Panel’s Recommendations
Prevention of Primary Exposure Some experts recommend that consideration be given to not placing a patient with Pneumocystis jirovecii pneumonia (PCP) in a hospital room with another patient and not placing an at-risk immunocompromised patient in a room with a patient who has a respiratory tract infection (BIII).
Chemoprophylaxis Chemoprophylaxis is highly effective in preventing PCP. Prophylaxis is recommended for all HIV-infected children aged ≥6 years who have CD4 T lymphocyte (CD4) cell counts <200 cells/mm3 or CD4 percentage <15%, for children aged 1 to <6 years with CD4 counts <500 cells/mm3 or CD4 percentage <15%, and for all HIV-infected infants aged <12 months regardless of CD4 count or percentage (AII). Infants with indeterminate HIV infection status should receive prophylaxis until they are determined to be HIV-uninfected or presumptively HIV-uninfected (AIII). HIV-infected infants should be administered prophylaxis until age 1 year, at which time they should be reassessed on the basis of the age-specific CD4 count or percentage thresholds mentioned above (AII). Trimethoprim–sulfamethoxazole (TMP–SMX; cotrimoxazole), administered either on 3 consecutive days/week or daily, is the drug of choice for prophylaxis because of its high efficacy, relative safety, low cost, and broad antimicrobial spectrum (AI). Other effective and safe prophylaxis regimens are available for patients unable to take TMP-SMX. A second choice would be either atovaquone (AI) or dapsone (BI*). Aerosolized pentamidine is recommended for children who cannot take TMP-SMX, atovaquone, or dapsone and who are old enough to use nebulization with a Respirgard II® nebulizer (Marquest; Englewood, CO) (BI*). Intravenous (IV) pentamidine is not recommended for prophylaxis unless no other options are available (BII). Discontinuation of PCP prophylaxis should be considered for HIV-infected children when, after receiving combination antiretroviral therapy for ≥6 months, CD4 percentage is ≥15% or CD4 count is ≥200 cells/mm3 for patients aged ≥ 6 years (BII) and CD4 percentage is ≥15% or CD4 count is ≥500 cells/mm3 for patients aged 1 to <6 years (BII) for >3 consecutive months. Thereafter, CD4 percentage and CD4 count should be reevaluated at least every 3 months and prophylaxis reinstituted if the age-specific criteria for prophylaxis are reached (BIII).
Treatment TMP-SMX, administered IV, is the recommended treatment for PCP (AI). As the acute pneumonitis subsides, children with mild-to-moderate disease who do not have malabsorption or diarrhea can be transitioned to oral treatment with the same total daily dose of TMP-SMX administered in 3 or 4 divided doses to complete a 21-day course (AII). IV pentamidine isethionate once daily is recommended for patients who cannot tolerate TMP-SMX or who demonstrate clinical treatment failure after 5 to 7 days of TMP-SMX therapy (AI*). Atovaquone is an alternative for treatment of mild-to-moderately severe PCP (BI*). Dapsone/TMP is effective in treating mild-to-moderate PCP (BI*). Clindamycin/primaquine has been used to treat mild-to-moderate PCP; data in children are unavailable (BIII). A short course of corticosteroids is recommended in cases of moderate or severe PCP, starting within 72 hours of diagnosis (AI*). Patients who have experienced an episode of PCP should continue on PCP prophylaxis after completion of treatment until CD4 counts exceed the threshold for initiating prophylaxis (AI). Children who present with clinical signs and symptoms compatible with PCP after discontinuation of prophylaxis should be evaluated thoroughly despite normal or high CD4 counts or percentages (BI*).

Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials in children^† with clinical outcomes and/or validated endpoints; I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children^† from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children^† with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children^† from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = Expert opinion

^†Studies that include children or children/adolescents, but not studies limited to post-pubertal adolescents