Table 2

Treatment of Pneumocystis carinii pneumonia (PCP)^14,²¹

Drug**	Duration of treatment	Side effects	Comments
po=by mouth; iv=intravenously.
* Consult HIV specialist for advice.
**Treatment of PCP infections should be undertaken where facilities for appropriate monitoring are available; consult a microbiologist/HIV specialist and the product literature before administering these drugs.
First line treatment
*Co-trimoxazole 120 mg/kg daily in 2–4 divided doses po/iv (480mg co-trimoxazole consists of sulfamethoxazole 400 mg and trimethoprim 80 mg)	21 days	Nausea, vomiting, fever, rash (including Stevens-Johnson’s syndrome, toxic epidermal necrolysis, photosensitivity), blood disorders (including neutropenia, thrombocytopenia, rarely agranulocytosis and purpura), rarely allergic reactions, diarrhoea, glossitis, stomatitis, anorexia, arthralgia, myalgia, liver damage, pancreatitis, antibiotic associated colitis, eosinophilia, aseptic meningitis, headache, depression, convulsions, ataxia, tinnitus, megaloblastic anaemia due to trimethoprim, crystaluria, renal disorders including interstitial nephritis	Intolerance common. Initial treatment with iv preparation. Comes in ampoule containing 480 mg; these should be diluted in at least 75 ml of 5% dextrose. Infuse over 60 minutes
Severe disease:
*Adjuvant high dose steroids (e.g. prednisolone 40–80 mg daily po. Alternatively, hydrocortisone may be given iv)	5 days; reduce dose over 14–21 days		Indicated in severe disease. Optimal dose not determined. Consult HIV specialist for advice
Second line treatment
Mild to moderate disease:
*Trimethoprim 20 mg/kg/day po/iv in 2–3 divided doses and dapsone 100 mg po daily	21 days	Trimethoprim: gastro intestinal disturbance, pruritus, rash, depression of haematopoiesis; rarely erythema multiforme, toxic epidermal necrolysis; aseptic meningitis Dapsone: haemolysis, methaemoglobinaemia, neuropathy, allergic dermatitis, anorexia, nausea, vomiting, insomnia, psychosis, agranulocytosis; dapsone syndrome (rash with fever and eosinophilia) - stop immediately (may progress to exfoliative dermatitis, hepatitis, hypoalbuminaemia, psychosis and death)	Avoid in G6PD deficiency
*Clindamycin 600 mg 6 hourly po/iv and primaquine 15 mg daily po	21 days	Clindamycin: diarrhoea, nausea and vomiting; jaundice, abnormal liver function tests; neutropenia, eosinophilia, agranulocytosis and thrombocytopenia; rash Primaquine: nausea and vomiting, abdominal pain; methaemoglobinaemia, heamolytic anaemia.	Clostridium difficile toxin associated diarrhoea is a complication of clindamycin therapy Primaquine: caution in G6PD deficiency
Atovaquone suspension 750 mg twice daily	21 days	Nausea, vomiting and diarrhoea; headache, insomnia; rash, fever; elevated liver enzymes and amylase; anaemia, neutropenia; hyponatraemia	Consider combination with iv pentamidine as resistance reported with monotherapy
Severe disease:
*Pentamidine isethionate 4 mg/kg/day as a slow intravenous infusion	21 days	Severe reactions, sometimes fatal, due to hypotension, hypoglycaemia, pancreatitis and arrythmias; also leucopenia, thrombocytopenia, acute renal failure, hypocalcaemia; also reported azotaemia, abnormal liver function tests, anaemia, hyperkalaemia, nausea and vomiting, dizziness, syncope, flushing, hyperglycaemia, rash, taste disturbance; Stevens-Johnson’s syndrome reported; on inhalation, bronchoconstriction, cough, shortness of breath and wheeze; discomfort, pain, induration, abscess formation, and muscle necrosis at injection site.	Give over at least 1 hour with patient lying flat. Monitor blood pressure closely. Important side effects include severe hypotension and hypoglycaemia. Monitor BMstix during and after infusion for 12 hours. If changing from co-trimoxazole to pentamidine due to poor clinical response, continue co-trimoxazole for 3 days. If intolerant, give nebulised pentamidine 600 mg daily for first 3 days.
*Trimetrexate 45 mg/m² iv and folinic acid 80 mg/m²	21 days	Blood disorders (thrombocytopenia, granulocytopenia and anaemia); diarrhoea and vomiting, oral and gastrointestinal mucosal ulceration; fever; confusion, rarely seizures; disturbed liver function tests, plasma calcium, potassium and magnesium reported; rash, anaphylaxis and local irritation at the injection site.	Used as an alternative for patients intolerant of co-trimoxazole and pentamidine isethionate or who do not respond to these drugs. Trimetrexate is a potent dihydrofolate reductase inhibitor and must be give with calcium folinate. Administer calcium folinate during treatment and for 72 hours after last dose (to avoid potentially serious bone marrow suppression, oral and gastrointestinal ulceration, and renal and hepatic dysfunction); suspend myelosuppressive drugs (e.g. zidovudine)