BNF for Children 2011-2012

342 5.4.8 Drugs for pneumocystis pneumonia BNFC 2011–20125 InfectionsSide-effects see under Co-trimoxazole, section 5.1.8;also hypothyroidism, benign intracranial hypertension,optic neuropathyLicensed use not licensed for use in toxoplasmosisIndication and doseToxoplasmosis in pregnancy (in combinationwith pyrimethamine and folinic acid (section8.1)), see notes above. By mouthChild 12–18 years 1 g 3 times daily until deliveryCongenital toxoplasmosis (in combination withpyrimethamine and folinic acid (section 8.1)). By mouthNeonate 50 mg/kg twice daily for 12 monthsSulfadiazine (Non-proprietary) ATablets, sulfadiazine 500 mg, net price 56-tab pack =£37.50. Label: 9, 27Extemporaneous formulations available seeExtemporaneous Preparations, p. 65.4.8 Drugs for pneumocystispneumoniaPneumonia caused by Pneumocystis jirovecii (Pneumocystiscarinii) occurs in immunosuppressed children; itis a common cause of pneumonia in AIDS. Pneumocystispneumonia should generally be treated by thoseexperienced in its management. Blood gas measurementis used to assess disease severity.TreatmentThe recommended duration of treatment is generally14–21 days.Mild to moderate disease Co-trimoxazole (section5.1.8) in high dosage is the drug of choice for thetreatment of mild to moderate pneumocystis pneumonia.Atovaquone or a combination of dapsone with trimethoprim5 mg/kg every 6–8 hours (section 5.1.8) isgiven by mouth for the treatment of mild to moderatedisease [unlicensed indication] in children who cannottolerate co-trimoxazole.A combination of clindamycin (section 5.1.6) andprimaquine (section 5.4.1) may be used in the treatmentof mild to moderate disease [unlicensed indication];this combination is associated with considerabletoxicity.Severe disease Co-trimoxazole (section 5.1.8) inhigh dosage, given by mouth or by intravenous infusion,is the drug of choice for the treatment of severepneumocystis pneumonia. Pentamidine isetionategiven by intravenous infusion is an alternative for childrenwho cannot tolerate co-trimoxazole, or who havenot responded to it. Pentamidine isetionate is a potentiallytoxic drug that can cause severe hypotensionduring or immediately after infusion. If there is clinicalimprovement after 7–10 days of intravenous therapywith pentamidine isetionate, patients can be switched tooral treatment (e.g. atovaquone) to complete 21 daystreatment.Corticosteroid treatment can be lifesaving in those withsevere pneumocystis pneumonia (see Adjunctive Therapybelow).Adjunctive therapy In moderate to severe pneumocystisinfections associated with HIV infection, prednisolone(section 6.3.2) is given by mouth in a dose of2 mg/kg (max. 80 mg daily) for 5 days (alternatively,hydrocortisone may be given parenterally); the dose isthen reduced over the next 16 days and then stopped.Corticosteroid treatment should ideally be started at thesame time as the anti-pneumocystis therapy and certainlyno later than 24–72 hours afterwards. The corticosteroidshould be withdrawn before anti-pneumocystistreatment is complete.ProphylaxisProphylaxis against pneumocystis pneumonia should begiven to all children with a history of this infection, andto all HIV-infected infants aged 1 month–1 year. Prophylaxisagainst pneumocystis pneumonia should also beconsidered for severely immunocompromised children.Prophylaxis should continue until immunity recoverssufficiently. It should not be discontinued if the childhas oral candidiasis, continues to lose weight, or isreceiving cytotoxic therapy or long-term immunosuppressanttherapy.Co-trimoxazole (section 5.1.8) by mouth is the drug ofchoice for prophylaxis against pneumocystis pneumonia.Co-trimoxazole may be used in infants born tomothers with a high risk of transmission of infection.Inhaled pentamidine isetionate is better tolerated thanparenteral pentamidine. Intermittent inhalation of pentamidineisetionate is used for prophylaxis againstpneumocystis pneumonia in children unable to tolerateco-trimoxazole. It is effective but children may be proneto extrapulmonary infection. Alternatively, dapsone canbe used.ATOVAQUONECautions initial diarrhoea and difficulty in taking withfood may reduce absorption (and require alternativetherapy); other causes of pulmonary disease should besought and treated; interactions: Appendix 1 (atovaquone)Hepatic impairment manufacturer advises caution—monitor more closelyRenal impairment manufacturer advises caution—monitor more closelyPregnancy manufacturer advises avoid unless potentialbenefit outweighs risk—no information availableBreast-feeding manufacturer advises avoidSide-effects nausea, diarrhoea, vomiting, headache,insomnia, fever, anaemia, neutropenia, hyponatraemia,rash, pruritus; also reported, Stevens-JohnsonsyndromeLicensed use not licensed for use in children