A Pilot Study of Echinocandin Combination with Trimethoprim/Sulfamethoxazole and Clindamycin for the Treatment of AIDS Patients with Pneumocystis Pneumonia

Trimethoprim-sulfamethoxazole combined with echinocandins versus trimethoprim-sulfamethoxazole alone for Pneumocystis pneumonia in patients without human immunodeficiency virus infection: A nationwide retrospective cohort study

BACKGROUND

Although combination therapy of echinocandins with trimethoprim-sulfamethoxazole (TMP-SMX) has been reported for patients with Pneumocystis jirovecii pneumonia (PCP), the effectiveness of this combination therapy in patients with PCP without human immunodeficiency virus (HIV) infection remains unknown.

METHODS

Data from the Japanese Diagnosis Procedure Combination inpatient database was used to identify non-HIV patients who underwent their first hospitalisation for PCP between April 2012 and March 2022. The patients were divided into those treated with TMP-SMX alone and those treated with TMP-SMX combined with echinocandins. We performed propensity-score overlap-weighting analysis to estimate in-hospital mortality.

RESULTS

Among the 1324 eligible patients, 122 received TMP-SMX plus echinocandins, while 1202 received TMP-SMX alone. The propensity-score overlap-weighting analysis showed that the combination therapy was not associated with reduced in-hospital mortality in comparison with TMP-SMX alone (22.2 % vs. 26.9 %; risk difference, 4.6 %; 95 % confidence interval, -6.1 %-15.3 %; P = 0.398).

CONCLUSIONS

Echinocandins combined with TMP-SMX may not improve in-hospital mortality due to PCP in patients without HIV infection.

Pneumocystis jirovecii pneumonia in people living with HIV: a review

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.

Successful treatment of severe Pneumocystis Jirovecii pneumonia in a diffuse large B-cell lymphoma patient after R-CHOP chemotherapy: A case report

R-CHOP chemotherapy has been established as the first-line standard treatment for elderly patients diagnosed with diffuse large B-cell lymphoma. However, an increased risk of Pneumocystis jirovecii pneumonia in diffuse large B-cell lymphoma patients after the rituximab-based chemotherapy has been reported. We describe a case who developed intermittent cough, fever and shortness of breath after five cycles of R-CHOP treatment for diffuse large B-cell lymphoma. A rapid deterioration in patient's respiratory condition prompted us to adopt an aggressive anti- Pneumocystis jirovecii pneumonia strategy that combined the conventional trimethoprim/sulfamethoxazole and another two antimicrobials, caspofungin and clindamycin. This is the first report mentioning the successful treatment of severe Pneumocystis jirovecii pneumonia with a triple-drug regimen in a HIV-uninfected patient. The aim of our report is also to emphasize that early and correct diagnosis of Pneumocystis jirovecii pneumonia in immunocompromised HIV-uninfected patients is very important. Relevant oncologists should be alert to the risk of Pneumocystis jirovecii pneumonia in patients receiving R-CHOP chemotherapy.

Targeting β-glucans, vital components of the Pneumocystis cell wall

β-glucan is the most abundant polysaccharide in the cell wall of Pneumocystis jirovecii, which has attracted extensive attention because of its unique immunobiological characteristics. β-glucan binds to various cell surface receptors, which produces an inflammatory response and accounts for its immune effects. A deeper comprehension of the processes by Pneumocystis β-glucan recognizes its receptors, activates related signaling pathways, and regulates immunity as required. Such understanding will provide a basis for developing new therapies against Pneumocystis. Herein, we briefly review the structural composition of β-glucans as a vital component of the Pneumocystis cell wall, the host immunity mediated by β-glucans after their recognition, and discuss opportunities for the development of new strategies to combat Pneumocystis.

Efficacy of Trimethoprim–Sulfamethoxazole in Combination with an Echinocandin as a First-Line Treatment Option for Pneumocystis Pneumonia: A Systematic Review and Meta-Analysis

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.

