MANAGEMENT OF PCP Dr Akaninyene A Otu MBBCh

MANAGEMENT OF PCP Dr. Akaninyene A. Otu, MBBCh, DTM&H, MPH, MRCP (UK), FWACP University of Calabar Teaching Hospital Calabar, Nigeria

Objectives § To be aware of the criteria for admission of patients with PCP § To understand the grading of PCP severity § To understand the options available for treatment § To understand the role of steroids in management of PCP

Introduction • Admission • Oxygen therapy and respiratory support • Nutrition • PCP treatment • Complications • Treatment of co-infections

Admission: WHO recommendations • All HIV infected children with severe pneumonia should be admitted due to increased risk of deterioration • Admit children with very severe pneumonia for nutrition, oxygen & monitoring

How severe is respiratory distress – Cough or Difficulty Breathing? Cyanosed or oxygen saturation <90%? Unable to drink? Reduced level of consciousness? Grunting ? Lower chest wall indrawing? OR Fast breathing? Y Y Severe Pneumonia (RR ≥ 50 ages 2 – 11 months RR ≥ 40 ages 12 – 59 months None of the above? Y No Pneumonia

Grading of PCP severity Mild • Defined as having both Pa. O 2 ≥ 70 mm. Hg and A-a gradient of≤ 35 mm. Hg at room air • Antibiotics can be administered either intravenously or orally

Grading of PCP severity Moderate-severe • Pa. O 2 of <70 mm. Hg or an A-a gradient >35 mm. Hg at room air • Children should be hospitalised. Admission to an intensive care unit or mechanical ventilation may be required • Antibiotics given intravenously if available • Addition of steroids is necessary

Therapy COTRIMOXAZOLE (COTRIM) • Can use IV initially for 3 -10 days • 20 mg/kg/day in 4 divided doses based on the trimethoprim component • Used even for children on cotrim prophylaxis as PCP breakthrough usually related to non-adherence (not resistance • Watch for hypersensitivity • Needs adjusting for renal failure

Alternative therapy q Clindamycin at 10 mg/kg/ dose every 6 hours combined with primaquine at 0. 3 mg/kg/day of the base is another alternative. Caution in G 6 PDH deficiency (no evidence for paediatrics) q IV pentamidine 4 mg/kg/day if cannot tolerate cotrim or not improving after 5 -7 days of cotrim q Trimethoprim and dapsone (all oral) for mild cases (no evidence for paediatrics)

Steroids • Indicated in moderate & severe disease • Reduces mortality and need for mechanical ventilation • No clear role in non HIV PCP • Commonly used regimenoral prednisone 2 mg/kg/day x 5 days, 1 mg/kg/day x 5 days, 0. 5 mg/kg/day x 11 days Newberry L et al. Early use of steroids in infants with a clinical diagnosis of PCP in Malawi: a double-blind RCT

Summary • Admission criteria used in managing all-cause childhood pneumonia may be used for PCP as well • Cotrimoxazole is the first line of treatment of PCP • The grading of severity of PCP is crucial in determining route of antimicrobial administration and addition of steroids • Steroid use is associated with reduction of mortality and need for mechanical ventilation

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