Treatment of Pneumocystis jirovecii pneumonia in HIV-infected patients: a review

ABSTRACT

Introduction: Pneumocystis pneumonia is a potentially life-threatening pulmonary infection that occurs in immunocompromised individuals and HIV-infected patients with a low CD4 cell count. Trimethoprim-sulfamethoxazole has been used as the first-line agent for treatment, but mutations within dihydropteroate synthase gene render potential resistance to sulfamide. Despite advances of combination antiretroviral therapy (cART), Pneumocystis pneumonia continues to occur in HIV-infected patients with late presentation for cART or virological and immunological failure after receiving cART.

Areas covered: This review summarizes the diagnosis and first-line and alternative treatment and prophylaxis for Pneumocystis pneumonia in HIV-infected patients. Articles for this review were identified through searching PubMed. Search terms included: ‘Pneumocystis pneumonia’, ‘Pneumocystis jirovecii pneumonia’, ‘Pneumocystis carinii pneumonia’, ‘trimethoprim-sulfamethoxazole’, ‘primaquine’, ‘trimetrexate’, ‘dapsone’, ‘pentamidine’, ‘atovaquone’, ‘echinocandins’, ‘human immunodeficiency virus infection’, ‘acquired immunodeficiency syndrome’, ‘resistance to sulfamide’ and combinations of these terms. We limited the search to English language papers that were published between 1981 and March 2017. We screened all identified articles and cross-referenced studies from retrieved articles.

Expert commentary: Trimethoprim-sulfamethoxazole will continue to be the first-line agent for Pneumocystis pneumonia given its cost, availability of both oral and parenteral formulations, and effectiveness or efficacy in both treatment and prophylaxis. Whether resistance due to mutations within dihydropteroate synthase gene compromises treatment effectiveness remains controversial. Continued search for effective alternatives with better safety profiles for Pneumocystis pneumonia is warranted.

KEYWORDS:

• Interstitial pneumonitis
• trimethoprim-sulfamethoxazole
• alternative therapy
• prophylaxis
• combination antiretroviral therapy

Declaration of interest

CC Hung has received research support from Janssen, AbbVie, Bristol-Myers Squibb, Merck, ViiV and speaker honoraria from Gilead Sciences, and served on the advisory boards for Gilead Sciences, ViiV, AbbVie and Janssen. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

The study was supported by grants from the Ministry of Science and Technology, Taiwan (Grant number:103-2314-B-0020176-MY3).