{"entity":{"id":"pneumocystis-pneumonia-prophylaxis","kind":"protocol","name":"Pneumocystis pneumonia (PJP) prophylaxis with co-trimoxazole","aka":["PJP prophylaxis","PCP prophylaxis","Pneumocystis prophylaxis","co-trimoxazole prophylaxis","Septrin prophylaxis","TMP-SMX prophylaxis","trimethoprim-sulfamethoxazole prophylaxis"],"tldr":"Pneumocystis is a fungus that can cause a dangerous pneumonia in people whose immune system is weakened by some cancer treatments, steroids or a stem cell transplant. An inexpensive antibiotic, co-trimoxazole, taken a few times a week or daily, prevents it very well. People who cannot take it have other options: atovaquone, dapsone or an inhaled medicine once a month.","summary":"AGIHO (2020) strongly recommends chemoprophylaxis for the groups its Table 7 lists at significant risk: acute lymphoblastic leukaemia, allogeneic stem cell transplant, long-term steroids above 20 mg prednisone equivalent daily for more than 4 weeks, and fludarabine with cyclophosphamide and rituximab (prevent PJP A-I, reduce mortality A-IIr), and for idelalisib, alemtuzumab and temozolomide with radiotherapy (A-IIu,t). Intermediate risk (R-CHOP14, escalated BEACOPP, nucleoside analogues, brain irradiation with high-dose steroids, CD4 below 200/µl) may or may not receive it (C-III). ASCO/IDSA (2018) set the threshold at regimens with more than 3.5% risk, for example 20 mg or more prednisone equivalent daily for a month or more, or purine analogues. ECIL-5 (2016) lists ALL, allogeneic HSCT, alemtuzumab, fludarabine with cyclophosphamide and rituximab, more than 4 weeks of corticosteroids and primary immune deficiencies in children, for the entire period at risk.\n\nCo-trimoxazole (trimethoprim-sulfamethoxazole) is first choice (AGIHO A-IIt,r; ECIL-5 A-II adults, A-I children), at one single-strength tablet daily or one double-strength tablet daily or thrice weekly (B-IIt); ECIL-5 gives it 2 to 3 times weekly and notes children may do equally well once weekly (B-II). Second line: atovaquone 1500 mg daily with a fatty meal (A-IIt), dapsone 100 mg daily after G6PD testing (A-IIt), or aerosolised pentamidine 300 mg monthly (B-IIt), which is probably less effective and needs staff protection. For idelalisib the label asks for prophylaxis from the start and for 2 to 6 months after stopping.","asOf":"2026-11-11","links":[],"tags":["protocol","pneumocystis","infection-prevention"],"related":["lymphoma-tx-pjp-and-infection-prophylaxis"],"cancers":["all-leukemia","cll","non-hodgkin-lymphoma","glioblastoma","childhood-cancers"],"sections":["supportive-care"],"technologies":["allogeneic-hsct"],"targets":[],"drugs":["idelalisib","alemtuzumab","temozolomide","fludarabine","rituximab"],"companies":[],"institutions":[],"pathways":[],"terms":["lymphoma-tx-pjp-and-infection-prophylaxis"],"trials":[],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"simple":"Some cancer treatments raise the risk of a rare but serious lung infection. A cheap antibiotic tablet, often taken only three days a week, prevents it.","domain":"infection-prevention","setting":{"who":["doctor","pharmacist","nurse","patient-or-carer"],"where":["outpatient-clinic","ward","home"]},"population":"People with cancer who are not living with HIV and are having treatment that suppresses cell-mediated immunity: haematological cancers, stem cell transplant, long-term corticosteroids, temozolomide with radiotherapy. AGIHO and ASCO/IDSA address adults; ECIL-5 grades adults and children separately; a 2017 guideline addresses children with solid tumours.","trigger":"A regimen or steroid course that carries a significant risk of Pneumocystis pneumonia is being planned.","steps":[{"action":"Identify the people at significant risk: ALL, allogeneic stem cell transplant, steroids above 20 mg prednisone equivalent a day for more than 4 weeks, or fludarabine with cyclophosphamide and rituximab","why":"In these groups the pneumonia is common enough, and deadly enough, that prevention clearly pays.","source":"agiho-2020","quote":"Oncologic patients at significant risk for PcP are those treated for acute lymphoblastic leukemia, those treated with a combination of fludarabine, cyclophosphamide, and rituximab [129], and patients undergoing allogeneic HSCT [128, 130]."