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Opportunistic Infections: TreatmentQuestion 1/20

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.

A 42-year-old man with HIV who has been out of medical care presents with a 2-week history of cough and dyspnea on exertion. 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 86 mm Hg and alveolar-arterial gradient (A-a gradient) of 28 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

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
January 29th, 2025

Table 1. **Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV**

Treating 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: Dapsone100 mg PO daily plus* trimethoprim 15 mg/kg/day PO given in three divided doses (BI), or Primaquine* 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)
Whenever possible, patients should be tested for glucose-6-phosphate dehydrogenase (G6PD) deficiency 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 Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Pneumocystis Pneumonia. Updated: September 16, 2024. [HIV.gov]

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

Treating Mild-to-Moderate PCP

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