PJP Prophylaxis Needed with Steroids and Rituximab Save

Pneumocystis jirovecii pneumonia (PJP) can be a life-threatening infection in immunocompromised patients. The 2023 EULAR Vasculitis guidelines recommends primary prophylaxis with antibiotics, especially in rheumatic disease patients receiving rituximab (RTX).

This analysis identified RTX treated patients from 3 medical centers in South Korea between 2004-2020, and analyzed 818 RTX treated rheumatic patients, 419 of whom received trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis.

Over 663 patient-years, they identified 11 PJP cases, with a 64% mortality rate.

The PJP risk was most influenced by concomitant high-dose glucocorticoid use (≥30mg/day of prednisone during 4 weeks after rituximab administration).

The incidence of PJP (per 100 person-years) was:

• 7.93 (2.91-17.25) on high-dose glucocorticoids
• 0.40 (0.01-2.25) NOT on steroids

For those on RTX alone, prophylactic TMP-SMX significantly reduced the overall PJP incidence (HR 0.11 [0.03-0.37]), the NNT to prevent one PJP was higher than the NNH (146 vs. 86). But with concomitant high-dose glucocorticoids, the protective effect of TMP-SMX was greater with the NNT falling to 20 (10.7-65.7) on TMP-SMX.

The benefit of primary PJP prophylaxis appears to be greatest in rheumatic patients receiving RTX and concomitant high-dose glucocorticoid treatment.