Adjunctive Corticosteroids decreased the risk of mortality of non-HIV Pneumocystis Pneumonia

Abstract

Objectives: A mortality rate of non-human immunodeficiency virus-infected pneumocystis pneumonia (non-HIV PCP) is 30-60%. But the effectiveness of adjunctive corticosteroids with trimethoprimsulfamethoxazole has been unclear, and we examined whether it lowered risk of mortality in non-HIV PCP. Methods: We did an observational study of adult non-HIV PCP patients from April 2010 through March 2016, using Japanese nationwide healthcare records of the Diagnostic Procedure Combination database (DPC). The risk was estimated by the time-dependent Cox regression analyses with inverse probability weights. Result: 1299 eligible non-HIV PCP patients were identified. 737 patients were severe respiratory status (partial pressure of oxygen in arterial blood [PaO 2 ] 60 mm Hg) and 562 were moderate (PaO 2 >60 mm Hg) at hospital admission. Among patients with severe respiratory status, the adjunctive corticosteroids was associated with lower risk of 60-day mortality (HR 0.71; 95% confidence interval [CI], 0.55-0.91), and significantly decreased mortality rates (24.7% vs 36.6%, P = 0.006). In contrast, no significant differences were observed in the risk of 60-day mortality (HR 1.17; 95% CI, 0.73-1.86) and the mortality rate (10.9% vs 9.1%, P = 0.516) among patients with moderate respiratory status. Conclusion: The adjunctive corticosteroids were associated with lower risk of 60-day mortality in severe non-HIV PCP patients.

Adjunctive corticosteroids may be associated with better outcome for non-HIV Pneumocystis pneumonia with respiratory failure: a systemic review and meta-analysis of observational studies

“…Finally, when we combined the results that CAT increased mortality in unselected non-HIV PCP patients, there was a trend of decreasing mortality in moderate and severe PCP patients with hypoxemia, and significantly decreased mortality in patients with respiratory failure, indicating that CAT may be associated with an increased mortality mainly in PCP without hypoxemia, and with a decreased mortality mainly in severe non-HIV PCP with respiratory failure. These findings is different from that in the HIV-PCP [4,5,7]. Therefore, based on our analysis, we speculated that CAT may be avoided in non-HIV PCP without hypoxemia, and may be considered in those with respiratory failure.…”

“…In a large RCT for HIV-PCP [7], clinical benefit of early CAT could not be demonstrated for HIVinfected patients with mild hypoxemia (a partial pressure of oxygen greater than 75 mmHg on room air), but CAT also showed no harm for mortality. In the most recent two large sample studies in non-HIV PCP, there was no difference in mortality between CAT and no CAT [4,5].…”

“…Lemiale et al [10] focused on the effect of CAT in non-HIV severe PCP admitted to ICU, and found that high dose steroid was even associated with increased mortality. And recently, Inoue et al [4] analyzed the severe non-HIV PCP group with and without CAT in a nationwide case series, and revealed that CAT was associated with lower risk of 60-day mortality in non-HIV PCP patients with severe respiratory failure. Moreover, even though a low PaO 2 (< 60 mmHg) is part of the definition of acute respiratory insufficiency, the use of the level of PaO 2 alone has some limits to adequately report the severity of Pneumocystis pneumonia.…”

“…Malignant disease with chemotherapy, corticosteroids treatment for inflammatory autoimmune diseases, and transplantation of solid organs or bone marrow are the leading causes of T cell suppression, which is associated with a high risk of opportunistic infections, including PCP [1,2]. The mortality associated with PCP in the non-HIV population group remains high, ranging from 19 to 76% [3][4][5], despite the availability of effective antimicrobial agents such as trimethoprim/sulfamethoxazole (TMP-SMZ) and pentamidine.…”

<i>Pneumocystis jirovecii</i> Pneumonia in a Patient with Breast Cancer Receiving Neoadjuvant Dose-dense Chemotherapy

“…jirovecii interacts with lung epithelial cells and immune cells in the lower respiratory tract, resulting in inflammation and causing significant respiratory impairment (1). Corticosteroids exert an anti-inflammatory effect, and there are some reports that, in combination with specific anti-Pneumocystis therapy, adjunctive corticosteroid therapy may reduce the morbidity and mortality in non-HIV-infected as well as in HIV-infected patients with PCP (12)(13)(14). Although only temporarily, our patient's symptoms and chest X-ray findings improved with steroid treatment before the start of TMP/SMX, likely because of its anti-inflammatory effect.…”