G15(W)
PJP PROPHYLAXIS IN RENAL TRANSPLANTATION: TIME TO REJECT THE
GUIDELINES?
McCaughan, J, Courtney, A
Belfast City Hospital
PROBLEM: Pneumocystis jiroveci pneumonia (PJP) is an opportunistic infection with an untreated
mortality of 90-100% in immunocompromised hosts. Current guidelines recommend the use of
prophylaxis for 3 to 6 months after renal transplantation but there have been a number of recent
outbreaks of PJP, including in our own centre, in patients much later after transplantation.
PURPOSE: The aims of this study were to identify risk factors for the development of PJP in the
recent outbreaks and to review the evidence for PJP prophylaxis in the renal transplant population.
DESIGN: Recent PJP outbreaks were identified and each report interrogated to identify the time of
infection and pre-disposing risk factors. A literature review of prophylactic antibiotics with anti-PJP
activity in renal transplant recipients was performed and the rationale for the current European Best
Practice and KDIGO guidelines was investigated.
FINDINGS: There have been 5 reported outbreaks of PJP in renal transplant populations in the past 4
years. Most cases occurred late after transplantation with greater than 60% beyond 1 year. There were
no consistently identified risk factors. There had been no change to local immunosuppressive practice
in any centre. PJP infection had previously been rare and none of these units routinely prescribed PJP
prophylaxis.
There are no randomised controlled trials to assess PJP prophylaxis in renal transplant recipients
although the two trials which assessed Trimepthoprim-Sulphamethoxazole prophylaxis against bacterial
infections in this population reported reduced PJP infection with treatment.
The current best practice guidelines have largely been extrapolated from evidence in HIV patients and
recipients of lung and stem cell transplants. It has been suggested that PJP prophylaxis is necessary
when the risk of contracting the infection is greater than 3%. The incidence of PJP in moderately
suppressed renal transplant recipients is 0.6%.
CONCLUSION: PJP remains an important pathogen in renal transplant recipients. The evidence to
support routine PJP prophylaxis in renal transplant recipients who receive moderate
immunosuppression is not robust; however it seems intuitively sensible if prophylaxis is given to
continue for 3-6 months after transplantation when the immunosuppressive load is greatest. The recent
outbreaks challenge this presumption as most PJP developed more than 1 year after transplant. None of
these centres routinely used prophylaxis therapy due to the previous rarity of PJP infection. The reason
for the increased incidence of PJP has not been identified.
Patients who receive enhanced immunosuppression are clearly at higher risk of PJP. Each recipient’s
individual risk should be assessed and prophylaxis offered to those at high risk of infection, regardless
of the time after transplantation.
RELEVANCE: This review of recent outbreaks and the rationale for PJP prophylaxis highlights the
need for high quality randomised controlled trials to evaluate the patient selection for, and optimal
duration of PJP prophylaxis in renal transplant recipients.