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PNEUMOCYSTIS jirovecii PROPHYLAXIS 

First Line 

Co-trimoxazole PO 480mg od

If documented allergy to co-trimoxazole consider desensitisation regimen a soon as patient able to tolerate oral medicines post-transplant.

Desensitisation can be attempted in patients with a non-severe (grade 3 or less) co-trimoxazole reaction. It should not be attempted in patients with a grade 4 reaction to co-trimoxazole or other sulfa drugs. Toxicities can be graded as follows in Table 1. 

Table 1: Grade 1-4 Co-trimoxazole toxicity

Toxicity Clinical description
Grade 1 Erythema
Grade 2 Diffuse maculopapular rash, dry deaquamation
Grade 3 Vesiculation, mucosal ulceration
Grade 4 Exfoliatie dermatitis, Stevens-Johnson syndreome or erythema multiforms, moist desquamation

 
If a minor reaction occurs during the desensitisation regimen, then repeat the same step for an additional day and progress to next step if the reaction subsides. If the reaction worsens or a sever reaction occurs, stop the desensitisation. Consider giving concurrent antihistamine (ie cetirizine 10mg  once daily), commenced one day prior to starting the desensitisation regimen.
 

Table 2- Co-trimoxazole desensitisation regimen

Step Dose
Day 1 80mg sulfamethoxazole + 16mg trimethoprim (1ml oral suspension)
Day 2 160mg sulfamethoxazole + 32mg trimethoprim (2ml oral suspension)
Day 3 240mg sulfamethoxazole + 48mg trimethoprim (3ml oral suspension)
Day 4 320mg sulfamethoxazole + 64mg trimethoprim (4ml oral suspension)
Day 5 400mg sulfamethoxazole + 80mg trimethoprim i.e. 1 x 480mg tablet

Co-trimoxazole oral suspension is 400mg sulfamethoxazole + 80mg trimethoprim per 5ml.

Second Line

Dapsone PO 100mg OD. Consider dose reduction to 50mg OD in severe renal dysfunction (creatinine clearance <10ml/min).


CMV INFECTION / PROPHYLAXIS

  • All transplant recipients except CMV–ve recipients of CMV–ve donors receive CMV prophylaxis with valganciclovir.
  • Therapy will be continued in primary care for up to a total of 180 days treatment.
  • The initial valganciclovir dose is dependent on renal function as shown in the table below:
Creatinine clearance (ml/min)
Prophylactic dose of Valganciclovir
>60 900mg od
40 to 59
450mg od
25 to 39
450mg every 2 days
10 to 24
450mg twice weekly

  • Valganciclovir is available as 450mg tablets (pink) and the brand name is Valcyteâ.  The tablets should be taken with food and not broken or crushed.
  • FBC and LFTs must be monitored during therapy.

Investigation of any episode of illness that might be CMV related, at any stage following a transplant operation.

  • An EDTA (9 ml or 3 x 2.5 mls sample for CMV should be sent to Virology whenever is clinically relevant. On request form include details of illness (e.g. pyrexia or hepatitis etc.)
  • Request CMV PCR.
  • Please try to ensure samples reach Virus Lab by midday. The rapid culture may provide an answer sooner than PCR in some cases.It will often be appropriate to send respiratory or other samples to virology – broncho-alveolar lavage or induced sputum for investigation as usual or colon biopsies.  


Treatment of CMV disease

  • Patients in whom the diagnosis of CMV disease has been made with positive CMV PCR should be treated with 2 weeks IV ganciclovir followed by oral valganciclovir.
  • This should be continued until two consecutive negative CMV results have been obtained.
  • Dose of IV gancyclovir will depend on creatinine clearance:
Creatinine clearance (ml/min)
Treatment dose of ganciclovir IV
>70 5mg/kg every 12 hours
50 to 69
2.5mg/kg every 12 hours
25 to 49
2.5mg/kg/day
10 to 24
1.25mg/kg/day
<10
1.25mg/kg/day after haemodialysis

  • Ganciclovir is made in the aseptic department in pharmacy, contact the renal transplant pharmacist to organize a supply.

If indicated treatment doses of Valganciclovir can be used as shown in table below:

Creatinine clearance (ml/min)
Treatment dose of ganciclovir IV
>60 900mg (2 tablets) twice daily
40 to 59
450mg (1 tablet) twice daily
25 to 39
450mg daily
10 to 24
450mg every 2 days
<10
Not recommended


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This page last modified 12.11.2013 14:09 by Emma Farrell. edren and edrep are produced by the Renal Unit at the Royal Infirmary of Edinburgh and the University of Edinburgh. CAUTIONS and Contact us.