1. Dr Immaculate Kariuki Consultant Paediatrician Nairobi, Kenya
PCP: Prophylaxis
Dr Immaculate Kariuki
Consultant Paediatrician
Nairobi, Kenya

2. Intended Learning Objectives
To familiarise oneself with the preventive strategies for all-cause pneumonia
To understand the differences between primary and secondary prophylaxis for PCP
To understand the current widely used WHO guidelines on cotrimoxazole prophylaxis for the HIV infected and the rationale for their use
To be aware of the indications for prophylaxis in the non-HIV immunosuppressed

3. Prevention of all-cause LRTI
Adequate nutrition
Breastfeeding
Appropriate immunization
Zinc supplementation
Indoor pollution
HAART
Cotrimoxazole prophylaxis

4. Primary Vs. secondary prophylaxis
Primary prophylactic approaches
Indicated for patients at risk before their first infection
Immune reconstitution using HAART
Prophylaxis for specific categories (age & CD4)
Secondary prophylaxis
Indicated after the first infection.
Continued for life or until immune reconstitution.

5. Cotrimoxazole for prophylaxis
Reduces mortality in HIV infected children of all ages and all CD4 counts as compared to placebo
Confers protection against other bacterial infections, toxoplasmosis & malaria in endemic areas
Dose:
5-10mg/kg/day based on the trimethoprim component
Alternative agents: dapsone, atovaquone, aerosolised pentamidine
Chintu C, Bhat GJ, Walker AS, et al.
Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP):
a doubleblind randomised placebo-controlled trial. Lancet 2004; 364:1865–1871.

6. Evidence for prophylaxis The Lancet 364 (9448):1865-1871.
Median age 4.4 years, most WHO stage 2 & above and only 16% had CD4>20%
Landmark study.
Notes:

7. WHO guidelines on prophylaxis
All HIV infected or HIV exposed infants ≤ 1 year regardless of symptoms or CD4 percentage.
>1 year recommended for symptomatic children defined as WHO stages 2, 3 or 4 or CD4% <25%.
Prophylaxis is continued until the age 5 years and then reassessed
Children ≥ 5 years use adult clinical staging & CD4 count thresholds for initiation or discontinuation (stage 2-4 or CD4 <350).
Prophylaxis should be offered to children with HIV irrespective of CD4 counts or WHO staging in countries with high burden of mortality & morbidity due to infectious diseases eg malaria & bacterial infections.

8. Prophylaxis in the HIV non-infected
Indications in HIV-negative patients without clinical symptoms or signs of PCP include patients with:
Haematological malignancies
Bone marrow & solid organ transplants
Inflammatory disorders, and who receive corticosteroids at a dose of at least mg of prednisone (prednisolone) daily for over 1 month
Not malnutrition

9. Recommendations for non-HIV infected
Shankar et al. Management of Pneumocystis jirovecii Pneumonia in Children Receiving Chemotherapy
Paediatric drugs 2007; 9 (5):301–309
Shankar et al Paediatric Drugs 2007; 9 (5):301–309

10. Challenges of prophylaxis
Adherence is poor. Studies show only 18%- 40% of HIV exposed infants taking prophylaxis
Antimicrobial resistance
Prolonged cotrim use may lead to development of resistant strains.
Cotrim is first line for Community acquired pneumonia in LMICs according to WHO
Side effects
Serious side effects are uncommon in children
A 3 year follow up study reported rash (28%), neutropenia (9.3%), anemia (2.2%), thrombocytopenia (8.8%)

11. Alternative agents Pentamidine Dapsone
300 mg inhaler every 28 days if ≥ 5years           OR
4 mg/kg/day IV OD every
2-4 weeks
2 mg/kg/day PO
(max 100mg/day)

12. Pentamidine and dapsone are alternative agents for PCP prophylaxis
Summary
Cotrimoxazole reduces morbidity and mortality associated with PCP in children of all ages and CD4 counts in low resource settings
PCP prophylaxis is indicated in some categories of non HIV related immunosuppression
Pentamidine and dapsone are alternative agents for PCP prophylaxis
A few but significant challenges to cotrimoxazole use in children exist

13. END