Academy Exchange

Hi All. Do you routinely use prophylaxis for Pneumocystis pneumonia (PCP) for patient with CD4 less than 200 copies? If so, which regimen do you use? TMP/SMX DS once a day? SS once a day? or DS three times per week? or any others?

Thanks,
Gryan

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Gryan Eroll Garcia
Scottsdale AZ
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Gryan,
I would recommend you go to the DHHS Guidelines -  which fully address your question. These were last updated about 8 months ago. 
All 3 are considered options - historically my own preference was one SS tablet daily unless you need prophylaxis as well for Toxoplasmosis which is rarely needed these days except for patients presenting late to care. ​
Jeff

aidsinfo.nih.gov/guidelines

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Jeffrey Kirchner
Lancaster General Health Physicians (LGHP) - Comprehensive Care
Lancaster PA
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Original Message:
Sent: 03-22-2020 17:38
From: Gryan Eroll Garcia
Subject: Prophylaxis for Pneumocystis pneumonia (PCP)

Hi All. Do you routinely use prophylaxis for Pneumocystis pneumonia (PCP) for patient with CD4 less than 200 copies? If so, which regimen do you use? TMP/SMX DS once a day? SS once a day? or DS three times per week? or any others?

Thanks,
Gryan

------------------------------
Gryan Eroll Garcia
Scottsdale AZ
------------------------------

Hey, Jeff!! 

Gryan- it really is a great question, once patients are on ARV's they do well without Bactrim. We all have patients who refuse to take Bactrim or take it for 30 days then never obtain the refill. I generally use Bactrim DS 3 times weekly. One reason I opt for this regimen is that it's easier for my young adults to be adherent when they know there's an end to taking this medication. It's incentive...take this 3 times weekly and once we've met the guidelines for discontinuation, we will stop it. Your question is relevant as the only patients we see anymore with PJP are at presentation. 

Thanks for the conversation. 

Michelle

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Michelle Ogle
Bronx NY
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Original Message:
Sent: 03-23-2020 15:12
From: Jeffrey Kirchner
Subject: Prophylaxis for Pneumocystis pneumonia (PCP)

Gryan,
I would recommend you go to the DHHS Guidelines -  which fully address your question. These were last updated about 8 months ago. 
All 3 are considered options - historically my own preference was one SS tablet daily unless you need prophylaxis as well for Toxoplasmosis which is rarely needed these days except for patients presenting late to care. ​
Jeff

aidsinfo.nih.gov/guidelines

------------------------------
Jeffrey Kirchner
Lancaster General Health Physicians (LGHP) - Comprehensive Care
Lancaster PA

Original Message:
Sent: 03-22-2020 17:38
From: Gryan Eroll Garcia
Subject: Prophylaxis for Pneumocystis pneumonia (PCP)

Hi All. Do you routinely use prophylaxis for Pneumocystis pneumonia (PCP) for patient with CD4 less than 200 copies? If so, which regimen do you use? TMP/SMX DS once a day? SS once a day? or DS three times per week? or any others?

Thanks,
Gryan

------------------------------
Gryan Eroll Garcia
Scottsdale AZ
------------------------------

Gryan,

Another great source is the HIV National Curriculum. I have provided the link to the OI section below, but it is a phenomenal course that can help build your knowledge and skills:

https://www.hiv.uw.edu/go/co-occurring-conditions/opportunistic-infections-prevention/core-concept/all

Dave

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David Hachey
Pocatello ID
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Original Message:
Sent: 03-22-2020 17:38
From: Gryan Eroll Garcia
Subject: Prophylaxis for Pneumocystis pneumonia (PCP)

Hi All. Do you routinely use prophylaxis for Pneumocystis pneumonia (PCP) for patient with CD4 less than 200 copies? If so, which regimen do you use? TMP/SMX DS once a day? SS once a day? or DS three times per week? or any others?

Thanks,
Gryan

------------------------------
Gryan Eroll Garcia
Scottsdale AZ
------------------------------

Gryan,

I agree with what the other comments made by Jeff and Michelle here. It is certainly nice for patients to have options regarding whether they want to take TMP-SMX 3x weekly vs once daily and DS vs SS. If you go to the DHHS guidelines you'll see that TMP-SMX DS or SS qDay both have level A1 ratings, whereas 3x weekly has a level B1 rating. Something to consider as well but do what works for your patients. Much of our data around prophylaxis is in the era before HAART. I think many would agree now that the vast majority of prophylactic benefit is actually going to be from the ART itself, as compared to the antimicrobial ppx such as TMP-SMX.

