pneumonia in people with HIV whose CD4 count is between 100 and 200 cells/mm³
US guidelines for the management of opportunistic infections in people living with HIV have made new recommendations for primary prophylaxis of Pneumocystic jirovecii pnuemonia. Prophylaxis is now indicated if:
CD4 count is <100 cells/mm³, regardless of plasma HIV level
CD4 count is 100-200 cells/mm³, if plasma HIV RNA level is above detection limits
Intermittent intravenous pentamidine is now an option for prophylaxis in people who are seronegative for Toxoplasma gondii, although trimethoprim-sulfamethoxazole remains the preferred treatment.[32]
Summary
Definition
History and exam
Key diagnostic factors
- HIV-positive
Other diagnostic factors
- oropharyngeal candidiasis
- recurrent bacterial pneumonia
- weight loss
- longer duration of symptoms (HIV-positive patients)
- rapid onset of symptoms (HIV-negative patients)
- fever
- dry cough
- dyspnea
- fatigue
- normal chest examination
- tachycardia
- tachypnea or respiratory distress
- cyanosis
- extrapulmonary manifestations
- pleuritic chest pain
- unilateral diminished breath sounds
Risk factors
- CD4 cell count <200 cells/microliter
- immunocompromised state
- chronic corticosteroid therapy
- prior Pneumocystis pneumonia
Diagnostic tests
1st tests to order
- chest x-ray
- arterial blood gas
- serum LDH level
- induced sputum
Tests to consider
- high-resolution computed tomography (HRCT) chest
- pulmonary function testing
- bronchoscopy and bronchoalveolar lavage (BAL)
- biopsy
Emerging tests
- polymerase chain reaction (PCR)
- plasma S-adenosylmethionine level
- serum (1,3)-beta-D-glucan level
Treatment algorithm
high-risk for Pneumocystis pneumonia (PCP) infection
adults or adolescents: HIV-positive
children: HIV-positive or at risk for HIV
immunocompromised adults or adolescents: HIV-negative and not solid-organ transplant recipients
immunocompromised adults or adolescents or children: HIV-negative and solid-organ transplant recipients
completed successful treatment of PCP infection
Contributors
Authors
Alison Morris, MD, MS
Professor of Medicine
Pulmonary, Allergy, Critical Care, and Sleep Medicine
University of Pittsburgh
Pittsburgh
PA
Disclosures
AM is an author of a number of references cited in this topic.
Ioannis Konstantinidis, MD, MS
Assistant Professor of Medicine
Pulmonary, Allergy, Critical Care, and Sleep Medicine
University of Pittsburgh
Pittsburgh
PA
Disclosures
IK declares that he has no competing interests.
Acknowledgements
Dr Alison Morris and Dr Ioannis Konstantinidis would like to gratefully acknowledge Dr Eric Nolley and Dr Matthew Gingo, previous contributors to this topic.
Disclosures
EN and MG declare that they have no competing interests.
Peer reviewers
Peter D. Walzer, MD, MSc
Associate Chief of Staff for Research
Cincinnati VA Medical Center
Professor of Medicine
University of Cincinnati
Cincinnati
OH
Disclosures
PDW declares that he has no competing interests.
David Spencer, MBChB(UCT), MMed (Wits)
Specialist Physician and Consultant
Toga Laboratory and Kimera Consultants
Edenvale
Johannesburg
South Africa
Disclosures
DS declares that he has no competing interests.
Graeme Meintjes, MBChB, MRCP, FCP, DipHIVMan
Infectious Diseases Physician
Institute of Infectious Diseases and Molecular Medicine
Faculty of Health Sciences
University of Cape Town
Observatory
South Africa
Disclosures
GM declares that he has no competing interests.
References
Key articles
Palella FJ, Delaney KM, Moorman FC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med. 1998 Mar 26;338(13):853-60.Full text Abstract
National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and American Academy of Pediatrics. Panel on Opportunistic Infections in Children with and Exposed to HIV. Guidelines for the prevention and treatment of opportunistic infections in children with and exposed to HIV: Pneumocystis jirovecii pneumonia. Nov 2013 [internet publication].Full text
National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Pneumocystis pneumonia. Sep 2024 [internet publication].Full text
Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018 Oct 20;36(30):3043-54.Full text Abstract
Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009 Oct;15(10):1143-238.Full text Abstract
Fishman JA, Gans H, AST Infectious Diseases Community of Practice. Pneumocystis jiroveci in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13587. Abstract
Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128.Full text Abstract
Ewald H, Raatz H, Boscacci R, et al. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV infection. Cochrane Database Syst Rev. 2015 Apr 2;(4):CD006150.Full text Abstract
Cooley L, Dendle C, Wolf J, et al. Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. Intern Med J. 2014 Dec;44(12b):1350-63.Full text Abstract
Maertens J, Cesaro S, Maschmeyer G, et al. ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother. 2016 Sep;71(9):2397-404.Full text Abstract
Classen AY, Henze L, von Lilienfeld-Toal M, et al. Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors: 2020 updated guidelines of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO/DGHO). Ann Hematol. 2021 Jun;100(6):1603-20.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Coronavirus disease 2019 (COVID-19)
- Bacterial pneumonia
- Coccidioidomycosis
More DifferentialsGuidelines
- Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: pneumocystis pneumonia
- Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors
More Guidelines
Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer