Use of Adjunctive Corticosteroids in Severe Adult Non-HIV Pneumocystis carinii Pneumonia

doi:10.1378/chest.113.5.1215

Chest

Volume 113, Issue 5, May 1998, Pages 1215-1224

https://doi.org/10.1378/chest.113.5.1215 Get rights and content

Study objective

To examine the use of adjunctive corticosteroids in cases of severe Pneumocystis carinii pneumonia (PCP) in non-HIV-infected adult patients.

Design

Retrospective review of medical records.

Setting

Tertiary care urban teaching hospital.

Patients

Review identified 31 consecutive histologically confirmed primary cases of adult non-HIV-related PCP. Complete records were available for 30 patients, including 20 male and 10 female patients with a mean age of 58.3±15 years (±SD). Underlying conditions included organ transplantation (n=13), long-term immunosuppressive therapy (n=9), and chemotherapy for malignancy (n=8). All patients had documented Po₂ <65 mm Hg or arterial oxygen saturation <90% on room air.

Interventions

Following the identification of P carinii, in addition to trimethoprim-sulfamethoxazole or pentamidine therapy, 16 patients received increased steroids (≥60 mg prednisone daily equivalent; increased high-dose steroid group), whereas 14 patients were maintained on a regimen of low doses (≤30 mg prednisone equivalent daily) or had steroid therapy tapered (low-dose steroid group).

Results

The increased high-dose steroid group demonstrated a shorter required duration for mechanical ventilation (6.3±6 days vs 18.0±21 days; p=0.047), a shorter duration of ICU admission (8.5±7 days vs 15.8±8 days; p=0.025), and a shorter duration of supplemental oxygen use (10.0±4 vs 32.2±33; p=0.05). The hospital duration to discharge for the nine survivors in each group favored the use of corticosteroids (15.4±5 days vs 36.3±33 days; p=0.077). Similar rates were observed for intubation (75% vs 57%; p=0.442) and in-hospital mortality (44% vs 36%; p=0.722).

Conclusions

These preliminary data suggest that high-dose adjunctive corticosteroids may accelerate recovery in cases of severe adult non-HIV PCP.

Section snippets

Setting

The Beth Israel Deaconess Medical Center, West Campus, is a large tertiary care urban teaching hospital with diverse medical and surgical patient populations, including active Hepatic and Renal Transplant Services, Hematology and Oncology services, and General Medical Service.

Identification of Patients

All cases of non-HIV-related PCP in persons ≥18 years of age were identified by review of computerized medical records that identified PCP as a discharge diagnosis, and by review of microbiological and pathologic records

Patient Characteristics

A total of 31 consecutive confirmed cases of non-HIV-related PCP were identified in 31 patients. There were no cases of recurrent PCP identified in any non-HIV-infected patients. Complete medical records were available for 30 of these cases, which included 20 male and 10 female patients (mean age=58.3±15 years; range, 30 to 88 years). Predisposing medical conditions included organ transplantation (n=13), collagen-vascular or inflammatory diseases requiring long-term immunosuppressive therapy

DISCUSSION

In this retrospective review of confirmed consecutive cases of severe adult non-HIV PCP, the use of high-dose adjunctive corticosteroids (the prednisone equivalent of ≥60 mg/d) was associated with a significant reduction in the duration of intubation and mechanical ventilation, duration of ICU admission, and duration of supplemental oxygen requirement. For patients who received high-dose corticosteroids, the duration of intubation and mechanical ventilation was reduced by 65%, the duration of

ACKNOWLEDGMENTS

The authors wish to thank Drs. Paula Pinkston and Joseph D. Zibrak for their insights and thoughtful review of this article.

