Table 4.

Prophylaxis for Pneumocystis jiroveci pneumonia (PCP)

Background: Low dose trimethoprim-sulfamethoxazole prophylaxis (in adults: 1 single strength per day orally) is well tolerated and essentially eradicates Pneumocystis infection from this patient population. Lower doses (3 days per week) prevent PCP but may not prevent other infections such as urinary tract infection, including those attributable to susceptible Nocardia and Listeria, toxoplasmosis, and a variety of gastrointestinal and pulmonary infections.

Regimen: One single strength trimethoprim-sulfamethoxazole tablet (containing 80 mg trimethoprim, 400 mg sulfamethoxazole) po qhs for a minimum of 4–6 mo posttransplant. Patients infected with CMV, with chronic rejection, recurrent infections, and most lung, liver, and heart recipients may benefit from lifelong prophylaxis.

Alternative regimen: For patients proven not to tolerate trimethoprim-sulfamethoxazole, alternative regimens include: (1) a combination of atovaquone 1500 mg po with meals once daily plus levofloxacin (or equivalent fluoroquinolone without antianaerobic spectrum) 250 mg once daily, (2) pentamidine (300 mg iv or inhaled q 3–4 weeks), and (3) dapsone (100 mg po qd to biw) ± pyrimethamine. Each of these agents has toxicities that must be considered including hemolysis in G6PD-deficient hosts with dapsone. None of these alternative programs offer the same broad protection of TMP-SMX.