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Chiu CY, Ching PR. Incidence of Pneumocystis pneumonia in Immunocompromised Patients without Human Immunodeficiency Virus with Intravenous Pentamidine Prophylaxis: A Systematic Review and Meta-Analysis. J Fungi (Basel) 2023; 9:jof9040406. [PMID: 37108861 PMCID: PMC10144649 DOI: 10.3390/jof9040406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Trimethoprim-sulfamethoxazole (TMP-SMX) is a first-line Pneumocystis pneumonia pneumonia) (PCP) prophylaxis agent, but monthly intravenous pentamidine (IVP) is used in human immunodeficiency virus (HIV)-uninfected immunocompromised hosts because IVP is not associated with cytopenia and delayed engraftment. Method: We performed a systematic review and meta-analysis to estimate breakthrough PCP incidence and adverse reactions in HIV-uninfected immunocompromised patients receiving IVP. MEDLINE, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov were searched from their inception until 15 December 2022. Results: The pooled incidence of breakthrough PCP with IVP was 0.7% (95% CI, 0.3–1.4%, 16 studies, 3025 patients) and was similar when used as first-line prophylaxis (0.5%; 95% CI, 0.2–1.4%, 7 studies, 752 patients). The pooled incidence of adverse reactions was 11.3% (95% CI, 6.7–18.6%, 14 studies, 2068 patients). The pooled adverse event-related discontinuation was 3.7% (95% CI, 1.8–7.3%, 11 studies, 1802 patients), but was lower in patients receiving IVP monthly (2.0%; 95% CI 0.7–5.7%, 7 studies, 1182 patients). Conclusion: Monthly IVP is an appropriate second-line agent for PCP prophylaxis in certain non-HIV immunocompromised hosts, especially in patients with hematologic malignancies and hematopoietic stem cell transplant recipients. Using IVP for PCP prophylaxis as an alternative to oral TMP-SMX while patients are unable to tolerate enteral medication administration is feasible.
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Mantadakis E. Pneumocystis jirovecii Pneumonia in Children with Hematological Malignancies: Diagnosis and Approaches to Management. J Fungi (Basel) 2020; 6:jof6040331. [PMID: 33276699 PMCID: PMC7761543 DOI: 10.3390/jof6040331] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects children with suppressed cellular immunity. PJP was the most common cause of infectious death in children with acute lymphoblastic leukemia prior to the inclusion of cotrimoxazole prophylaxis as part of the standard medical care in the late 1980s. Children with acute leukemia, lymphomas, and those undergoing hematopoietic stem cell transplantation, especially allogeneic transplantation, are also at high risk of PJP. Persistent lymphopenia, graft versus host disease, poor immune reconstitution, and lengthy use of corticosteroids are significant risk factors for PJP. Active infection may be due to reactivation of latent infection or recent acquisition from environmental exposure. Intense hypoxemia and impaired diffusing capacity of the lungs are hallmarks of PJP, while computerized tomography of the lungs is the diagnostic technique of choice. Immunofluorescence testing with monoclonal antibodies followed by fluorescent microscopy and polymerase chain reaction testing of respiratory specimens have emerged as the best diagnostic methods. Measurement of (1-3)-β-D-glucan in the serum has a high negative predictive value in ruling out PJP. Oral cotrimoxazole is effective for prophylaxis, but in intolerant patients, intravenous and aerosolized pentamidine, dapsone, and atovaquone are effective alternatives. Ιntravenous cotrimoxazole is the treatment of choice, but PJP has a high mortality even with appropriate therapy.
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatrics, Hematology/Oncology Unit, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68 100 Alexandroupolis, Thrace, Greece
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Hanisch B, Sprott K, Ardura MI. Pneumocystis jirovecii and toxoplasmosis prophylaxis strategies among pediatric organ transplantation recipients: A US National Survey. Transpl Infect Dis 2020; 22:e13290. [PMID: 32278336 DOI: 10.1111/tid.13290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
There is a paucity of pediatric-specific data to guide consensus recommendations for the prevention of Pneumocystis jirovecii pneumonia (PCP) and toxoplasmosis after solid organ transplantation. We surveyed pediatric transplantation providers and found considerable variability in prophylaxis strategies, despite current guideline recommendations that are based primarily on adult data.