},{"action":"Give these patients prophylaxis","why":"It prevents the pneumonia and reduces deaths from it.","source":"agiho-2020","quote":"The administration of chemoprophylaxis in patients with one of these three risk factors is thus strongly recommended to prevent PcP (A-I) and reduce mortality (A-IIr).","grade":"A-I (prevent PcP); A-IIr (reduce mortality)"},{"action":"Give prophylaxis with idelalisib, alemtuzumab, or temozolomide given with radiotherapy","why":"These treatments carry a documented high risk, and for idelalisib the drug label requires it.","source":"agiho-2020","quote":"Based on the documented high-risk situation, we strongly recommend chemoprophylaxis against PcP for patients receiving temozolomide (in combination with radiotherapy), idelalisib, or alemtuzumab (A-IIu,t) (Tables 7 and 8).","grade":"A-IIu,t"},{"action":"Decide case by case for intermediate risk, such as R-CHOP14, escalated BEACOPP, nucleoside analogues, brain radiotherapy with high-dose steroids, or a CD4 count below 200","why":"These patients occasionally get the infection, but no study shows prophylaxis helps them and many more would need treating to prevent one case.","source":"agiho-2020","quote":"Such patients at moderate risk may or may not receive chemoprophylaxis to prevent PcP (C-III) and to reduce mortality (C-III).","grade":"C-III"},{"action":"Use co-trimoxazole (trimethoprim-sulfamethoxazole) first","why":"It is the most effective option, and also protects against toxoplasmosis, nocardiosis and actinomycosis.","source":"agiho-2020","quote":"For these reasons, TMP-SMX is the first-choice agent for PcP prophylaxis (A-IIt,r).","grade":"A-IIt,r"},{"action":"Give one single-strength tablet daily, or one double-strength tablet daily or three times a week","why":"The schedules work equally well; three times a week caused fewer stoppings for side effects in a study in people with HIV.","source":"agiho-2020","quote":"We recommend using any of these dosing regimens (B-IIt).","grade":"B-IIt"},{"action":"Continue it for the whole time the person is at risk","why":"The risk lasts as long as the immune suppression, not just the days of chemotherapy.","source":"ecil5-2016","quote":"Trimethoprim/sulfamethoxazole given 2-3 times weekly is the drug of choice for the primary prophylaxis of PCP in adults ( A-II: ) and children ( A-I: ) and should be given during the entire period at risk.","grade":"A-II (adults); A-I (children)"},{"action":"If co-trimoxazole is not tolerated, use atovaquone 1500 mg once daily with a fatty meal","why":"It worked well and does not lower blood counts; lower doses were less effective, and fat helps it absorb.","source":"agiho-2020","quote":"Low-dose atovaquone has been described to be less effective in PcP prophylaxis [164]; thus, 1500 mg atovaquone should be administered once daily (off-label use) (A-IIt).","grade":"A-IIt"},{"action":"Or use dapsone 100 mg daily, after testing for G6PD deficiency","why":"Dapsone works as well as co-trimoxazole but can break down red cells in G6PD deficiency and cause methaemoglobinaemia.","source":"agiho-2020","quote":"Testing for glucose-6-phosphat dehydrogenase deficiency is recommended prior to administration of dapsone.","grade":"A-IIt"},{"action":"Keep