Rates Of Prophylaxis Among Pneumocystis Jirovecii Pneumonia Cases Attributable To High-Dose Steroid Therapy A Single-Center Experience

Background The incidence of Pneumocystis jirovecii pneumonia (PJP) among patients on high-dose steroid therapy is not well established, and few guidelines exist to help guide decisions regarding prophylaxis. We assessed provider prescribing practices regarding pneumocystis prophylaxis and conducted a retrospective chart review of 306 PJP cases at a tertiary care center to identify preventable cases and target interventions to reduce harm. Methods We surveyed providers regarding their threshold to initiate PJP prophylaxis among patients receiving steroid therapy. Subsequently, all encounters with a positive PJP PCR from sputum or bronchoalveolar lavage from June 2012 to November 2018 were reviewed for signs and symptoms, radiographic imaging, laboratory tests, and expert consultation consistent with a clinical diagnosis of PJP. Cases were reviewed for steroid exposure within 3 months before diagnosis to identify at-risk populations. We defined high dose steroids as prednisone 20 mg or higher for a period greater than 4 weeks. Results Most survey respondents used their own clinical judgment in place of published guidelines (65%), though the majority used prednisone 20 mg as their threshold to prescribe PJP prophylaxis. Of 214 encounters with a clinical diagnosis of PJP, 65 (30%) cases were considered potentially preventable as they received high-dose steroid therapy without PJP prophylaxis. Of these 65 cases, 13 deaths occurred with PJP or its complications as a cause of death. We recommend consideration of prophylaxis in all patients on prednisone 20 mg or higher for greater than 4 weeks, especially if on concomitant immunosuppression.