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Semin Arthritis Rheum. 2018 Nov 3. pii: S0049-0172(18)30263-4. doi: 10.1016/j.semarthrit.2018.10.018. [Epub ahead of print]

Pneumocystis jirovecii pneumonia (PJP) prophylaxis patterns among patients with rheumatic diseases receiving high-risk immunosuppressant drugs.

Author information

1
Division of Rheumatology, University of California San Francisco, United States; Veterans Affairs Medical Center, 4150 Clement St., Mailstop 111R, San Francisco, CA 94121 United States; Center for Healthcare Value, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, United States. Electronic address: Gabriela.schmajuk@ucsf.edu.
2
Division of Rheumatology, University of California San Francisco, United States.
3
Department of Epidemiology and Biostatistics, University of California, San Francisco, United States.
4
Center for Vulnerable Populations & Division of General Internal Medicine at the Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, United States.
5
Center for Healthcare Value, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, United States.

Abstract

INTRODUCTION/OBJECTIVES:

Pneumocystis jirovecii pneumonia (PJP) is a rare but potentially fatal opportunistic infection; however, consensus varies around which conditions or medications confer a level of risk sufficient to justify antibiotic prophylaxis for PJP. We used electronic health record (EHR) data to assess the current patterns of PJP prophylaxis, PJP outcomes, and prophylaxis-related adverse events among patients with rheumatic diseases who were receiving high-risk immunosuppressant drugs.

METHODS:

Data derive from the EHR of a large health system. We included new immunosuppressant users with diagnoses of vasculitis, myositis, or systemic lupus erythematosus. We calculated the proportion of patients who received PJP prophylaxis for each diagnosis and drug combination. We also calculated the number of PJP infections and the number of antibiotic adverse drug events (ADEs) per patient-year of exposure.

RESULTS:

We followed 316 patients for 23.2 + /- 14.2 months. Overall, 124 (39%) of patients received prophylactic antibiotics for PJP. At least 25% of patients with the highest risk conditions (e.g. vasculitis) or highest risk immunosuppressants (e.g. cyclophosphamide) did not receive PJP prophylaxis. We found no cases of PJP infection over 640 patient-years of follow up, including among those not receiving prophylaxis, and an overall incidence rate of ADEs of 2.2% per patient-year.

CONCLUSIONS:

PJP prophylaxis for patients with rheumatic conditions is inconsistent, with one quarter of patients who have high risk conditions or high risk immunosuppressants not receiving prophylaxis. However, given extremely low rates of PJP infection, but detectable ADEs to prophylactic antibiotics, our findings suggest that evidence to guide more personalized risk assessments are needed to inform PJP prophylaxis.

KEYWORDS:

Immunosuppression; Infection; Vasculitis

PMID:
30449650
PMCID:
PMC6499720
[Available on 2020-05-03]
DOI:
10.1016/j.semarthrit.2018.10.018

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