On the Treatment of Pneumocystis jirovecii Pneumonia: Current Practice Based on Outdated Evidence

Pneumocystis jirovecii pneumonia (PCP) is a common opportunistic infection causing more than 400000 cases annually worldwide. Although antiretroviral therapy has reduced the burden of PCP in persons with human immunodeficiency virus (HIV), an increasing proportion of cases occur in other immunocompromised populations. In this review, we synthesize the available randomized controlled trial (RCT) evidence base for PCP treatment. We identified 14 RCTs that were conducted 25-35 years ago, principally in 40-year-old men with HIV. Trimethoprim-sulfamethoxazole, at a dose of 15-20 mg/kg per day, is the treatment of choice based on historical practice rather than on quality comparative, dose-finding studies. Treatment duration is similarly based on historical practice and is not evidence based. Corticosteroids have a demonstrated role in hypoxemic patients with HIV but have yet to be studied in RCTs as an adjunctive therapy in non-HIV populations. The echinocandins are potential synergistic treatments in need of further investigation.

The Long-Acting Echinocandin, Rezafungin, Prevents Pneumocystis Pneumonia and Eliminates Pneumocystis from the Lungs in Prophylaxis and Murine Treatment Models

Rezafungin is a novel echinocandin in Phase 3 development for prevention of invasive fungal disease caused by Candida spp., Aspergillus spp. and Pneumocystis jirovecii in blood and marrow transplantation patients. For such patients, standard antifungal prophylaxis currently comprises an azole for Candida and Aspergillus plus trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis pneumonia (PCP) despite drug-drug-interactions and intolerability that may limit their use, thus, alternatives are desirable. Rezafungin demonstrates a favorable safety profile and pharmacokinetic properties that allow for once-weekly dosing in addition, to antifungal activity against these predominant pathogens. Herein, the in vivo effects of rezafungin against Pneumocystis murina pneumonia were evaluated in immunosuppressed mouse models of prophylaxis and treatment using microscopy and qPCR assessments. In the prophylaxis model, immunosuppressed mice inoculated with P. murina were administered TMP-SMX (50/250 mg/kg 1×/week or 3×/week), caspofungin (5 mg/kg 3×/week), rezafungin (20 mg/kg, 1×/week or 3×/week; 5 mg/kg, 3×/week) intraperitoneally for 2, 4, 6 and 8 weeks, then immunosuppressed for an additional 6 weeks. Rezafungin administered for 4 weeks prevented P. murina from developing infection after rezafungin was discontinued. In the treatment model, immunosuppressed mice with P. murina pneumonia were treated with rezafungin 20 mg/kg 3×/week intraperitoneally for 2, 4, 6 and 8 weeks. Treatment with rezafungin for 8 weeks resulted in elimination of P. murina. Collectively, these studies showed that rezafungin could both prevent infection and eliminate P. murina from the lungs of mice. These findings support the obligate role of sexual reproduction for survival and growth of Pneumocystis spp. and warrant further investigation for treatment of P. jirovecii pneumonia in humans.

Pneumocystis jirovecii: a review with a focus on prevention and treatment

Introduction: Pneumocystis jirovecii (PJ) is an opportunistic fungal pathogen that can cause severe pneumonia in immunocompromised hosts. Risk factors for Pneumocystis jirovecii pneumonia (PJP) include HIV, organ transplant, malignancy, certain inflammatory or rheumatologic conditions, and associated therapies and conditions that result in cell-mediated immune deficiency. Clinical signs of PJP are nonspecific and definitive diagnosis requires direct detection of the organism in lower respiratory secretions or tissue. First-line therapy for prophylaxis and treatment remains trimethoprim-sulfamethoxazole (TMP-SMX), though intolerance or allergy, and rarely treatment failure, may necessitate alternate therapeutics, such as dapsone, pentamidine, atovaquone, clindamycin, primaquine and most recently, echinocandins as adjunctive therapy. In people living with HIV (PLWH), adjunctive corticosteroid use in treatment has shown a mortality benefit.Areas covered: This review article covers the epidemiology, pathophysiology, diagnosis, microbiology, prophylaxis indications, prophylactic therapies, and treatments.Expert opinion: TMP-SMX has been first-line therapy for treating and preventing pneumocystis for decades. However, its adverse effects are not uncommon, particularly during treatment. Second-line therapies may be better tolerated, but often sacrifice efficacy. Echinocandins show some promise for new combination therapies; however, further studies are needed to define optimal antimicrobial therapy for PJP as well as the role of corticosteroids in those without HIV.