Is There a Role for Consensus Guidelines forP. jiroveciPneumonia Prophylaxis in Immunosuppressed Patients with Rheumatic Diseases?

Abstract

Pneumocystis jiroveci pneumonia (PCP) is the most common opportunistic infection in patients with human immunodeficiency virus (HIV)1. PCP can also affect patients with autoimmune diseases [e.g., systemic lupus erythematosus (SLE), Wegener’s granulomatosis (WG), rheumatoid arthritis (RA), and inflammatory bowel disease] as well as hematological malignancies, organ transplants, and those receiving longterm immunosuppression. In the HIV population, the significant morbidity and mortality of PCP led to the development of specific guidelines for prevention, which has resulted in a dramatic reduction in the incidence of PCP. Similar guidelines for PCP prophylaxis have been developed for patients with organ transplants and undergoing cancer treatment2,3. The absolute incidence and need for chemoprophylaxis in patients with autoimmune diseases has not been well defined, and there are currently no consensus guidelines for PCP prophylaxis. This is due at least in part to a lack of clinical studies in patients with rheumatic diseases. The lack of consensus has led to significant differences in the use of PCP prophylaxis among rheumatologists, as highlighted in a study in this issue by Cettomai, et al 4. The requirement for PCP prophylaxis is based on a risk-benefit assessment taking into consideration several important issues: (1) the incidence of PCP in the specific population (disease and/or immunosuppressive regimen); (2) the morbidity and/or mortality associated with PCP; and (3) the adverse effect profile of the chosen prophylactic regimen. Whether other key clinical and/or laboratory risk factors can help define who should receive PCP prophylaxis and whether the risk-benefit assessment falls in favor of prophylaxis has not been adequately addressed in patients with rheumatic diseases. Infection risk in patients with connective tissue disease (CTD) is increased by the immune dysregulation associated with the disease itself, as well as the use of … Address correspondence to Prof. L. Stamp, Department of Medicine, University of Otago, Christchurch, PO Box 4345, Christchurch 8140, New Zealand. E-mail: lisa.stamp{at}cdhb.govt.nz