Question 1 - Opportunistic Infections: Treatment Question Bank

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Opportunistic Infections: TreatmentQuestion 1/20

A 61-year-old man with HIV who has been out of medical care presents with a 3-week history of dyspnea on exertion and cough. He is not taking any medications. Oxygen saturation is normal at rest but decreases to 92% with ambulation. A chest radiograph (Figure 1) reveals perihilar infiltrates, more prominent on the left. An arterial blood gas demonstrates partial pressure of arterial oxygen (PaO2) of 89 mm Hg and alveolar-arterial gradient (A-a gradient) of 27 mm Hg. A diagnosis of Pneumocystis pneumonia is strongly suspected (and subsequently confirmed). He has no known medication allergies.

Which one of the following would you recommend to treat this man with Pneumocystis pneumonia?

Oral pyrimethamine

Oral atovaquone

Oral trimethoprim-sulfamethoxazole

Oral clindamycin

Chest radiograph showing diffuse pulmonary infiltrates in an adult with HIV and mild <em>Pneumocystis</em> pneumonia.

Figure 1. Chest Radiograph of Patient with Pneumocystis Pneumonia.

Chest radiograph showing diffuse pulmonary infiltrates in an adult with HIV and mild Pneumocystis pneumonia.

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Question Last Updated
April 29th, 2026

Table 1. HIV Clinical Guidelines: Recommendations for Treating Mild-to-Moderate Pneumocystis Pneumonia

Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV
For Mild-to-Moderate PCP
People with HIV who develop PCP despite trimethoprim-sulfamethoxazole prophylaxis usually can be treated effectively with standard doses of trimethoprim-sulfamethoxazole (BIII) If not already started, antiretroviral therapy should be initiated in patients within 2 weeks of diagnosis of PCP, if possible (AI).
Preferred Therapy Trimethoprim-sulfamethoxazole (trimethoprim 15–20 mg and sulfamethoxazole 75–100 mg)/kg/day, PO given in three divided doses (AI), or Trimethoprim-sulfamethoxazole two DS tablets PO three times daily (AI)
Alternative Therapy Dapsone^a100 mg PO daily plus trimethoprim 15 mg/kg/day PO given in three divided doses (BI), or Primaquine^a 30 mg (base) PO daily plus clindamycin PO (450 mg every 6 hours or 600 mg every 8 hours) (BI), or Atovaquone 750 mg PO twice daily with food (BI)
Duration of Therapy The recommended duration of therapy (irrespective of regimen) is 21 days (AII). Secondary prophylaxis should be initiated immediately after completion of treatment.
Other Considerations/Comments For people with HIV with non-life-threatening adverse reactions to trimethoprim-sulfamethoxazole, the drug should be continued if clinically feasible. If trimethoprim-sulfamethoxazole is discontinued because of a mild adverse reaction, reinstitution of therapy should be considered after the reaction has resolved (AII). The dose of trimethoprim-sulfamethoxazole can be increased gradually (desensitization) (BI) or the drug can be given at a reduced dose or frequency (CIII). Trimethoprim-sulfamethoxazole should be permanently discontinued, with no rechallenge, in people with HIV with life-threatening adverse reactions including suspected or confirmed Stevens-Johnson Syndrome or toxic epidermal necrolysis (AIII). See above for alternative options for PCP treatment.
^aGlucose-6-phosphate dehydrogenase (G6PD) (G6PD) levels should be checked before administration of dapsone or primaquine. An alternative agent should be used if the patient is found to have G6PD deficiency. Abbreviations: PCP = Pneumocystis pneumonia; PO = orally; DS = double strength Rating System for Prevention and Treatment Recommendations Strength of Recommendation: A = Strong; B = Moderate; C = Weak Quality of Evidence for the Recommendation: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, non-randomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Source:

Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. National Institutes of Health, HIV Medicine Association, and Infectious Diseases Society of America. Pneumocystis Pneumonia. Updated: September 9, 2025. [HIV.gov]

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