Late Onset Cluster of Pneumocystis Jirovecii Pneumonia (PJP) in Renal Transplant Patients: Re-Examining Prophylaxis Strategies
1Division of Nephrology, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada
2Coordinator, Infection Prevention and Control, London Health Sciences Centre, London, ON, Canada
3Division of Infectious Diseases, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada.
Meeting: 2015 American Transplant Congress
Abstract number: A84
Keywords: Pneumonia
Session Information
Session Time: 5:30pm-7:30pm
Presentation Time: 5:30pm-7:30pm
Location: Exhibit Hall E
PJP may be associated with severe pulmonary involvement in kidney transplant recipients. We have had a long term policy of routine prophylaxis for 1 year post transplant. No patient with late-onset PJP had been diagnosed following institution of this policy. Between December 2013 and December 2014, we had a cluster of 'late-onset PJP' cases (beyond the first year after transplantation), with 7 renal transplant recipients (4 men, 3 women, age median 56, inter-quartile range (IQR) 13.5 years) with confirmed diagnosis of late-onset PJP admitted to our institution. None were on PJP prophylaxis at the time of diagnosis. Time to disease onset was median 37 (IQR 36) months post-transplant. Unexpectedly, all developed severe pneumonia with the length of hospital stay at approximately 9 days in patients not requiring intubation and median 44 (IQR 26) days in those requiring intubation. 5 patients (71%) required ICU admission, intubation and prolonged ventilation support (median 27 (IQR 8) days) associated with lack of response to high-dose Trimethoprim-Sulfamethoxazole (Septra) and corticosteroids. We added Clindamycin and Primaquin for patients with treatment failure to Septra. None of these episodes of severe pneumonia was associated with mortality. 5 patients (71%) had developed CMV infection prior to PJP. 6 patients (86%) had history of rejection prior to PJP and treatment included rATG (n= 1), Alemtuzumab (n= 1), Rituximab (n= 1), Cyclophosphamide (n= 1), pulse corticosteroids (n= 4) and Plasma Exchange/ Intravenous Immunoglobulin (n= 4). We had switched our immunosuppressive protocol from short to long acting Tacrolimus and from Mycophenolate Mofetil to Myfortic (Mycophenolic acid) over the last 2 years. Outbreak investigation showed a probable exposure in 4 patients through shared clinic space. Given the numbers and severity of illness, we have instituted universal life-long PJP prophylaxis in renal transplant recipients. Genotyping for this unexplained cluster of late-onset PJP is pending.
To cite this abstract in AMA style:
Sekhon G, Gunaratnam L, Iyer H, Johnson J, Muirhead N, Newman A, Rehman F, Weir M, Silverman M, House A, Jevnikar A, Hosseini-Moghaddam S. Late Onset Cluster of Pneumocystis Jirovecii Pneumonia (PJP) in Renal Transplant Patients: Re-Examining Prophylaxis Strategies [abstract]. Am J Transplant. 2015; 15 (suppl 3). https://atcmeetingabstracts.com/abstract/late-onset-cluster-of-pneumocystis-jirovecii-pneumonia-pjp-in-renal-transplant-patients-re-examining-prophylaxis-strategies/. Accessed November 11, 2024.« Back to 2015 American Transplant Congress