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Breakthrough PJP AAV Prophylaxis — ESENeph MCQ

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ModerateRenal VasculitisBreakthrough PJP AAV ProphylaxisESENeph

A 55-year-old woman with ANCA vasculitis (MPO-ANCA) and CKD G4 develops Pneumocystis jirovecii pneumonia despite being on Co-trimoxazole prophylaxis 480 mg daily. She is on Rituximab maintenance. What should be considered regarding her prophylaxis?

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Correct answer: C — Consider whether the Co-trimoxazole dose is adequate (960 mg daily or 480 mg daily are both used; some patients may need dose escalation or alternative prophylaxis); check adherence and consider drug interactions

Co-trimoxazole PJP prophylaxis regimens vary between centres (480 mg or 960 mg daily, or 960 mg three times weekly). Breakthrough PJP can occur with lower doses, poor adherence, or drug interactions. After Rituximab, prolonged B-cell depletion and hypogammaglobulinaemia increase infection risk. Immunoglobulin levels should be checked – IgG <4 g/L may warrant IVIg replacement. Consider dose escalation of prophylaxis or switch to Dapsone/Atovaquone if Co-trimoxazole is insufficient. Continue appropriate immunosuppression reduction.

Reference: KDIGO 2024 – AAV Guideline; BHIVA/BTS PJP Prophylaxis Guidelines