Primary Prophylaxis Reduces Pneumocystis Pneumonia in Rheumatic Disease

Pneumonia, microbe
Pneumonia, microbe
Prolonged treatment with high-dose steroids is a significant risk factor for pneumocystis pneumonia in patients with hematologic malignancies, solid organ transplants, and rheumatic diseases.

Primary prophylaxis with trimethoprim/sulfamethoxazole was shown to reduce the incidence of pneumocystis pneumonia among patients with rheumatic diseases receiving high-dose steroids, according to the results of a recent study published in the Annals of Rheumatic Diseases.

To evaluate the safety and efficacy of trimethoprim/sulfamethoxazole primary prophylaxis among patients with rheumatic diseases receiving prolonged high-dose steroids, researchers evaluated 1522 treatment episodes with ≥4-week courses of ≥30 mg/day prednisone in 1092 patients. A total of 235 participants from the prophylaxis group were matched with 235 participants who did not receive prophylaxis, and pneumocystic pneumonia incidences and related mortality were compared between these groups. Safety was evaluated in the entire treated population.

Of the 30 reported cases of pneumocystis pneumonia in the 1474.4 person-years evaluated, 1 nonfatal case occurred in the prophylaxis group. Compared with no prophylaxis, trimethoprim/sulfamethoxazole reduced the 1-year risk for pneumocystis pneumonia (adjusted hazard ratio, 0.07; 95% CI 0.01-0.54).

The mortality rate of pneumocystis pneumonia was 36.7%. Prophylaxis with trimethoprim/sulfamethoxazole significantly reduced the risk for related mortality (adjusted hazard ratio, 0.08; 95% CI, 0.0006-0.71).

The rate of treatment-related adverse drug reactions was 21.2 per 100 person-years, with most adverse drug reactions mild or moderate in nature. Serious adverse drug reactions included 1 case of pancytopenia and 1 case of Stevens-Johnson syndrome, which resolved after discontinuation.

The number needed to treat to prevent 1 case of pneumocystis pneumonia was 52, which the researchers noted was less than the number needed to harm of 131.

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In conclusion, the study authors explained that the results suggest “the benefit of [trimethoprim/sulfamethoxazole] as primary prophylaxis for [pneumocystis pneumonia] in patients with rheumatic diseases who were treated with prolonged high-dose steroids.”


Park JW, Curtis JR, Moon J, Song YW, Kim S, Lee EB. Prophylactic effect of trimethoprim-sulfamethoxazole for pneumocystis pneumonia in patients with rheumatic diseases exposed to prolonged high-dose glucocorticoids [published online November 1, 2017]Ann Rheum Dis. doi:10.1136/annrheumdis-2017-211796