This protocol applies to Pneumocystis pneumonia of mild-to-moderate severity — defined by an alveolar-arterial oxygen gradient of ≤4.7 kPa — in patients whose initial oral treatment has not produced the expected clinical response by the reassessment window.
Mild-to-moderate PCP is characterised by an alveolar-arterial oxygen gradient ≤4.7 kPa. This severity threshold distinguishes the population for whom oral treatment is appropriate and informs when a change of regimen is warranted.
First-line treatment for this severity was oral trimethoprim-sulfamethoxazole. The expected goal was clinical improvement, including improvement in oxygenation, assessed between days 4 and 8. This protocol is indicated when that improvement has not been achieved within that window.
When trimethoprim-sulfamethoxazole has not achieved adequate clinical and oxygenation improvement, the protocol involves switching to one of several alternative oral regimens. These include combination regimens pairing different antiprotozoal and antibacterial agents. The full regimen options and selection guidance are in the complete protocol.
the severity of PCP can be classified as mild-to-moderate if ≤4.7 kPa or moderate-to-severe if >4.7 kPa (Table 1).
Several alternative regimens can be used for treatment of mild-to-moderate PCP (Table 2).
A combination of trimethoprim with dapsone, both given orally, has been shown to be as effective as trimethoprim-sulfamethoxazole in patients with mild-to-moderate PCP, and is less toxic.
Several studies have shown that the combination of clindamycin and primaquine has comparable efficacy and toxicity to trimethoprim-sulfamethoxazole and trimethoprim with dapsone in the treatment of mild-to-moderate PCP.
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