aerosolised pentamidine, 300 mg once a month, for when the tablets cannot be used, and protect the staff giving it","why":"It has no blood or drug interactions but probably works less well, gives no protection against toxoplasmosis, and exposes staff to the drug.","source":"agiho-2020","quote":"Our recommendation to use aerosolized pentamidine (300 mg once/month) is moderate (B-IIt) (Table 9).","grade":"B-IIt"}],"bestInClass":{"statement":"Co-trimoxazole for the whole period of risk is the agreed first choice (AGIHO 2020 A-IIt,r; ECIL-5 2016 A-II adults, A-I children). The guidelines agree on the core indications (ALL, allogeneic transplant, fludarabine-based chemoimmunotherapy, alemtuzumab, prolonged steroids) but draw the line differently: AGIHO names significant, intermediate and special-indication groups and leaves intermediate risk to judgement (C-III); ASCO/IDSA (2018) use a numerical threshold of more than 3.5% risk, with 20 mg or more prednisone equivalent daily for a month or longer as the example; ECIL-5 adds primary immune deficiencies in children and other regimens case by case. On the schedule, AGIHO accepts daily or thrice-weekly dosing (B-IIt), ECIL-5 recommends 2 to 3 times weekly and allows once weekly in children (B-II). For children with solid tumours, a 2017 guideline suggests offering prophylaxis to all children having immunosuppressive therapy unless contraindicated.","sources":["agiho-2020","ecil5-2016","asco-idsa-2018","jpho-2017"]},"variants":[{"name":"Numerical risk threshold (ASCO/IDSA 2018)","differs":"Recommends prophylaxis for chemotherapy regimens associated with more than 3.5% risk of Pneumocystis pneumonia, for example 20 mg or more prednisone equivalents daily for a month or more, or purine analogues.","evidence":"Read as an abstract only, so the grade is not given here.","sources":["asco-idsa-2018"]},{"name":"Once-weekly co-trimoxazole in children (ECIL-5)","differs":"Uses a single weekly dose instead of 2 to 3 times weekly in children.","evidence":"ECIL-5 says recent data indicate children may benefit equally, graded B-II.","sources":["ecil5-2016"]},{"name":"Prophylaxis for every child on immunosuppressive therapy for a solid tumour","differs":"Offers co-trimoxazole to all children with malignancies on immunosuppressive therapy unless there are clear contraindications, rather than only those in named high-risk groups.","evidence":"A paediatric guideline read as an abstract only; it argues from the high mortality of the pneumonia and the safety and low cost of co-trimoxazole.","sources":["jpho-2017"]}],"grades":[{"claim":"Prophylaxis for significant-risk groups, to prevent PJP","grade":"A-I","source":"agiho-2020"},{"claim":"Prophylaxis for significant-risk groups, to reduce mortality","grade":"A-IIr","source":"agiho-2020"},{"claim":"Prophylaxis with idelalisib, alemtuzumab or temozolomide with radiotherapy","grade":"A-IIu,t","source":"agiho-2020"},{"claim":"Intermediate-risk groups may or may not receive prophylaxis","grade":"C-III","source":"agiho-2020"},{"claim":"Co-trimoxazole as first choice","grade":"A-IIt,r","source":"agiho-2020"},{"claim":"Co-trimoxazole 2 to 3 times weekly for the entire period at risk","grade":"A-II (adults); A-I (children)","source":"ecil5-2016"},{"claim":"Once-weekly co-trimoxazole in children","grade":"B-II","source":"ecil5-2016","quote":"Recent data indicate that children may benefit equally from a once-weekly regimen ( B-II: )."