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PCP prophylaxis recommended for HIV-exposed infants in resource-limited settings
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Precise, timely testing for HIV can safely spare most HIV-exposed infants from needing pneumocystis jirovecii pneumonia prophylaxis, but universal prophylaxis should be maintained in resource-limited settings, according to researchers.
P. jirovecii is a small, single-celled fungus most likely spread through airborne transmission and animals. Pneumocystis pneumonia (PCP) occurs in hosts with impaired immune systems, reproducing in high numbers in the alveolae and smaller airways.
The infection commonly results in hypoxia, which is often seen to a disproportionate extent in relation to more common pneumonia symptoms such as fever, cough and respiratory difficulty. It can be diagnosed through the detection of Pneumocystis organisms in pulmonary samples such as induced sputum.
According to the researchers, infants who have been exposed to HIV may not require PCP prophylaxis if HIV can be reasonably ruled out. They said maternal antibodies may complicate a neonatal blood test by crossing the placenta and causing a positive serological result. The researchers advised a testing algorithm consisting of a test at birth, followed by subsequent testing at 4 weeks, 2 months and 4 months of life.
Children younger than 1 year, in whom HIV infection has been confirmed, should undergo PCP prophylaxis starting after age 1 month. Treatment should continue through the first year notwithstanding viral load, CD4+ T-cell numbers or treatment regimen. At age 12 months, children should be re-evaluated, and PCP prophylaxis continued if necessary based on immunologic markers. Because of the risk for kernicterus, infants younger than 28 days should not receive the first-line drug for PCP prophylaxis, trimethoprim/sulfamethoxazole. The researchers cited alternative options, such as dapsone (Aczone, Allergan), atovaquone (Mepron, GlaxoSmithKline) and pentamidine (NebuPent, Fresenius Kabi).
The researchers said unequivocal PCP prophylaxis is no longer considered necessary, but prophylaxis should still be utilized in resource-limited settings.
“Universal prophylaxis for PCP in HIV-exposed neonates is already no longer recommended assuming early, accurate HIV testing can be performed to presumptively rule out HIV infection,” the researchers wrote. “What is clear is that in resource-poor settings without state-of-the-art testing available for HIV, PCP prophylaxis should be initiated universally on HIV-exposed neonates.”
Disclosure: The researchers report no relevant financial disclosures.
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