MANAGEMENT OF PCP Dr. Akaninyene A. Otu, MBBCh, DTM&H, MPH, MRCP (UK), FWACP University of Calabar Teaching Hospital Calabar, Nigeria

Objectives To be aware of the criteria for admission of patients with PCP To understand the grading of PCP severity To understand the options available for treatment To understand the role of steroids in management of PCP

Oxygen therapy and respiratory support Nutrition PCP treatment Introduction Admission Oxygen therapy and respiratory support Nutrition PCP treatment Complications Treatment of co-infections

Admission: WHO recommendations All HIV infected children with severe pneumonia should be admitted due to increased risk of deterioration Admit children with very severe pneumonia for nutrition, oxygen & monitoring Recap of the WHO classifications in the next slide

How severe is respiratory distress – Cough or Difficult Breathing? Cyanosed or oxygen saturation <90%? Unable to drink? Reduced level of consciousness? Grunting ? Y Severe Pneumonia Lower chest wall indrawing? OR Fast breathing? (RR ≥ 50 ages 2 –11 months RR ≥ 40 ages 12 – 59 months Y Pneumonia As a result of this research the WHO proposes a classification of pneumonia based on key signs – this is part of the IMCI (and previously the ARI) programme. Working from the severe end downwards one can check for only a few signs in a child with cough and difficulty breathing and classify into one of four categories that provide a measure of the severity of the child’s disease. Once the severity is classified it becomes easier to decide who should be in hospital – only those with severe pneumonia. There is evidence that this classification works to identify those at greatest risk of death and thus most in need of hospital care (see pneumonia severity of disease summary). Syndromic classification – based on the clinical signs In the 4th Edition Basic Paediatric Protocol pneumonia is simply classified into 2 classification on if there are danger signs or not If there are danger signs then that is Severe pneumonia If not danger signs then its is ‘pneumonia ‘–non severe. Thus patients who have in-drawing OR fast breathing with danger signs is classified as PNEUMONIA Y None of the above? No Pneumonia

Grading of PCP severity Mild Defined as having both PaO2 ≥70 mmHg and A-a gradient of≤ 35 mmHg at room air Antibiotics can be administered either intravenously or orally Adapted from best practice bmj http://bestpractice.bmj.com/best-practice/monograph/19/treatment/step-by-step.html

Grading of PCP severity Moderate-severe PaO2 of <70 mmHg or an A-a gradient >35 mmHg at room air Children should be hospitalised. Admission to an intensive care unit or mechanical ventilation may be required Antibiotics given intravenously if available Addition of steroids is necessary

Therapy COTRIMOXAZOLE (COTRIM) Can use IV initially for 3-10 days 20mg/kg/day in 4 divided doses based on the trimethoprim component Used even for children on cotrim prophylaxis as PCP breakthrough usually related to non-adherence (not resistance Watch for hypersensitivity Needs adjusting for renal failure

Alternative therapy Clindamycin at 10mg/kg/ dose every 6 hours combined with primaquine at 0.3mg/kg/day of the base is another alternative. Caution in G6PDH deficiency (no evidence for paediatrics) IV pentamidine 4mg/kg/day if cannot tolerate cotrim or not improving after 5-7 days of cotrim Trimethoprim and dapsone (all oral) for mild cases (no evidence for paediatrics)

Steroids Indicated in moderate & severe disease Reduces mortality and need for mechanical ventilation No clear role in non HIV PCP Commonly used regimen- oral prednisone 2mg/kg/day x 5 days, 1mg/kg/day x 5 days, 0.5mg/kg/day x 11 days References: Bye et al. Markedly Reduced Mortality Associated With Corticosteroid Therapy of Pneumocystis carinii Pneumonia in Children With Acquired Immunodeficiency Syndrome Arch Pediatr Adolesc Med. 1994;148(6):638-641. ii) Adjunctive corticosteroids for Pneumocystis jirovecii pneumonia in patients with HIV infection. [Cochrane Database Syst Rev. 2006 Newberry L et al .Early use of steroids in infants with a clinical diagnosis of PCP in Malawi: a double-blind RCT

Summary Admission criteria used in managing all-cause childhood pneumonia may be used for PCP as well Cotrimoxazole is the first line of treatment of PCP The grading of severity of PCP is crucial in determining route of antimicrobial administration and addition of steroids Steroid use is associated with reduction of mortality and need for mechanical ventilation

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