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Quigley N, d’Amours L, Gervais P, Dion G. Epidemiology, Risk Factors, and Prophylaxis Use for Pneumocystis jirovecii Pneumonia in the Non-HIV Population: A Retrospective Study in Québec, Canada. Open Forum Infect Dis 2024; 11:ofad639. [PMID: 38274551 PMCID: PMC10810061 DOI: 10.1093/ofid/ofad639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/13/2023] [Indexed: 01/27/2024] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) remains a significant threat in immunocompromised cases. Recent data on epidemiology and risk factors for PJP in non-HIV cases are scarce, and guidelines on appropriate prophylaxis are lacking. Methods In this multicenter retrospective trial, all non-HIV adult cases admitted to hospitals in Québec City, Canada, between January 2011 and January 2021 with a diagnosis of PJP were assessed for eligibility. Results An overall 129 cases of PJP were included. More than two-thirds had an underlying hematologic disease or an autoimmune/inflammatory condition. Prior to diagnosis, 83.7% were taking corticosteroids, 71.3% immunosuppressive agents (alone or in combination with corticosteroids), and 62% both. A diagnosis of PJP was noted in 22 patients receiving corticosteroids for treatment <28 days. Two patients developed PJP while undergoing corticosteroid monotherapy at a mean daily prednisone-equivalent dose <20 mg/d; 4.7% of our cohort received a PJP prophylaxis. Current recommendations or accepted clinical practices for PJP prophylaxis would not have applied to 48.8% of our patients. Conclusions The use of corticosteroids-in monotherapy or in coadministration with other immunosuppressive agents-remains the principal risk factor for PJP in the non-HIV population. Current prophylaxis guidelines and accepted practices are insufficient to adequately prevent PJP and need to be broadened and updated.
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Affiliation(s)
- Nicholas Quigley
- Department of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Université Laval, Québec City, Québec
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Laurence d’Amours
- Department of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Université Laval, Québec City, Québec
| | - Philippe Gervais
- Department of Microbiology and Infectious Diseases, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Université Laval, QuébecCity, Québec, Canada
| | - Geneviève Dion
- Department of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Université Laval, Québec City, Québec
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Outcomes and factors contributing to poor prognosis of Pneumocystis jirovecii pneumonia in HIV-negative patients: a cross-sectional retrospective study in a Chinese single center. Eur J Clin Microbiol Infect Dis 2023; 42:109-112. [PMID: 36319918 DOI: 10.1007/s10096-022-04518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 10/24/2022] [Indexed: 01/06/2023]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is a life-threatening opportunistic infection mainly occurring in immunocompromised patients. Almost half of the 30 HIV-negative patients enrolled in this study from 2016-2020 in a Chinese single-center contracted 17 hematological malignancies, and 25 received long-term systemic corticosteroids. Only 4 patients received prophylaxis. The overall mortality was 30%. Patients with older age (> 43 years), dyspnea, and LDH > 404U/L had significantly higher risk of developing into a severe form. LDH > 424 U/L, PaO2 < 60 mmHg, monocyte < 0.2 × 10^9/L, and lymphocyte < 0.3 × 10^9/L were factors contributing to a poor survival outcome.
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Vargas Barahona L, Molina KC, Pedraza-Arévalo LC, Sillau S, Tagawa A, Scherger S, Chastain DB, Shapiro L, Tuells J, Franco-Paredes C, Hawkins KL, Maloney JP, Thompson GR, Henao-Martínez AF. Previous corticosteroid exposure associates with an increased Pneumocystis jirovecii pneumonia mortality among HIV-negative patients: a global research network with a follow-up multicenter case-control study. Ther Adv Infect Dis 2023; 10:20499361231159481. [PMID: 36938147 PMCID: PMC10017958 DOI: 10.1177/20499361231159481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/07/2023] [Indexed: 03/15/2023] Open
Abstract
Background HIV-negative patients have substantial mortality from Pneumocystis jirovecii pneumonia (PJP). We lack predictors of HIV-negative PJP-associated mortality. Objective We aim to characterize the role of prior corticosteroid exposure in PJP-related mortality. Methods We queried a global research network to identify adult HIV-negative patients with PJP with or without corticosteroid exposure in the preceding year before diagnosis (n = 8,021). We performed a propensity score-matched analysis to adjust baseline patient characteristics and analyzed outcomes. We follow-up the results with a multicenter ten years retrospective case-control cohort of HIV-negative patients tested for PJP by PCP Direct Fluorescent Antigen. We used a Cox proportional hazards model for survival analysis. Results 1822 HIV-negative propensity-scored matched patients with prior corticosteroid exposure had significantly increased 10 weeks (16% versus 9%, p < 0.0001) and one-year mortality after PJP diagnosis (23% versus 14%, p < 0.0001). (1→3)-β-D-glucan (197.6 ± 155.8 versus 63 ± 0 pg/ml, p = 0.014), ferritin levels (1227 ± 2486 versus 768 ± 1060 mcg/l, p = 0.047), lymphopenia (1.5 ± 1.5 versus 2.0 ± 1.6 103 cells/µl, p < 0.0001) and hypoxia (SatO2: 86.7% versus 91.6%, p < 0.0001) were higher or worse in those with prior steroid use. Patients who died were more likely to have previously received dexamethasone (35% versus 16%, p < 0.001) or prednisone (49% versus 29%, p < 0.001). Adjusted Cox proportional-hazard model validation showed an independently increased mortality at 10 weeks (HR: 3.7, CI: 1.5-9.2, p = 0.004) and 1 year (HR: 4.5, CI: 2.0-10.4, p < 0.0001) among HIV-negative patients with previous corticosteroid exposure. Conclusion Preceding corticosteroids in HIV-negative patients with PJP are associated with higher mortality. A higher fungal burden may influence corticosteroid-mediated mortality. Assessment of PJP prophylaxis must become a standard clinical best practice when instituting corticosteroid therapy courses.
