This handout is for pneumocystis jirovecii pneumonia (pjp/pcp). Your care team identified this based on: subacute progressive dyspnea + dry cough + fever in immunocompromised host (classic pjp triad).
Other reasons your team may use this plan: profound exertional desaturation with widened a-a gradient; bilateral perihilar ground-glass opacities on cxr/hrct in immunocompromised host; elevated ldh with hypoxia in hiv / transplant / chronic high-dose steroids.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| sulfamethoxazole/trimethoprim | 15-20 mg/kg/day TMP-component IV/PO divided q6-8h | IV→PO | q6-8h | IDSA OI first-line; 21 d HIV, 14-21 d non-HIV; AKI/hyperK/BM suppression/hepatotoxicity monitoring |
| prednisone | 40 mg PO BID × 5 d → 40 mg daily × 5 d → 20 mg daily × 11 d (Bozzette taper) | PO | tapered | Bozzette NEJM 1990 (PMID 2233917) + NIH Consensus 1990 (PMID 2136587) — mortality + respiratory-failure reduction when started within 72 h of TMP-SMX in HIV severe PJP; non-HIV evidence weaker (Wang 2021 meta-analysis) |
| methylprednisolone | 30 mg IV BID equivalent to prednisone 40 mg PO BID | IV | tapered per Bozzette | IV equivalent of prednisone Bozzette taper for NPO patients |
| primaquine | 30 mg base PO daily (combined with clindamycin) | PO | daily | IDSA OI preferred salvage with clindamycin; G6PD screen mandatory before initiation |
| clindamycin | 600 mg IV q6h (or 300-450 mg PO q6h) | IV→PO | q6h | Pairs with primaquine; C. difficile + rash monitoring (IDSA OI) |
| pentamidine | 4 mg/kg IV daily over ≥60 min | IV | daily | IDSA OI — severe nephrotoxicity, pancreatitis, dysglycemia, QTc; reserved when other options exhausted |
| atovaquone | 750 mg PO BID with food | PO | BID | IDSA OI — mild-moderate disease only; requires high-fat meal for absorption; not for severe disease |
| dapsone | 100 mg PO daily (combined with trimethoprim 5 mg/kg q8h for treatment; or alone for prophylaxis 100 mg daily) | PO | daily | IDSA OI alternative for prophylaxis (alone) or treatment (with trimethoprim); G6PD screen required; methemoglobinemia + hemolysis monitoring |
| caspofungin | 70 mg IV load → 50 mg IV daily | IV | daily | Off-label combination data (e.g., Lazarte-Lalo 2025 and prior reports) — non-HIV severe refractory; not standard first-line; targets cyst-wall β-glucan |
Plan: PJP first-line TMP-SMX + Bozzette adjunctive steroids (HIV severe)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Secondary prophylaxis: HIV TMP-SMX 1 SS daily OR DS thrice weekly until CD4 >200 ×6 mo on ART; transplant per institutional protocol; reinforce primary prophylaxis triggers (CD4 <200, ≥20 mg pred-eq ≥4 wk, biologics, lymphoma); ART initiation if HIV-naive (2-wk delay OK); pulmonology if persistent lung impairment
Guideline: IDSA/CDC/HIVMA Adult/Adolescent Opportunistic Infections Guidelines (Pneumocystis section) + Bozzette NEJM 1990 RCT + NIH Consensus 1990 + ATS 2006 PCP workshop + ECIL 2016 prevention + ATS 2019 microbiologic testing CPG (Hage/Limper) + Wang 2021 non-HIV PCP meta-analysis