Pneumocystis jiroveci Pneumonia in Inflammatory Bowel Disease Patients: A Survey of Prophylaxis Patterns among Gastroenterology Providers

Abstract

Purpose: The use of combination immunosuppressive agents has been associated with reports of pneumocystis jiroveci pneumonia (PJP) in patients with inflammatory bowel disease (IBD). The aim of this study was to determine gastroenterology providers practice patterns for PJP prophylaxis in IBD patients on immunosuppressive therapy. Methods: An internet-based survey of 14 questions was sent via electronic mail to a random sampling of 4000 gastroenterologists, NPs and PAs between November 2011 and February 2012. Three reminder emails were sent to providers who had not completed the survey. Statistical significance was defined as an alpha level = 0.05 using a two-tailed t test. Results: The invitation email which contained a link to the survey was opened by 504 providers, and completed surveys returned by 123 providers (78% MDs, 11% NPs, 11% PAs). The response rate was 24.4%. Seventy-nine percent of respondents had managed more than 25 IBD patients in the past year with as much as a third of all respondents managing more than 100 patients. Eight percent of respondents reported patients who developed PJP on immunosuppressive therapy and 11% reported initiating PJP prophylaxis, mostly for patients on triple immunosuppressive therapy. Prescription of PJP prophylaxis was not significantly associated with number of years in practice or number of IBD patients managed. However, providers with patients that had developed PJP were 7.4 times more likely to prescribe prophylaxis (p=0.01). Providers in academic centers were 4 times more likely to initiate PJP prophylaxis than those in non-academic centers (p=0.03). The most common reasons for not prescribing PJP prophylaxis included the absence of guidelines on the benefit of prophylaxis, lack of personal experience with PJP, and the lack of knowledge on the need for prophylaxis in IBD patients on combination immunosuppressive therapy. Conclusion: Several factors including a lack of guidelines appear to influence the decision not to prescribe PJP prophylaxis in IBD patients. Additional studies are needed to determine PJP risk factors in immunosuppressed IBD patients and the risks and benefits of prophylaxis.Figure: Gastroenterology providers' reasons for not prescribing PJP prophylaxis.