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Affiliation(s)
- Lilian Vargas Barahona
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, 12700 E. 19th Avenue, Mail Stop B168, Aurora, CO 80045, USA
| | - Kyle C. Molina
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | | | - Stefan Sillau
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alex Tagawa
- Center for Gait and Movement Analysis (CGMA), Children’s Hospital Colorado, Aurora, CO, USA
| | - Sias Scherger
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel B. Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Leland Shapiro
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Jose Tuells
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante, Alicante, Spain
| | | | - Kellie L. Hawkins
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Denver Health Medical Center, Denver, CO, USA
| | - James P. Maloney
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - George R. Thompson
- Division of Infectious Diseases, University of California –Davis, Davis, CA, USA
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Chung C, Lim CM, Oh YM, Hong SB, Choi CM, Huh JW, Lee SW, Lee JS, Jo KW, Ji W, Park CJ, Kim M, Sung H, Cho YU, Cho HS, Kim HC. Prognostic implication of bronchoalveolar lavage fluid analysis in patients with Pneumocystis jirovecii pneumonia without human immunodeficiency virus infection. BMC Pulm Med 2022; 22:251. [PMID: 35754032 PMCID: PMC9233854 DOI: 10.1186/s12890-022-02041-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/20/2022] [Indexed: 11/20/2022] Open
Abstract
Background The prognostic value of bronchoalveolar lavage (BAL) fluid analysis in non-human immunodeficiency virus (HIV)-infected patients with Pneumocystis jirovecii pneumonia (PJP) has not been well elucidated. We aimed to investigate the prognostic implication of BAL fluid analysis in non-HIV patients with PJP. Methods The data of 178 non-HIV patients diagnosed with PJP based on the results of the polymerase chain reaction assay of BAL fluid specimens between April 2018 and December 2020 were retrospectively reviewed. The clinical characteristics, laboratory findings, and BAL fluid analysis results of patients who died within 90 days after hospital admission were compared. Results Twenty patients (11.2%) died within 90 days from admission. The neutrophil count in BAL fluid was significantly higher (median 22.0%, interquartile range [IQR] 2.0–46.0% vs. median 6.0%, IQR 2.0–18.0%, P = 0.044), while the lymphocyte count was significantly lower (median 24.0%, IQR 7.0–37.0% vs. median 41.0%, IQR 22.5–60.5%, P = 0.001) in the non-survivor group compared with that in the survivor group. In the multivariate analysis, the C-reactive protein level (odds ratio [OR] 1.093, 95% confidence interval [CI] 1.020–1.170, P = 0.011) and a BAL fluid lymphocyte count of ≤ 30% (OR 3.353, 95% CI 1.101–10.216, P = 0.033) were independently associated with mortality after adjusting for albumin and lactate dehydrogenase levels. Conclusion A low lymphocyte count in BAL fluid may be a predictor of mortality in non-HIV patients with PJP. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02041-8.
