*Purpose: The incidence of Pneumocystis jiroveci pneumonia (PJP) in lung transplant recipients (LTRs) on PJP prophylaxis is not well documented yet reported as high as 28.7%.¹ At this institution, the lifelong prophylaxis regimens for LTRs are overall dosed lower than typical due to concern of toxicity, with sulfamethoxazole/trimethoprim (SMX/TMP) dosed 400/80 mg (SS) three-times weekly (TIW) and dapsone 100 mg TIW. These lower dosing strategies are of particular concern in cystic fibrosis (CF) LTRs as they display altered drug pharmacokinetics, including SMX/TMP. The objective of this study was to evaluate the current PJP prophylaxis protocol for LTRs by assessing the incidence and severity of PJP infection with a focus on LTRs with CF.

*Methods: In this single-center, retrospective study, we evaluated 396 patients who received a lung transplant between January 2007 to December 2019. LTRs who died within 30 days of transplant, were multiple organ recipients, or with incomplete data were excluded. The primary outcome was the incidence of PJP infection, defined as warranting treatment. Secondary outcomes included time to PJP infection and severity of PJP infection, defined on outpatient versus inpatient treatment.

*Results: 383 LTRs met criteria and 11 positive cases of PJP were identified (2.9%). Four of the 11 cases were on prophylaxis at the time of diagnosis with the remaining 7 cases having stopped prophylaxis before developing PJP. Thus, the overall incidence of PJP in LTRs on prophylaxis was 1.0% and 6.0% in CF LTRs in particular. The average time to infection was 997 days. In the 7 cases who were not on prophylaxis, PJP prophylaxis was held and not restarted in 86% and 14% mistakenly stopped taking prophylaxis. Reasons prophylaxis was held: acute kidney injury (33%), unknown (33%), leukopenia/anemia (34%), hyperkalemia (17%). The average time to PJP infection in these cases was 1325 days, and in 71% a rejection episode and/or a cytomegalovirus (CMV) infection occurred before developing PJP.

*Conclusions: The incidence of PJP in LTRs at our institution is lower than reported in the literature, but LTRs with CF represented the majority of PJP cases, suggesting a need for CF specific dosing regimens for prophylaxis. The incidence of PJP in LTRs not on prophylaxis highlights the importance of ensuring lifelong adherence.

Reference: 1. Wojarski J, et al. Transplant Proc. Sep 2018;50(7):2053-2058.

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