Question | Discussion | References | CME Credit

Updated October 27, 2010

Case 1: Prophylaxis for Pneumocystis Pneumonia

Author: Robert D. Harrington, MD

A 38-year-old man presents for care with newly diagnosed HIV infection. In the past 12 months, he has received treatment for three episodes of community-acquired pneumonia. He currently takes no medications, but in the past he has taken azithromycin (Zithromax), penicillin, and trimethoprim-sulfamethoxazole (Bactrim, Septra) without difficulty. He currently has no respiratory symptoms and his physical examination is notable for seborrheic dermatitis, poor dentition, and extensive oral candidiasis. His initial laboratory studies show a CD4 count of 214 cells/mm3 and a positive IgG Toxoplasma antibody.

Which of the following is true regarding prophylaxis for Pneumocystis pneumonia?

A This patient should receive Pneumocystis pneumonia prophylaxis, but prior to initiating prophylaxis, a sputum sample should be sent to perform Pneumocystis jiroveci resistance testing.
B The patient does not need Pneumocystis pneumonia prophylaxis; he should start prophylaxis if his CD4 count decreases to less than 200 cells/mm3.
C The patient should start on Pneumocystis pneumonia prophylaxis using trimethoprim-sulfamethoxazole at a dose of one double strength tablet per day.
D The patient should receive Pneumocystis pneumonia prophylaxis, but first should undergo bronchoscopy to rule out active Pneumocystis pneumonia prior to receiving prophylaxis.