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Affiliation(s)
- Chiwook Chung
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chae Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chang-Min Choi
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Kyung-Wook Jo
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Wonjun Ji
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chan-Jeoung Park
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mina Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Uk Cho
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyo Sin Cho
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho Cheol Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Dashti-Khavidaki S, Saidi R, Lu H. Current status of glucocorticoid usage in solid organ transplantation. World J Transplant 2021; 11:443-465. [PMID: 34868896 PMCID: PMC8603633 DOI: 10.5500/wjt.v11.i11.443] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 11/03/2021] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids (GCs) have been the mainstay of immunosuppressive therapy in solid organ transplantation (SOT) for decades, due to their potent effects on innate immunity and tissue protective effects. However, some SOT centers are reluctant to administer GCs long-term because of the various related side effects. This review summarizes the advantages and disadvantages of GCs in SOT. PubMed and Scopus databases were searched from 2011 to April 2021 using search syntaxes covering “transplantation” and “glucocorticoids”. GCs are used in transplant recipients, transplant donors, and organ perfusate solution to improve transplant outcomes. In SOT recipients, GCs are administered as induction and maintenance immunosuppressive therapy. GCs are also the cornerstone to treat acute antibody- and T-cell-mediated rejections. Addition of GCs to organ perfusate solution and pretreatment of transplant donors with GCs are recommended by some guidelines and protocols, to reduce ischemia-reperfusion injury peri-transplant. GCs with low bioavailability and high potency for GC receptors, such as budesonide, nanoparticle-mediated targeted delivery of GCs to specific organs, and combination use of dexamethasone with inducers of immune-regulatory cells, are new methods of GC application in SOT patients to reduce side effects or induce immune-tolerance instead of immunosuppression. Various side effects involving different non-targeted organs/tissues, such as bone, cardiovascular, neuromuscular, skin and gastrointestinal tract, have been noted for GCs. There are also potential drug-drug interactions for GCs in SOT patients.
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Affiliation(s)
- Simin Dashti-Khavidaki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran 14155, Iran
| | - Reza Saidi
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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Gharamti AA, Mundo W, Chastain DB, Franco-Paredes C, Henao-Martínez AF, Shapiro L. Pneumocystis jirovecii pneumonia: a proposed novel model of corticosteroid benefit. Ther Adv Infect Dis 2021; 8:20499361211032034. [PMID: 34349985 PMCID: PMC8295936 DOI: 10.1177/20499361211032034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Amal A Gharamti
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - William Mundo
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Carlos Franco-Paredes
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA
| | - Andrés F Henao-Martínez
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, 12700 E. 19th Avenue, Mail Stop B168. Aurora, CO 80045, USA
| | - Leland Shapiro
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA
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Ruiz-Camps I, Aguilar-Company J. Risk of infection associated with targeted therapies for solid organ and hematological malignancies. Ther Adv Infect Dis 2021; 8:2049936121989548. [PMID: 33680453 PMCID: PMC7897815 DOI: 10.1177/2049936121989548] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/26/2020] [Indexed: 12/15/2022] Open
Abstract
Higher risks of infection are associated with some targeted drugs used to treat solid organ and hematological malignancies, and an individual patient’s risk of infection is strongly influenced by underlying diseases and concomitant or prior treatments. This review focuses on risk levels and specific suggestions for management, analyzing groups of agents associated with a significant effect on the risk of infection. Due to limited clinical experience and ongoing advances in these therapies, recommendations may be revised in the near future. Bruton tyrosine kinase (BTK) inhibitors are associated with a higher rate of infections, including invasive fungal infection, especially in the first months of treatment and in patients with advanced, pretreated disease. Phosphatidylinositol 3-kinase (PI3K) inhibitors are associated with an increased risk of Pneumocystis pneumonia and cytomegalovirus (CMV) reactivation. Venetoclax is associated with cytopenias, respiratory infections, and fever and neutropenia. Janus kinase (JAK) inhibitors may predispose patients to opportunistic and fungal infections; need for prophylaxis should be assessed on an individual basis. Mammalian target of rapamycin (mTOR) inhibitors have been linked to a higher risk of general and opportunistic infections. Breakpoint cluster region-Abelson (BCR-ABL) inhibitors are associated with neutropenia, especially over the first months of treatment. Anti-CD20 agents may cause defects in the adaptative immune response, hypogammaglobulinemia, neutropenia, and hepatitis B reactivation. Alemtuzumab is associated with profound and long-lasting immunosuppression; screening is recommended for latent infections and prevention strategies against CMV, herpesvirus, and Pneumocystis infections. Checkpoint inhibitors (CIs) may cause immune-related adverse events for which prolonged treatment with corticosteroids is needed: prophylaxis against Pneumocystis is recommended.
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Affiliation(s)
- Isabel Ruiz-Camps
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Juan Aguilar-Company
- Infectious Diseases Department and Oncology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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