},{"claim":"Aerosolised pentamidine 300 mg monthly as second choice","grade":"B-IIt","source":"agiho-2020"}],"sources":[{"key":"agiho-2020","label":"Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors: 2020 updated guidelines of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO/DGHO)","publisher":"AGIHO/DGHO, Annals of Hematology","year":2021,"url":"https://europepmc.org/article/PMC/PMC8116237","doi":"10.1007/s00277-021-04452-9","gradingScheme":"Strength of recommendation A (strongly supports use) to D (supports a recommendation against use) and quality of evidence I to III, with indices r (meta-analysis), t (transferred evidence), h (historical control), u (uncontrolled trial), a (abstract), printed as A-IIt,r.","read":"full-text","accessed":"2026-11-11"},{"key":"ecil5-2016","label":"ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients","publisher":"European Conference on Infections in Leukaemia (ECIL-5), Journal of Antimicrobial Chemotherapy","year":2016,"url":"https://europepmc.org/abstract/MED/27550992","doi":"10.1093/jac/dkw157","gradingScheme":"IDSA grading: strength A to C, evidence I to III.","read":"abstract","accessed":"2026-11-11"},{"key":"asco-idsa-2018","label":"Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update","publisher":"ASCO and IDSA, Journal of Clinical Oncology","year":2018,"url":"https://europepmc.org/abstract/MED/30179565","doi":"10.1200/JCO.18.00374","read":"abstract","accessed":"2026-11-11"},{"key":"jpho-2017","label":"Guidelines for the Prophylaxis of Pneumocystis jirovecii Pneumonia (PJP) in Children With Solid Tumors","publisher":"Journal of Pediatric Hematology/Oncology","year":2017,"url":"https://europepmc.org/abstract/MED/28267082","doi":"10.1097/mph.0000000000000771","read":"abstract","accessed":"2026-11-11"}],"upgrades":[],"gaps":["The ECIL-5 full text could not be read: the publisher's page returned a bot challenge to a script. Its paediatric doses and the additional regimen-specific indications it proposes are not given here.","ASCO/IDSA 2018 was read only as an abstract, so its grade and drug choices for PJP prophylaxis are not stated.","No source read here gives a duration after treatment ends beyond 'the entire period at risk', except the idelalisib label's 2 to 6 months cited by AGIHO.","Evidence for co-trimoxazole schedules comes largely from people living with HIV and is transferred to cancer (AGIHO grades it B-IIt).","Whether prophylaxis helps intermediate-risk groups, such as people on long-term anti-CD20 antibodies or R-CHOP14, has not been studied."]},"route":"/protocols/pneumocystis-pneumonia-prophylaxis/","neighbours":{"term":[{"id":"lymphoma-tx-pjp-and-infection-prophylaxis","kind":"term","name":"Infection prophylaxis in lymphoma: PJP, herpes, fungal risk and vaccination","route":"/terms/lymphoma-tx-pjp-and-infection-prophylaxis/"}],"cancer":[{"id":"all-leukemia","kind":"cancer","name":"Acute lymphoblastic leukaemia","route":"/cancers/all-leukemia/"},{"id":"childhood-cancers","kind":"cancer","name":"Childhood cancers (all types)","route":"/cancers/childhood-cancers/"},{"id":"cll","kind":"cancer","name":"Chronic lymphocytic leukaemia","route":"/cancers/cll/"},{"id":"glioblastoma","kind":"cancer","name":"Glioma & glioblastoma","route":"/cancers/glioblastoma/"},{"id":"non-hodgkin-lymphoma","kind":"cancer","name":"Non-Hodgkin lymphoma (all types)","route":"/cancers/non-hodgkin-lymphoma/"}],"section":[{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"technology":[{"id":"allogeneic-hsct","kind":"technology","name":"Allogeneic stem cell transplantation","route":"/technologies/allogeneic-hsct/"}],"drug":[{"id":"alemtuzumab","kind":"drug","name":"Alemtuzumab","route":"/drugs/alemtuzumab/"},{"id":"fludarabine","kind":"drug","name":"Fludarabine","route":"/drugs/fludarabine/"},{"id":"idelalisib","kind":"drug","name":"Idelalisib","route":"/drugs/idelalisib/"},{"id":"rituximab","kind":"drug","name":"Rituximab","route":"/drugs/rituximab/"},{"id":"temozolomide","kind":"drug","name":"Temozolomide","route":"/drugs/temozolomide/"}]}}