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Affiliation(s)
- Benjamin Hanisch
- Division of Infectious Diseases, Department of Pediatrics, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Kathleen Sprott
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - Monica I Ardura
- Division of Infectious Diseases and Host Defense Program, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
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Brown KS, Reed MD, Dalal J, Makii MD. Tolerability of Aerosolized Versus Intravenous Pentamidine for Pneumocystis jirovecii Pneumonia Prophylaxis in Immunosuppressed Pediatric, Adolescent, and Young Adult Patients. J Pediatr Pharmacol Ther 2020; 25:111-116. [PMID: 32071585 DOI: 10.5863/1551-6776-25.2.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Pentamidine is an antifungal that is used alternatively to sulfamethoxazole-trimethoprim for the prophylaxis and treatment of Pneumocystis jirovecii pneumonia (PJP). The primary objective of this study was to assess the tolerability of aerosolized versus intravenous pentamidine for PJP prophylaxis in pediatric, adolescent, and young adult immunosuppressed patients. Secondary objectives included comparing pentamidine formulation reaction to dosing frequency and diagnosis. METHODS This retrospective chart review used electronic medical record (EMR) data from patients at a tertiary care pediatric teaching institution from January 1, 2014, to January 1, 2017. Information used from the EMR included pentamidine dosing, ordering, and laboratory values. Inclusion criteria consisted of patients with a cancer diagnosis, hematopoietic stem cell transplant (HSCT) recipients, and renal transplant recipients who received pentamidine for PJP prophylaxis. RESULTS Ninety-six patients met inclusion criteria, of which 31 received aerosolized pentamidine. Ten of the 96 patients experienced a drug-related reaction to either aerosolized or intravenous pentamidine (p = 0.134). Nine of 10 patients who experienced a reaction received intravenous pentamidine versus 1 patient who received aerosolized pentamidine (p = 0.132). In those patients who reacted to pentamidine there was a higher incidence of reactions after subsequent administration (p = 0.039) and in patients with a blood cancer diagnosis (p = 0.042). CONCLUSIONS Data suggest that patients who receive aerosolized pentamidine may tolerate therapy better compared to intravenous administration. Additional studies involving larger numbers of pediatric, adolescent, and young adult patients are needed for stronger statistically significant clinical differences in tolerability of aerosolized versus intravenous pentamidine.
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Sweiss K, Anderson J, Wirth S, Oh A, Quigley JG, Khan I, Saraf S, Mactal-Haaf C, Rondelli D, Patel P. A prospective study of intravenous pentamidine for PJP prophylaxis in adult patients undergoing intensive chemotherapy or hematopoietic stem cell transplant. Bone Marrow Transplant 2017; 53:300-306. [DOI: 10.1038/s41409-017-0024-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/18/2017] [Accepted: 10/30/2017] [Indexed: 11/09/2022]
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Kruizinga MD, Bresters D, Smiers FJ, Lankester AC, Bredius RGM. The use of intravenous pentamidine for the prophylaxis of Pneumocystis pneumonia in pediatric patients. Pediatr Blood Cancer 2017; 64. [PMID: 28074607 DOI: 10.1002/pbc.26453] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 11/25/2016] [Accepted: 12/18/2016] [Indexed: 11/06/2022]
Abstract
Pneumocystis jiroveci pneumonia was common in the immunocompromised host before the widespread use of prophylaxis. When trimethoprim-sulfamethoxazole is not tolerated, prophylaxis with intravenous pentamidine (IVP) may be initiated. We performed a retrospective analysis of all pediatric patients who received IVP regarding efficacy, safety, and reason for initiation. Of 106 patients included in our analysis, one patient tested positive for Pneumocystis DNA. Adverse events were reported in 18% of IVP courses, and main reason for initiation was cytopenia (59%). We found IVP to be effective and safe, and recommend the use of IVP in pediatric patients in whom first-line prophylaxis is contraindicated.
