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Regimens for Pneumocystis pneumonia prophylaxis in adults and adolescents

Regimens for Pneumocystis pneumonia prophylaxis in adults and adolescents
Drug Oral dose* Selected adverse reactions
Preferred regimen
Trimethoprim-sulfamethoxazole (cotrimoxazole)

1 DS tablet daily

OR

1 SS tablet dailyΔ		 Fever, rash, neutropenia, gastrointestinal upset, transaminase elevation
Alternative regimens◊
Trimethoprim-sulfamethoxazole (cotrimoxazole) 1 DS tablet three times per weekΔ Fever, rash, neutropenia, gastrointestinal upset, transaminase elevation
OR
Dapsone

50 mg twice daily

OR

100 mg daily		 Fever, rash, gastrointestinal upset, methemoglobinemia, hemolytic anemia (check for G6PD deficiency)
OR
Atovaquone suspension 1500 mg orally once daily given with foodΔ Gastrointestinal distress, rash
OR
Combination of:Δ
Dapsone 50 mg daily plus Fever, rash, gastrointestinal upset, methemoglobinemia, hemolytic anemia (check for G6PD deficiency)
Pyrimethamine 50 mg weekly plus Folate deficiency, gastrointestinal upset, rash
Leucovorin 25 mg weekly Rash, thrombocytosis, wheezing, anaphylactoid reactions
OR
Combination of:Δ
Dapsone 200 mg weekly plus Fever, rash, gastrointestinal upset, methemoglobinemia, hemolytic anemia (check for G6PD deficiency)
Pyrimethamine 75 mg weekly plus Folate deficiency, gastrointestinal upset, rash
Leucovorin 25 mg weekly Rash, thrombocytosis, wheezing, anaphylactoid reactions
OR
Aerosolized pentamidine 300 mg monthly (via Respirgard II nebulizer) Cough, wheezing, extrapulmonary pneumocystosis
A regimen that provides prophylaxis for PCP and toxoplasmosis should be administered to HIV-infected patients who are IgG seropositive for toxoplasmosis AND have a CD4 count <100 cells/microL.
DS: double-strength oral tablet, 160 mg trimethoprim with 800 mg sulfamethoxazole; SS: single-strength oral tablet, 80 mg trimethoprim with 400 mg sulfamethoxazole; G6PD: glucose-6-phosphate dehydrogenase; PCP: Pneumocystis pneumonia; HIV: human immunodeficiency virus; IgG: immunoglobulin G; TMP-SMX: trimethoprim-sulfamethoxazole.
* The doses recommended in the table are intended for patients with normal renal function; the doses of some of these agents must be adjusted in patients with renal insufficiency.
¶ This regimen is also the preferred regimen for prevention of toxoplasmosis.
Δ This regimen is considered an alternative regimen for prevention of toxoplasmosis.
◊ Of the alternative regimens for prevention of PCP, TMP-SMX three times weekly is generally preferred. If patients cannot tolerate TMP-SMX, we prefer to use dapsone (or dapsone with pyrimethamine and leucovorin for patients who require prophylaxis for toxoplasmosis) rather than atovaquone. Dapsone is a sulfone that is usually tolerated by persons who have adverse reactions to TMP-SMX. However, in patients who have had serious reactions to TMP-SMX (eg, Stevens-Johnson syndrome/toxic epidermal necrolysis, rash with fever and systemic symptoms, serum sickness, or hemolytic anemia), it may be prudent to avoid dapsone. Aerosolized pentamidine should be used for PCP prophylaxis only when no other alternatives are available.
Adapted from: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. https://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on June 23, 2017).
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