Mild to moderate disease
Co-trimoxazole p. 350 in high dosage is the drug of choice
for the treatment of mild to moderate pneumocystis
pneumonia.
Atovaquone below or a combination of dapsone below
with trimethoprim p. 359 is given by mouth for the
treatment of mild to moderate disease [unlicensed
indication] in children who cannot tolerate co-trimoxazole.
A combination of clindamycin p. 327 and primaquine
p. 396 may be used in the treatment of mild to moderate
disease [unlicensed indication]; this combination is
associated with considerable toxicity.Severe disease
Co-trimoxazole in high dosage, given by mouth or by
intravenous infusion, is the drug of choice for the treatment
of severe pneumocystis pneumonia. Pentamidine isetionate
p. 381 given by intravenous infusion is an alternative for
children who cannot tolerate co-trimoxazole, or who have
not responded to it. Pentamidine isetionate is a potentially
toxic drug that can cause severe hypotension during or
immediately after infusion. If there is clinical improvement
after 7 – 10 days of intravenous therapy with pentamidine
isetionate, patients can be switched to oral treatment (e.g.
atovaquone) to complete 21 days treatment.
Corticosteroid treatment can be lifesaving in those with
severe pneumocystis pneumonia.
Adjunctive therapy
In moderate to severe pneumocystis infections associated
with HIV infection, prednisolone p. 442 is given by mouth for
5 days (alternatively, hydrocortisone p. 440 may be given
parenterally); the dose is then reduced over the next 16 days
and then stopped. Corticosteroid treatment should ideally be
started at the same time as the anti-pneumocystis therapy
and certainly no later than 24 – 72 hours afterwards. The
corticosteroid should be withdrawn before anti-
pneumocystis treatment is complete.Prophylaxis
Prophylaxis against pneumocystis pneumonia should be
given to all children with a history of this infection, and to all
HIV-infected infants aged 1 month– 1 year. Prophylaxis
against pneumocystis pneumonia should also be considered
for severely immunocompromised children. Prophylaxis
should continue until immunity recovers sufficiently. It
should not be discontinued if the child has oral candidiasis,
continues to lose weight, or is receiving cytotoxic therapy or
long-term immunosuppressant therapy.
Prophylaxis should also be given to infants aged 1 month–
1 year who are suspected to be HIV-positive,orwhose
mothers had a viral load greater than 1000 HIV RNA
copies/mL between 36 weeks’gestation and delivery;
prophylaxis should be continued until HIV infection is
excluded or until immunity recovers.
Co-trimoxazole by mouth is the drug of choice for
prophylaxis against pneumocystis pneumonia. Co-
trimoxazole may be used in infants born to mothers with a
high risk of transmission of infection.
Inhaled pentamidine isetionate is better tolerated than
parenteral pentamidine isetionate. Intermittent inhalation
of pentamidine isetionate is used for prophylaxis against
pneumocystis pneumonia in children unable to tolerate co-
trimoxazole. It is effective but children may be prone to
extrapulmonary infection. Alternatively, dapsone can be
used.ANTIPROTOZOALS
Atovaquone
lINDICATIONS AND DOSE
Treatment of mild to moderatePneumocystis jirovecii
(Pneumocystis carinii) pneumonia in patients intolerant
of co-trimoxazole
▶BY MOUTH
▶Child 1–2 months: 15 – 20 mg/kg twice daily for
14 – 21 days, dose to be taken with food, particularly
high fat food
▶Child 3 months–1 year: 22. 5 mg/kg twice daily for
14 – 21 days, dose to be taken with food, particularly
high fat food
▶Child 2–17 years: 15 – 20 mg/kg twice daily (max. per
dose 750 mg) for 14 – 21 days, dose to be taken with
food, particularly high fat foodlUNLICENSED USENot licensed for use in children.
lCAUTIONSOther causes of pulmonary disease should be
sought and treated.initial diarrhoea and difficulty in
taking with food may reduce absorption (and require
alternative therapy)
lINTERACTIONS→Appendix 1 : antimalarials
lSIDE-EFFECTS
▶Common or very commonAnaemia.angioedema.
bronchospasm.diarrhoea.headache.hypersensitivity.
hyponatraemia.insomnia.nausea.neutropenia.skin
reactions.throat tightness.vomiting
▶Frequency not knownStevens-Johnson syndrome
lPREGNANCYManufacturer advises avoid unless potential
benefit outweighs risk—no information available.
lBREAST FEEDINGManufacturer advises avoid.
lHEPATIC IMPAIRMENTManufacturer advises caution.
MonitoringMonitor more closely in hepatic impairment.
lRENAL IMPAIRMENTManufacturer advises caution.
MonitoringMonitor more closely in renal impairment.
lPRESCRIBING AND DISPENSING INFORMATIONFlavours of
oral liquid formulations may include tutti-frutti.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Oral suspension
CAUTIONARY AND ADVISORY LABELS 21
▶Wellvone(GlaxoSmithKline UK Ltd)
Atovaquone 150 mg per 1 mlWellvone 750 mg/ 5 ml oral suspension
sugar-free| 226 mlP£ 486. 37Dapsone
lINDICATIONS AND DOSE
Treatment of mild to moderatePneumocystis jirovecii
(Pneumocystis carinii) pneumonia (in combination with
trimethoprim)
▶BY MOUTH
▶Child 1 month–11 years: 2 mg/kg once daily (max. per
dose 100 mg)
▶Child 12–17 years: 100 mg once daily
Prophylaxis ofPneumocystis jirovecii(Pneumocystis
carinii) pneumonia
▶BY MOUTH
▶Child: 2 mg/kg once daily (max. per dose 100 mg)lUNLICENSED USENot licensed for treatment of
pneumocystis (P. jirovecii) pneumonia. Monotherapy not
licensed for children for prophylaxis ofP. jirovecii
pneumonia.380 Fungal infection BNFC 2018 – 2019
Infection5