Prophylaxis of Pneumocystis Pneumonia Protocol
Indications:
Pneumocystis Pneumonia (PCP), caused by Pneumocystis Jirovecii is a common cause of pneumonia among
immunocompromised individuals. In Solid Organ Transplant recipients, the risk of Pneumocystis infection is
greatest between the second and sixth months post transplant, during the periods of prolonged neutropenia, and
during periods of intensified immunosuppressant (e.g. due to high doses of corticosteroids, calcineurin inhibitors,
or antilymphocyte antibody or T cell depleting therapies.
“The incidence of PCP in infant heart transplantation recipients is approximately 7% and appears most frequently
in the first 6 months after the operation. Increased risk for Pneumocystis Carnii may be related to early
antithymocyte induction and increased episodes of rejection. Because the period of maximal vulnerability to PCP
remains unclear, transplant centers vary in the duration of PCP prophylaxis ranging from 6 months after the
operation to indefinitely.”
Protocol:
1. Infants and Children will remain on TMP/SMX for 12 months following transplantation given
that they are on immunosuppressant therapy.
2. TMP/SMX (Bactrim) Dose 8-10mg TMP/kg/day divided BID on Monday and Thursdays Only. Start
dose at hospital discharge. Dose should not exceed 320 mg trimethoprim and 1600 mg
sulfamethoxazole/day.
3. Restart Bactrim in patients with hemodynamically significant rejection requiring ATG, Rituximab,
or prolonged steroids (>1 month).
4. Discontinue Bactrim for WBC <3K or serious adverse reactions, or elevation of LFT >2x baseline.
5. If TMP/SMX is held due to low WBC then you may restart TMP/SMX once WBC improves.
6. For serious reactions to TMP/SMX (especially allergic) or continued intolerance change
prophylaxis to Atovaquone.
Atovaquone dose: Prophylaxis of Pneumocystis jiroveci pneumonia:

Infants 1-3 months of age and >24 months of age: 30 mg/kg/day once daily (maximum
dose: 1500 mg/day);
4-24 months of age: 45 mg/kg/day once daily (maximum dose: 1500 mg/day)
7.

Children: 40 mg/kg/day divided twice daily (maximum dose: 1500 mg/day)

Adolescents 13-16 years old: 1500 mg Once Daily
If Bactrim or Atovaquone is not tolerated, PCP prophylaxis may be discontinued if no longer
on steroids.
References:
Yasuhisa Ohata, MD,1 Hideaki Ohta , “Intermittent Oral Trimethoprim/Sulfamethoxazole on Two Non-Consecutive Days Per Week
Is Effective as Pneumocystis jiroveci Pneumonia Prophylaxis in Pediatric Patients Receiving Chemotherapy or Hematopoietic Stem Cell
Transplantation”(2008)
Janner, Donald, Bork, Jane, Baum, Marti, Chinnock, Richard. Pneumocystis carnii Pneumonia in Infants after Heart
Transplantation.(1996)
Steven M. Gordon, Steven P. LaRosa,* Sujith Kalmadi, Alejandro C. Arroliga, Robin K. Avery Laura Truesdell-LaRosa, and David
L. Longworth. Should Prophylaxis for Pneumocystis carinii Pneumonia in Solid Organ Transplant Recipients Ever Be Discontinued? (1999)
Last Updated 9/3/2010