Question 3 - Opportunistic Infections: Treatment Question Bank

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Opportunistic Infections: TreatmentQuestion 3/20

A 29-year-old woman with HIV and a CD4 count of 124 cells/mm³ is admitted to the medical intensive care unit for fever, cough, dyspnea, and significant hypoxia. She is not currently taking antiretroviral therapy or any opportunistic infection prophylactic medications. Chest computed tomographic (CT) imaging reveals scattered ground glass opacities and cystic cavities (Figure 1). An arterial blood gas shows a pO2 = 68 mm Hg. The plan is to perform bronchoscopy and start empiric treatment for Pneumocystis pneumonia with adjunctive corticosteroids. She has a history of a life-threatening rash to trimethoprim-sulfamethoxazole.

Which one of the following is an acceptable alternative to trimethoprim-sulfamethoxazole for the treatment of this woman with moderate-to-severe Pneumocystis pneumonia?

Oral primaquine plus oral clindamycin

Inhaled pentamidine

Oral pyrimethamine plus sulfadiazine

Oral atovaquone

Computed tomographic (CT) scan of lungs in patient with <em>Pneumocystis</em> pneumonia showing diffuse infiltrates and cavitary lesions.

Figure 1. Computed Tomographic (CT) Scan of Lungs

Computed tomographic (CT) scan of lungs in patient with Pneumocystis pneumonia showing diffuse infiltrates and cavitary lesions.

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Question Last Updated
April 29th, 2026

Table 1. Recommendations for Treating Moderate-to-Severe Pneumocystis Pneumonia

Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV
For Moderate-to-Severe PCP
People with HIV who develop Pneumocystis pneumonia (PCP) despite trimethoprim-sulfamethoxazole prophylaxis usually can be treated effectively with standard treatment 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/kg/day and sulfamethoxazole 75–100 mg)/kg/day) IV given in divided doses every 6 or 8 hours (AI); may switch to PO formulations after clinical improvement (AI)
Alternative Therapy Primaquine^a 30 mg (base) PO once daily plus Clindamycin (600 mg IV every 6 hours or 900 mg IV every 8 hours or 450 mg PO every 6 hours or 600 mg PO every 8 hours) (AI), or Pentamidine 4 mg/kg IV once daily infused over ≥60 minutes (AI); may reduce the dose to pentamidine 3 mg/kg IV once daily in the event of toxicities (BI) Note: Some clinicians prefer primaquine plus clindamycin because it is more effective and less toxic than pentamidine.
Adjunctive Corticosteroids for Moderate-to-Severe PCP Based on the Following Criteria: (AI) PaO₂ <70 mm Hg at room air, or Alveolar-arterial (A-a) gradient ≥35 mmHg
Corticosteroid Dosing Schedule Prednisone doses (beginning as early as possible and within 72 hours of initiating PCP therapy) (AI) Days 1–5: 40 mg PO twice daily Days 6–10: 40 mg PO daily Days 11–21: 20 mg PO daily IV methylprednisolone can be given as 80% of prednisone dose. Benefit of corticosteroid if started after 72 hours of PCP treatment is unknown, but some clinicians will use it for moderate-to-severe PCP (BIII).
Additional 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) 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; IV = intravenous; PaO₂ = room air arterial oxygen partial pressure; PO = orally; DS = double; strength; SS = single 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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