McKinnell J A, Cannella A P, Kunz D F, Hook E W, Moser S A, Miller L G, Baddley J W, Pappas P G
Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Transpl Infect Dis. 2012 Oct;14(5):510-8. doi: 10.1111/j.1399-3062.2012.00739.x. Epub 2012 May 1.
Pneumocystis jirovecii pneumonia (PCP) is a life-threatening infection for immunocompromised individuals. Robust data and clear guidelines are available for prophylaxis and treatment of human immunodeficiency virus (HIV)-related PCP (HIV-PCP), yet few data and no guidelines are available for non-HIV-related PCP (NH-PCP). We postulated that prevention and inpatient management of HIV-PCP differed from NH-PCP.
We performed a retrospective case review of all pathologically confirmed cases of PCP seen at the University of Alabama Medical Center from 1996 to 2008. Data on clinical presentation, hospital course, and outcome were collected using a standardized data collection instrument. Bivariate analysis compared prophylaxis, adjunctive corticosteroids, and clinical outcomes between patients with HIV-PCP and NH-PCP.
Our analysis of the cohort included 97 cases of PCP; 65 HIV and 32 non-HIV cases. Non-HIV cases rarely received primary prophylaxis (4% vs. 38%, P = 0.01) and received appropriate antibiotics later in the course of hospitalization (5.2 days vs. 1.1 days, P < 0.005). Among transplant patients, NH-PCP was diagnosed a mean of 1066 days after transplantation and most patients were on low-dose corticosteroids (87%) at the time of disease onset. No significant differences in adjunctive corticosteroid use (69% vs. 77%, P = 0.39) and 90-day mortality (41% vs. 28%, P = 0.20) were detected.
Patients who have undergone organ or stem cell transplant remain at risk for PCP for many years after transplantation. In our cohort, patients who developed NH-PCP were rarely given prophylaxis, and initiation of appropriate antibiotics was significantly delayed compared to cases of HIV-PCP. Medical providers should be aware of the ongoing risk for NH-PCP, even late after transplantation, and consider more aggressive approaches to both prophylaxis and earlier empirical therapy for PCP.
耶氏肺孢子菌肺炎（PCP）对免疫功能低下的个体来说是一种危及生命的感染。对于人类免疫缺陷病毒（HIV）相关的PCP（HIV-PCP）的预防和治疗有丰富的数据和明确的指南，但对于非HIV相关的PCP（NH-PCP），数据很少且没有指南。我们推测HIV-PCP的预防和住院管理与NH-PCP不同。
我们对1996年至2008年在阿拉巴马大学医学中心确诊的所有PCP病例进行了回顾性病例分析。使用标准化的数据收集工具收集临床表现、住院过程和结局的数据。双变量分析比较了HIV-PCP患者和NH-PCP患者的预防措施、辅助性皮质类固醇使用情况和临床结局。
我们对该队列的分析包括97例PCP病例；65例HIV相关病例和32例非HIV相关病例。非HIV相关病例很少接受一级预防（4%对38%，P = 0.01），且在住院后期才开始使用合适的抗生素（5.2天对1.1天，P < 0.005）。在移植患者中，NH-PCP平均在移植后1066天被诊断出来，大多数患者在疾病发作时正在使用低剂量皮质类固醇（87%）。在辅助性皮质类固醇的使用（69%对77%，P = 0.39）和90天死亡率（41%对28%，P = 0.20）方面未检测到显著差异。
器官或干细胞移植患者在移植后多年仍有患PCP的风险。在我们的队列中，发生NH-PCP的患者很少接受预防措施，与HIV-PCP病例相比，合适抗生素的使用明显延迟。医疗服务提供者应意识到NH-PCP的持续风险，即使在移植后很久，并且应考虑采取更积极的预防措施和更早的PCP经验性治疗方法。
