Reviewed by Jose Lucar, MD, The George Washington University
Bottom line: A network meta-analysis concludes that TMP-SMX remains the most effective agent for PJP prophylaxis in PWH and is the only agent associated with PJP-related & all-cause mortality benefit.
Pneumocystis jirovecii pneumonia (PJP) is still an important opportunistic infection in people with HIV (PWH), particularly among those with advanced disease in the absence of effective antiretroviral therapy (ART). Prophylactic regimens include trimethoprim-sulfamethoxazole (TMP-SMX), dapsone-based regimens (DBRs), atovaquone, and aerosolized pentamidine (AP). In this study, Connor Prosty and colleagues aimed to compare the efficacy and safety of PJP prophylactic regimens in PWH by performing a systematic review and network meta-analysis of comparative randomized controlled trials (RCTs) published from inception to June 2023. They included a total of 26 RCTs in the analysis (23 published before 1997), consisting of 55 treatment arms that included 7516 PWH participants. The authors found that TMP-SMX is the most effective agent for PJP prophylaxis in PWH and is the only agent to confer a mortality benefit compared with no treatment/placebo but has a higher risk of discontinuation due to adverse events. No significant differences among other regimens were found, however, when evaluating the trials restricted to patients with intolerance to TMP-SMX, AP was found to be the best agent for PJP prevention. In conclusion, TMP-SMX should continue to be recommended as the first-line agent for prophylaxis among PJP. The authors propose further study to find the optimal prophylactic dose of TMP-SMX to balance efficacy and safety.
Reference:
Prosty C, Katergi K, Sorin M, et al. Comparative efficacy and safety of Pneumocystis jirovecii pneumonia prophylaxis regimens for people living with HIV: a systematic review and network meta-analysis of randomized controlled trials. Clin Microbiol Infect. 2024;30(7):866-876. doi:10.1016/j.cmi.2024.03.037