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Affiliation(s)
- Matthijs D Kruizinga
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
| | - Dorine Bresters
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J Smiers
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan C Lankester
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
| | - Robbert G M Bredius
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
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Guidelines for the Prophylaxis of Pneumocystis jirovecii Pneumonia (PJP) in Children With Solid Tumors. J Pediatr Hematol Oncol 2017; 39:194-202. [PMID: 28267082 DOI: 10.1097/mph.0000000000000771] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Although it is well-established that children undergoing allogeneic stem cell transplants and treatment for leukemia should be offered prophylaxis against Pneumocystis jirovecii pneumonia, the risk for children with solid malignancies is less certain. This guideline has been developed with the aim of standardizing practice and optimizing the benefit versus risk of prophylactic medication in this group of patients. P. jirovecii pneumonia has a high mortality rate even with prompt antimicrobial treatment. Since prophylaxis with co-trimoxazole is safe, effective, and inexpensive, we suggest that all children with malignancies undergoing immunosuppressive therapy are offered prophylaxis unless there are clear contraindications.
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Safety and Effectiveness of Intravenous Pentamidine for Prophylaxis of Pneumocystis jirovecii Pneumonia in Pediatric Hematology/Oncology Patients. J Pediatr Hematol Oncol 2016; 38:e180-5. [PMID: 27164533 DOI: 10.1097/mph.0000000000000584] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection that can lead to significant morbidity and mortality in immunocompromised pediatric hematology/oncology patients. Trimethoprim/sulfamethoxazole is the gold standard for prophylaxis. Intravenous (IV) pentamidine is the preferred second-line agent for PCP prophylaxis at our institution and is used first-line under certain circumstances. The purpose of this study is to evaluate the effectiveness and safety of IV pentamidine for PCP prophylaxis in pediatric hematology/oncology patients. MATERIALS AND METHODS A retrospective analysis of pediatric hematology/oncology patients (N=121) who received ≥1 dose of IV pentamidine between January 2009 and July 2014 was conducted. Electronic health records were reviewed to determine baseline characteristics, rate of breakthrough PCP infection, characteristics of IV pentamidine use, and adverse events. The follow-up period was 6 months after the last reported IV pentamidine dose or the last recorded clinic visit/hospital admission. RESULTS No patients developed PCP during the entirety of their IV pentamidine course or during the follow-up period. Nineteen patients (16%) experienced adverse events and 5 of the 19 patients required discontinuation of IV pentamidine. CONCLUSIONS IV pentamidine is a safe, tolerable, and effective agent for PCP prophylaxis in pediatric hematology/oncology patients and may be considered a reasonable therapeutic alternative when trimethoprim/sulfamethoxazole cannot be used for PCP prophylaxis.
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Safe and Effective Prophylaxis with Bimonthly Intravenous Pentamidine in the Pediatric Hematopoietic Stem Cell Transplant Population. Pediatr Infect Dis J 2016; 35:135-41. [PMID: 26418240 DOI: 10.1097/inf.0000000000000946] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Without prophylaxis, Pneumocystis jiroveci pneumonia (PCP) develops in 5%-15% of pediatric hematopoietic stem cell transplant (HCT) patients with mortality above 50%. Trimethoprim-sulfamethoxazole is a standard PCP prophylaxis; pentamidine is frequently used as second-line prophylaxis because of trimethoprim-sulfamethoxazole's potential for cytopenias. Monthly intravenous (IV) pentamidine has variable efficacy with PCP infection rates of 0%-10% in pediatric patients, and higher breakthrough rates in those younger than 2 years. We hypothesized that bimonthly (twice monthly) pentamidine might have equivalent safety and improved efficacy; therefore, we conducted a retrospective analysis of bimonthly pentamidine PCP prophylaxis. METHODS We retrospectively reviewed records of all pediatric HCT patients who received bimonthly IV pentamidine between December 2006 and June 2013, and collected data regarding demographics, clinical course, prophylaxis rationale, laboratory values and adverse events. RESULTS Between December 2006 and June 2013, 111 pediatric HCT patients received bimonthly IV pentamidine (574 doses, 8758 patient-days); 31 patients were younger than 2 years at initiation. In the majority (53% of courses), pentamidine was initiated because of cytopenias. Fourteen patients (12.6% of patients, 2.4% of doses) experienced a side-effect prompting discontinuation, including 3 patients with infusion-related hypotension/anaphylaxis and 3 with acute pancreatic dysfunction. No patients [0% (95% confidence interval: 0-3.2)] developed PCP during or after bimonthly IV pentamidine prophylaxis. CONCLUSIONS Bimonthly IV pentamidine for PCP prophylaxis in the HCT pediatric population has comparable safety to monthly IV pentamidine and was highly effective, including in the very young. Bimonthly IV pentamidine should be considered in pediatric patients as second-line PCP prophylaxis.
