Evaluation of the corticosteroid dose at Pneumocystis pneumonia onset in non-HIV patients receiving steroids and the period from the discontinuation of trimethoprim-sulfamethoxazole prophylaxis to the onset of Pneumocystis pneumonia

Abstract

\n Background\n\n Pneumocystis pneumonia (PCP) is a life-threatening opportunistic infection among non-human immunodeficiency virus (non-HIV) immunocompromised patients. The prophylactic use of trimethoprim-sulfamethoxazole (TMP-SMX) reduces PCP incidence. However, it remains unclear when TMP-SMX can be safely discontinued among patients for whom corticosteroid tapering is underway, and occasionally, PCP develops after TMP-SMX discontinuation despite tapering of corticosteroids to considerably lower dose.\nMethods\n\nWe retrospectively reviewed non-HIV immunocompromised patients who were diagnosed with PCP in our institution during a 12-year period (January 2007 to December 2018). We analysed the clinical information including corticosteroid doses when PCP developed and the period from TMP-SMX discontinuation to PCP onset for these patients.\nResults\n\nIn all, 39 patients were included. The median patient age was 70 years (range: 27–92 years), and 18 patients (46.2%) were female. Thirty-two patients (82.1%) were administered corticosteroids. The median daily corticosteroid dose converted to the prednisolone equivalent dose was 14 mg (range: 2–60 mg). Further, six (15.4%) patients were treated with a dose of 5 mg or less. Twenty-eight patients (71.8%) were never administered TMP-SMX, and TMP-SMX was discontinued before PCP development in the remaining 11 patients. The median period from TMP-SMX discontinuation to PCP development was 95 days (range: 44–175 days), and in nine patients, PCP developed 14\u2009±\u20092 weeks after TMP-SMX discontinuation.\nConclusions\n\nPCP developed in non-HIV patients treated with corticosteroids at doses considerably lower than the daily 20 mg prednisolone equivalent dose. Non-HIV immunocompromised patients are more likely to develop PCP approximately 3 months after TMP-SMX discontinuation.