Treatment training manual

5. 6 PCP

Type of infection

PCP stands for pneumocystis pneumonia. It is caused by a relatively common organism that behaves like a fungus.

PCP is mainly a lung infection – a pneumonia.

The full name is pneumocystis jiroveci (pronounced: yee-row-vet-zee). PCP used to be called pneumocystis carinii.

A CD4 count of under 200 cells/mm3 increases the risk of PCP. It is rare at higher CD4 counts. Most cases of PCP occur in people with a CD4 count under 100 cells/mm3.

Main symptoms

  • Difficulty breathing (shortness of breath), tightness in the chest.
  • Dry cough.
  • Feeling tired, fever and weight loss.

Symptoms in an HIV positive person with a low CD4 count are sufficient to start treatment.

PCP can sometimes grow in other area of the body like the bones and eye. This is rare.

Diagnosis

Analysis of sputum is used for definite diagnosis. This can be from either bronchoscopy or ‘induced’ sputum (after breathing salty mist which brings up fluid from deeper in the lungs).

Treatment

  • First-line treatment: co-trimoxazole (Septrin, Bactrim, TMP-SMX). Co-trimoxazole is made up of two drugs trimethoprim (TMP) and sulphamethoxazole (SMX). Standard doses are TMP 15-20 mg per kg body weight a day + SMX 75 mg per kg body weight a day, by continuous drip or 3-4 injections a day for 3-4 days, followed by tablets.
  • Other treatments: trimethoprim plus dapsone, pentamidine, trimetrexate, atovaquone and clindamycin plus primaquine.

Prophylaxis

Prophylaxis against PCP, at a lower dose that used for treatment, is recommended for anyone with a CD4 count below 200 cells/mm3 whether or not they are using HIV treatment (ART).

Prophylaxis can be stopped after the CD4 count has increased to over 200 on ARVs. Some studies show that prophylaxis can be stopped a bit earlier than this if someone has not had active symptoms.

Co-trimoxazole (Septrin or Bactrim) at 960mg/day is the most widely used prophylaxis.

Other prophylaxis used when co-trimoxazole causes side effects or if resistance has developed: dapsone (often has side effect in people who cannot tolerate co-trimoxazole), aerosolised pentamidine (every 2-4 weeks), atovaquone, sulphadiazine plus pyrimethamine and dapsone plus pyrimethamine.

Prophylaxis for PCP can be safely stopped at a CD4 count over 200 cells/mm3.

Prophylaxis for PCP with co-trimoxazole protects against other infections including toxoplasmosis.

Last updated: 1 January 2016.