Is Routine Prophylaxis Against Pneumocystis jirovecii Needed in Liver Transplantation? A Retrospective Single-Centre Experience and Current Prophylaxis Strategies in Spain.

José Ignacio Fortea,María Luisa Cagigal Cobo,Juan Andrés Echeverri Cifuentes,Emilio Fábrega,Javier Crespo,Paloma Álvarez Fernández,Fernando Casafont,Roberto Fernández Santiago,Carmen Álvarez Tato,Jorge Calvo Montes,Federico José Castillo Suescun,Carlos Ruiz De Alegría Puig,Ángela Puente,Antonio Cuadrado,Marina Cobreros,Patricia Huelin,Inés García Carrera,Juan Carlos Rodríguez Sanjuán

doi:10.3390/jcm9113573

Abstract

In liver transplant (LT) recipients, Pneumocystis jirovecii pneumonia (PJP) is most frequently reported before 1992 when immunosuppressive regimens were more intense. It is uncertain whether universal PJP prophylaxis is still applicable in the contemporary LT setting. We aimed to examine the incidence of PJP in LT recipients followed at our institution where routine prophylaxis has never been practiced and to define the prophylaxis strategies currently employed among LT units in Spain. All LT performed from 1990 to October 2019 were retrospectively reviewed and Spanish LT units were queried via email to specify their current prophylaxis strategy. During the study period, 662 LT procedures were carried out on 610 patients. Five cases of PJP were identified, with only one occurring within the first 6 months. The cumulative incidence and incidence rate were 0.82% and 0.99 cases per 1000 person transplant years. All LT units responded, the majority of which provide prophylaxis (80%). Duration of prophylaxis, however, varied significantly. The low incidence of PJP in our unprophylaxed cohort, with most cases occurring beyond the usual recommended period of prophylaxis, questions a one-size-fits-all approach to PJP prophylaxis. A significant heterogeneity in prophylaxis strategies exists among Spanish LT centres.

Highlights

Pneumocystis jirovecii, formerly Pneumocystis carinii, is a ubiquitous, opportunistic fungus that causes Pneumocystis jirovecii pneumonia (PJP) in immunocompromised individuals, including solid organ transplant (SOT) recipients
We aim to examine the incidence and characteristics of PJP in liver transplant (LT) recipients followed at our transplant centre where routine prophylaxis has not been practiced since the beginning of our LT program in 1990, and to define the prophylaxis strategies currently employed for PJP prevention among LT units in Spain
PJP is most frequently reported before 1992 when immunosuppressive regimens were more intense [8,9]. As these regimens have evolved over time, it is uncertain whether universal PJP prophylaxis is still applicable in the contemporary LT setting

Summary

Introduction

Pneumocystis jirovecii, formerly Pneumocystis carinii, is a ubiquitous, opportunistic fungus that causes Pneumocystis jirovecii pneumonia (PJP) in immunocompromised individuals, including solid organ transplant (SOT) recipients This infection leads to substantial morbidity and mortality and, prior to the broad implementation of prophylaxis, the risk of developing PJP among SOT recipients was approximately 5–15% [1]. Only one study concerning LT patients was included in the two meta-analyses reporting the efficacy of TMP-SMX prophylaxis, and this randomized clinical trial did not include a control group without prophylaxis as it assessed the efficacy and safety of weekly sulfadoxine/pyrimethamine compared with daily TMP-SMX [18] These data question the risk–benefit ratio of a systematic PJP prophylaxis in LT recipients and may lead to variability in prophylactic strategies among centres. Few data are available in this latter regard and, to our knowledge, are restricted to the paediatric SOT setting [26,27]

Objectives

Results

Conclusion