I also want to say that the decisions around prophylaxis should be informed in part by your patient population as well. What I mean by that is this: some positive care clinics seldom see new patients present so late to care with stage 3 clinical criteria (AIDS). However, at our clinic in LA County and our positive care team on Skid Row we very frequently see patients present very late to care. We may also see patients who have been out of care for many years and now have AIDS. So the incidence of PCP or other OI's may be higher among our cohort of patients who, in aggregate, are more likely to have AIDS. So we are pretty cautious with ppx because of our patient population.

Hope everyone is staying safe out there!

------------------------------
Michael Stefanowicz
Los Angeles CA
------------------------------

Original Message:
Sent: 03-22-2020 17:38
From: Gryan Eroll Garcia
Subject: Prophylaxis for Pneumocystis pneumonia (PCP)

Hi All. Do you routinely use prophylaxis for Pneumocystis pneumonia (PCP) for patient with CD4 less than 200 copies? If so, which regimen do you use? TMP/SMX DS once a day? SS once a day? or DS three times per week? or any others?

Thanks,
Gryan

------------------------------
Gryan Eroll Garcia
Scottsdale AZ
------------------------------

Thank you so much, everyone, for all your responses. Much appreciated! I'm so glad we have such a strong community of HIV E/S/P. 

Stay safe everyone,
Gryan

------------------------------
Gryan Eroll Garcia
Scottsdale AZ
------------------------------

Original Message:
Sent: 03-25-2020 11:03
From: Michael Stefanowicz
Subject: Prophylaxis for Pneumocystis pneumonia (PCP)

Gryan,

I agree with what the other comments made by Jeff and Michelle here. It is certainly nice for patients to have options regarding whether they want to take TMP-SMX 3x weekly vs once daily and DS vs SS. If you go to the DHHS guidelines you'll see that TMP-SMX DS or SS qDay both have level A1 ratings, whereas 3x weekly has a level B1 rating. Something to consider as well but do what works for your patients. Much of our data around prophylaxis is in the era before HAART. I think many would agree now that the vast majority of prophylactic benefit is actually going to be from the ART itself, as compared to the antimicrobial ppx such as TMP-SMX.

I also want to say that the decisions around prophylaxis should be informed in part by your patient population as well. What I mean by that is this: some positive care clinics seldom see new patients present so late to care with stage 3 clinical criteria (AIDS). However, at our clinic in LA County and our positive care team on Skid Row we very frequently see patients present very late to care. We may also see patients who have been out of care for many years and now have AIDS. So the incidence of PCP or other OI's may be higher among our cohort of patients who, in aggregate, are more likely to have AIDS. So we are pretty cautious with ppx because of our patient population.

Hope everyone is staying safe out there!

------------------------------
Michael Stefanowicz
Los Angeles CA

Original Message:
Sent: 03-22-2020 17:38
From: Gryan Eroll Garcia
Subject: Prophylaxis for Pneumocystis pneumonia (PCP)

Hi All. Do you routinely use prophylaxis for Pneumocystis pneumonia (PCP) for patient with CD4 less than 200 copies? If so, which regimen do you use? TMP/SMX DS once a day? SS once a day? or DS three times per week? or any others?

Thanks,
Gryan

------------------------------
Gryan Eroll Garcia
Scottsdale AZ
------------------------------

Original Message------

Gryan,

I agree with what the other comments made by Jeff and Michelle here. It is certainly nice for patients to have options regarding whether they want to take TMP-SMX 3x weekly vs once daily and DS vs SS. If you go to the DHHS guidelines you'll see that TMP-SMX DS or SS qDay both have level A1 ratings, whereas 3x weekly has a level B1 rating. Something to consider as well but do what works for your patients. Much of our data around prophylaxis is in the era before HAART. I think many would agree now that the vast majority of prophylactic benefit is actually going to be from the ART itself, as compared to the antimicrobial ppx such as TMP-SMX.

I also want to say that the decisions around prophylaxis should be informed in part by your patient population as well. What I mean by that is this: some positive care clinics seldom see new patients present so late to care with stage 3 clinical criteria (AIDS). However, at our clinic in LA County and our positive care team on Skid Row we very frequently see patients present very late to care. We may also see patients who have been out of care for many years and now have AIDS. So the incidence of PCP or other OI's may be higher among our cohort of patients who, in aggregate, are more likely to have AIDS. So we are pretty cautious with ppx because of our patient population.

Hope everyone is staying safe out there!

------------------------------
Michael Stefanowicz
Los Angeles CA
------------------------------