Miscellaneous
Primary Prophylaxis for Pneumocystis jirovecii Pneumonia in Patients with Connective Tissue Diseases

https://doi.org/10.1016/j.semarthrit.2011.05.004Get rights and content

Objectives

The aim of our study was to examine the primary prophylactic effect of sulfamethoxazole/trimethoprim single strength (SMZ/TM SS) against Pneumocystis jirovecii pneumonia (PCP) in connective tissue disease (CTD) patients with immune dysfunction induced by the long-term use of prednisolone. Prevalence of adverse drug reactions (ADRs) to sulfonamide in these patients was the secondary outcome.

Methods

This was a retrospective cohort study. Medical records of CTD patients who were treated with prednisolone ≥20 mg per day or equivalent doses of corticosteroid for more than 2 weeks and were followed for at least 12 weeks after receiving this dosage of corticosteroids at the Rheumatology clinic of Ramathibodi Hospital between October 2006 and September 2007 were reviewed. Information regarding clinical status, laboratory features, and clinical course of the enrolled subjects was recorded.

Results

There were 138 episodes of PCP risk in 132 CTD patients; 59 episodes received SMZ/TM SS, while 79 episodes did not. All 6 PCP cases developed in patients without prophylaxis with an overall incidence of 4.3%. The incidence of PCP between the 2 groups was significantly different (P = 0.038). Absolute risk reduction and relative risk reduction were 7.3% and 100%, respectively. All ADR developed in 5 systemic lupus erythematosus patients (8.5%): 4 had drug rashes and 1 had mild hepatitis. There was no correlation between the use of, or allergic reactions to, SMZ/TM and lupus flare.

Conclusions

Sulfamethoxazole/trimethoprim single strength can be used effectively as a primary prophylaxis against PCP in high-risk CTD patients. Only mild ADR developed at this dosage. Further evaluations in larger groups of CTD patients are warranted.

Section snippets

Patients and Methods

This study was approved by the Institutional Ethics Committee of Ramathibodi Hospital, Mahidol University, Thailand. We retrospectively selected the medical records through a search of the patient database for the corresponding ICD-10 codes for CTD, for both inpatients and outpatients, who had been followed up between October 2006 and September 2007. The inclusion criteria were the following: adult patients (age ≥15 years) who were diagnosed with CTD and had taken prednisolone ≥20 mg/d or

Patient Characteristics

A total of 138 risk episodes of Pneumocystis infection from 132 patients with CTD fulfilled the criteria for analysis. Of the 132 patients, 126 were female. One hundred nineteen patients had SLE, 4 had Behcet's disease, 4 had dermatomyositis, 2 had Takayasu's arteritis, 2 had microscopic polyangiitis (MPA), and 1 had Churg-Strauss syndrome. Six patients had 2 episodes of risk; 1 was a patient with a diagnosis of Behcet's disease and the others were SLE patients.

The demographic data of CTD

Discussion

P jirovecii pneumonia is an uncommon but often fatal occurrence in patients with connective tissue diseases. However, standard guidelines for the administration of PCP prophylaxis to patients with CTDs, especially those with SLE who are receiving immunosuppressive agents, have not been established. This reluctance may be due to overriding concerns about risk of developing ADR from SMZ/TM, the most effective regimen for PCP prophylaxis, and consequently overcomes its potential benefits. Some

Acknowledgment

The authors would like to acknowledge U Udomsubpayakul, MSC, Department of Clinical Epidemiology and Biostatistics, Ramathibodi Medical School, Mahidol University for statistical analysis.

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