1. Dr Immaculate Kariuki Consultant Paediatrician Nairobi, Kenya
Management of PCP
Dr Immaculate Kariuki
Consultant Paediatrician
Nairobi, Kenya

2. Intended Leaning 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

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

4. 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

5. 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
None of the above? Y
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
No Pneumonia

6. 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

7. 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

8. 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 cotrimoxazole prophylaxis as PCP breakthrough usually related to non-adherence (not resistance
Watch for hypersensitivity
Needs adjusting for renal failure

9. 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 pediatrics)
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 pediatrics)

10. 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):
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

11. 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

12. END