), whereas the number needed to prevent one PJP infection was 32 (24.8-39.4). INTERPRETATION TMP-SMX prophylaxis significantly reduces PJP incidence with a tolerable safety profile in patients receiving rituximab treatment.
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Affiliation(s)
- Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeffrey R Curtis
- Division of Clinical Immunology & Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kang Il Jun
- Division of Infectious Disease, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Tae Min Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Dae Seog Heo
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea; Transplantation Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hajeong Lee
- Division of Nephrology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jaeseok Yang
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Jung Kim
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea.
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Honda N, Tagashira Y, Kawai S, Kobayashi T, Yamamoto M, Shimada K, Yokogawa N. Reduction of Pneumocystis jirovecii pneumonia and bloodstream infections by trimethoprim-sulfamethoxazole prophylaxis in patients with rheumatic diseases. Scand J Rheumatol 2021; 50:365-371. [PMID: 33749507 DOI: 10.1080/03009742.2020.1850854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: Trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis against Pneumocystis jirovecii pneumonia (PJP) is routinely administered to patients with rheumatic diseases in Japan. The present study aimed to evaluate the effect of TMP/SMX prophylaxis on PJP and non-central line-associated bloodstream infections (BSIs) in patients receiving high-dose glucocorticoids for the treatment of rheumatic diseases.Method: This study enrolled patients who were admitted between 1 October 2003 and 31 March 2018 and began high-dose glucocorticoid therapy for rheumatic diseases during hospitalization. The observation period was 4 months from the commencement of high-dose glucocorticoid therapy. The effect of TMP/SMX prophylaxis on PJP and non-central line-associated BSI was analysed.Results: Of the 437 patients included in the study, 376 received TMP/SMX prophylaxis and 61 patients did not. During the observation period, TMP/SMX prophylaxis was discontinued in 76 patients (20.2%). Three PJP cases (0.7%) occurred. Among the 399 patients included in our analysis of non-central line-associated BSI, eight experienced non-central line-associated BSI (2.0%). Among the covariates, TMP/SMX prophylaxis was associated with reduced PJP and non-central line-associated BSI incidence [odds ratio (OR) 0, 95% confidence interval (CI) 0.00-0.38, and OR 0.08, 95% CI 0.01-0.42, respectively].Conclusion: Routine TMP/SMX prophylaxis reduced the incidence of both PJP and BSI in patients with rheumatic diseases undergoing high-dose glucocorticoid therapy.
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Affiliation(s)
- N Honda
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Y Tagashira
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - S Kawai
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - T Kobayashi
- Department of Infection Prevention and Control, Tokyo Medical University Hospital, Tokyo, Japan
| | - M Yamamoto
- Department of Rheumatology and Nephrology, Chubu Rosai Hospital, Nagoya, Japan
| | - K Shimada
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - N Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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Kronbichler A, Gauckler P. The value of Pneumocystis jirovecii pneumonia prophylaxis in the era of personalized medicine. Scand J Rheumatol 2020; 49:343-344. [DOI: 10.1080/03009742.2020.1762924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- A Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - P Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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