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Solid organ transplant recipients (SOTRs) frequently receive adjunctive glucocorticoid therapy (AGT) for Pneumocystis jirovecii pneumonia (PJP). This multicenter cohort of SOTRs with PJP admitted to 20 transplant centers in Canada, the United States, Europe, and Australia, was examined for whether AGT was associated with a lower rate of all-cause intensive care unit (ICU) admission, 90-day death, or a composite outcome (ICU admission or death). Of 172 SOTRs with PJP (median [IQR] age: 60 (51.5-67.0) years; 58 female [33.7%]), the ICU admission and death rates were 43.4%, and 20.8%, respectively. AGT was not associated with a reduced risk of ICU admission (adjusted odds ratio [aOR] [95% CI]: 0.49 [0.21-1.12]), death (aOR [95% CI]: 0.80 [0.30-2.17]), or the composite outcome (aOR [95% CI]: 0.97 [0.71-1.31]) in the propensity score-adjusted analysis. AGT was not significantly associated with at least 1 unit of the respiratory portion of the Sequential Organ Failure Assessment score improvement by day 5 (12/37 [32.4%] vs 39/111 [35.1%]; P = .78). We did not observe significant associations between AGT and ICU admission or death in SOTRs with PJP. Our findings should prompt a reevaluation of routine AGT administration in posttransplant PJP treatment and highlight the need for interventional studies.
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To investigate the clinical outcomes and risk factors of mortality in patients with rheumatic diseases complicated by Pneumocystis pneumonia (PCP).
Between November 2015 and April 2021, patients with rheumatic diseases with PCP in a tertiary referral hospital were retrospectively enrolled. The diagnosis of PCP requires the fulfillment of clinical, radiographic, and microbiological criteria. Factors associated with in-hospital, 30-day, and 90-day mortality were evaluated.
A total of 128 patients with rheumatic diseases who had a positive quantitative polymerase chain reaction assay for Pneumocystis jirovecii were screened, and 72 patients were included in the final analysis. The median (interquartile range [IQR]) pneumonia severity index (PSI) was 101.5 (77.0-132.0). The median (IQR) adjunctive corticosteroid dosage was 0.6 (0.4-0.9) mg/kg/day prednisolone equivalent. The receiver operating characteristic curve analysis showed that the optimal cutoff point of median adjunctive corticosteroid dosage was 0.6 mg/kg/day to predict in-hospital, 30-day, and 90-day mortality. In the multivariable logistic regression analysis, median adjunctive corticosteroid dosage ≥0.6 mg/kg/day and PSI >90 were independent factors of in-hospital, 30-day, and 90-day mortality.
A median adjunctive corticosteroid dosage of ≥0.6 mg/kg/day might be associated with mortality in patients with rheumatic diseases complicated by PCP.
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Orthotopic liver transplant (LT) represents an important treatment strategy for end-stage liver disease. While transplant recipient survival has improved dramatically, greater than two-thirds of LT patients suffer from infectious complications within the first year after transplant. LT patients are at risk for infections originating from donor organs, surgical complications, hospital and community exposures, and from their own latent infections. A patient’s risk for infection by specific pathogens is related to their net state of immunosuppression—the collective effect of all patient, medication, and disease-related factors on the immune system’s ability to combat infection. Temporal variations in immunosuppression and pathogen exposure produce predictable trends in infection type. Early infections are most often related to surgical complications or latent infection. Opportunistic infections become prevalent during the intermediate phase, against which microbial prophylaxis regimens are utilized. The late phase is characterized by a return to a community-acquired infection profile, although patients with graft dysfunction/rejection episodes remain at risk for opportunistic infections. The understanding of these factors is critical for effective diagnosis and management of infection in post-LT patients.
Risk factors associated with increased discontinuation rate of trimethoprim–sulfamethoxazole used as a primary prophylaxis for Pneumocystis pneumonia: A retrospective cohort study
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Citation Excerpt :
Respiratory diseases are also a risk factor for PcP [4,5]. PcP is associated with a high mortality rate of approximately 30%–60% in patients without HIV infection [3,6–8]; therefore, PcP prophylaxis is essential for improving long-term outcomes in these patients. Trimethoprim–sulfamethoxazole (TMP–SMX) is the recommended first-line agent for PcP prophylaxis, owing to its considerable preventive effect and cost-effectiveness compared with alternative prophylaxis regimens including aerosolised pentamidine, atovaquone, and dapsone [9–11].
The use of trimethoprim–sulfamethoxazole (TMP–SMX) for Pneumocystis pneumonia (PcP) prophylaxis is often discontinued owing to adverse drug reactions. Half-dosage of TMP–SMX (40/200 mg daily) is considered more tolerable than the conventional dosage (80/400 mg daily). However, patient background characteristics that are associated with the discontinuation of TMP–SMX prophylaxis and suitable for reduced dosage remain unclear. In this study, we aimed to identify the risk factors for the discontinuation of and efficacy of different doses of TMP–SMX prophylaxis in patients with creatinine clearance higher than 30 mL/min.
We retrospectively evaluated 318 immunocompromised non-human immunodeficiency virus (HIV)-infected patients (194 men and 124 women; median age, 68.5 [interquartile range, 59–75] years) who underwent TMP–SMX therapy as a primary PcP prophylaxis between July 2014 and August 2019. The patients were segregated into two groups on the basis of dosage: single-strength (SS; n = 244) and half-strength (HS; n = 74) groups. We evaluated PcP occurrence, TMP–SMX discontinuation rate, and discontinuation-related risk factors in these groups.
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Presented in part at the American Lung Association/American Thoracic Society Meeting, May 1996, New Orleans.

Supported in part by a grant from the Parker B. Francis Foundation (Dr. Koziel).

View full text

Chest

Clinical Investigations: HIVUse of Adjunctive Corticosteroids in Severe Adult Non-HIV Pneumocystis carinii Pneumonia

Study objective

Design

Setting

Patients

Interventions

Results

Conclusions

Section snippets

Setting

Identification of Patients

Patient Characteristics

DISCUSSION

ACKNOWLEDGMENTS

Mayo Clin Proc

Am J Med

Chest

Am J Med

Clin Immunol Immunopathol

Chest

Lancet

Experimental models for Pneumocystis carinii infections

Lung Biol Health Dis

Pneumoncystis carinii pneumonia: differences in lung parasite number and inflammation in patients with and without AIDS

Am Rev Respir Dis

Pneumocystis carinii pneumonia among patients without AIDS at a cancer hospital

JAMA

Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies

Ann Intern Med

Pneumocystis carinii pneumonia in patients without AIDS

Clin Infect Dis

Corticosteroids as adjunctive therapy in severe Pneumocystis carinii pneumonia: a prospective placebo-controlled trial [abstract]

Am Rev Respir Dis

Corticosteroids as adjunctive therapy for severe Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome: a double-blind, placebo-controlled trial

N Engl J Med

A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

N Engl J Med

Corticosteroids prevent early deterioration in patients with moderately severe Pneumocystis carinii pneumonia and the acquired immunodeficiency syndrome (AIDS)

Ann Intern Med

Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in the acquired innumodeficiency syndrome

N Engl J Med

Guildelines for the use of systemic glucocorticosteroids in the management of selected infections

J Infect Dis

Transplantation pneumonia

JAMA

Pneumocystis carinii infection

Medicine

Pneumocystis carinii pneumonia in patients with cancer: an increasing incidence

Cancer

Pneumocystis carinii pneumonia in patients without AIDS, 1980 through 1993

Arch Intern Med

Clinical Investigations: HIV
Use of Adjunctive Corticosteroids in Severe Adult Non-HIV Pneumocystis carinii Pneumonia