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Diri R, Anwer F, Yeager A, Krishnadasan R, McBride A. Retrospective review of intravenous pentamidine forPneumocystispneumonia prophylaxis in allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2016; 18:63-9. [DOI: 10.1111/tid.12486] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/14/2015] [Accepted: 09/27/2015] [Indexed: 11/29/2022]
Affiliation(s)
- R. Diri
- The University of Arizona College of Pharmacy; Tucson Arizona USA
- College of Pharmacy; King Abdulaziz University; Jeddah Saudi Arabia
| | - F. Anwer
- Medicine Department; The University of Arizona College of Medicine; Tucson Arizona USA
| | - A. Yeager
- Medicine Department; The University of Arizona College of Medicine; Tucson Arizona USA
| | - R. Krishnadasan
- Medicine Department; The University of Arizona College of Medicine; Tucson Arizona USA
| | - A. McBride
- Pharmacy Department; The University of Arizona Cancer Center; Tucson Arizona USA
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Clark A, Hemmelgarn T, Danziger-Isakov L, Teusink A. Intravenous pentamidine for Pneumocystis carinii/jiroveci pneumonia prophylaxis in pediatric transplant patients. Pediatr Transplant 2015; 19:326-31. [PMID: 25712369 DOI: 10.1111/petr.12441] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 11/30/2022]
Abstract
SMX/TMP is the current gold standard for prophylaxis against PCP in immunocompromised pediatric patients. Currently, there are several second-line options for prophylaxis but many, including intravenous (IV) pentamidine, have not been reported to be as effective or as safe as SMX/TMP in the pediatric transplant population. This study is to determine the efficacy and safety of IV pentamidine in preventing PCP in pediatric transplant patients. A retrospective chart review was conducted to evaluate all transplant patients that received at least one dose of IV pentamidine from January 2010 to July 2013. The primary outcome, IV pentamidine efficacy, was evaluated by the incidence of PCP diagnosis for 28 days after the last dose of IV pentamidine if patient was transitioned to another agent for PCP prophylaxis. Patients on IV pentamidine for entire course of PCP prophylaxis were followed at least six months after discontinuation of IV pentamidine. The safety of IV pentamidine was assessed by the incidence of adverse events leading to pentamidine discontinuation. All data were analyzed using descriptive statistics. All transplant patients at CCHMC who had received IV pentamidine were reviewed, and 333 patients met inclusion criteria. The overall incidence of PCP was found to be 0.3% for pediatric transplant patients on pentamidine. Pentamidine was found to be safe, and the incidence of adverse events leading to discontinuation was 6% with the most common reason being tachycardia 2.1%. IV pentamidine is safe and effective as PCP prophylaxis in pediatric transplant patients with a PCP breakthrough rate of 0.3% (1 of 333 patients), and only 20 adverse events led to discontinuation. We recommend that IV pentamidine be considered as a second-line option in pediatric transplant patients who cannot tolerate SMX/TMP.
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Affiliation(s)
- Abigail Clark
- Pharmacy Department, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Pneumocystis Pneumonia: Epidemiology and Options for Prophylaxis in Non-HIV Immunocompromised Pediatric Patients. CURRENT FUNGAL INFECTION REPORTS 2014. [DOI: 10.1007/s12281-014-0177-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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