OP0077 Primary prophylaxis for pneumocystis pneumonia in patients with rheumatic disease and treated with prolonged, high-dose steroid: a retrospective cohort study with 12-year observation
Authors: JW Park, J Moon, JR Curtis, JK Park, EY Lee, YW Song, EB Lee
Journal: Annals of the Rheumatic Diseases (2017)

<h3>Background</h3> Pneumocystis pneumonia (PCP) is a significant cause of morbidity and mortality in patients with rheumatic diseases, especially in the case of patients receiving high-dose steroid treatment. <h3>Objectives</h3> To investigate the efficacy and safety of PCP prophylaxis using trimethoprim/sulfamethoxazole (TMP-SMX) in patients with rheumatic disease receiving prolonged, high-dose steroids <h3>Methods</h3> This study includes 1522 cases of prolonged (≥4 weeks), high-dose (≥30mg/day prednisone or equivalent) steroid treatment from 1092 patients with any rheumatic diseases during a 12-year period in a single tertiary referral center in South Korea. Of them, prophylactic TMP-SMX was administered in 262 cases (prophylaxis group) with a mean (SD) duration of 229.0 (272.7) days whereas other 1260 cases received no prophylaxis (control group). Primary outcome was 1-year incidence of PCP between the two groups. Secondary outcomes included PCP-related mortality, ICU admission rate, all-cause in-hospital mortality and incidence of any adverse drug reactions (ADRs) of TMP-SMX. To minimize the baseline imbalance between the two groups, we introduced propensity-score matching and performed the same analysis in the post-matched population as a sensitivity analysis. <h3>Results</h3> Patients in the prophylaxis group were treated more often with secondary immunosuppressive drugs and had a higher proportion of patients with PCP high-risk diseases (ANCA-associated vasculitis and dermatomyositis) and lymphopenia at baseline. Overall, 30 cases of PCP occurred and resulted in death in 11 cases (36.7%). In the prophylaxis group, only one non-fatal case of PCP occurred. One-year PCP incidence was significantly lower in the prophylaxis group (adjusted HRs=0.096 [0.013–0.719]) (Figure). TMP-SMX also significantly reduced the PCP-related mortality (adjusted HR=0.101 [0.001–0.809]) whereas ICU admission rate and in-hospital mortality rate were not different between the two groups during the observation. This result was consistent in the sensitivity analysis where same analysis was performed in the post-matched population. Thirty-four cases of ADRs of TMP-SMX occurred, with an incidence rate (95% CI) of 24.2 (17.3–33.0) per 100 person-year. There were two cases of serious ADR (one pancytopenia and one Steven9s Johnson syndrome) but they all recovered shortly after the discontinuation of TMP-SMX. The number needed to harm (NNH) of serious ADR was 109 whereas the number needed to treat (NNT) to prevent one case of PCP in the whole population was 52. <h3>Conclusions</h3> In patients with rheumatic disease receiving prolonged, high-dose steroid treatment, TMP-SMX prophylaxis significantly lower the incidence of PCP with favorable safety. <h3>References</h3> Stern A, Green H, Paul M, Vidal L, Leibovici L. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. The Cochrane database of systematic reviews. 2014(10):CD005590. <h3>Disclosure of Interest</h3> None declared