title: Clindamycin-primaquine for pneumocystis jiroveci pneumonia in renal transplant patients.
abstract: BACKGROUND
  Trimethoprim/sulfamethoxazole (TMP/SMX) is considered first-line therapy for pneumocystis jiroveci pneumonia (PCP) in renal transplant patients. Alternatives have not been formally studied. Clindamycin-primaquine (C-P) is effective in HIV-associated PCP, but data in renal transplant patients are lacking.
  
  
  METHODS
  Retrospective cohort study of 57 consecutive renal transplant patients who developed PCP and were treated with C-P (n = 23) or TMP/SMX (n = 34).
  
  
  RESULTS
  A non-significantly higher failure rate was observed in patients on C-P due to lack of efficacy (30.4 versus 20.6%, p = 0.545). The difference was more pronounced in severe PCP (60 versus 37.5%, p = 0.611) and a significantly lower efficacy of C-P was seen when used as salvage therapy. The two patients who had received C-P after not responding to TMP/SMX failed this regimen, but all seven patients who had failed initial treatment with C-P and had been switched to TMP/SMX were cured (p = 0.028). No treatment-limiting adverse reactions were reported for patients on C-P while six patients (17.6%) on TMP/SMX developed possibly related treatment-limiting toxicity (p = 0.071). However, in only two patients adverse events were definitely related to TMP/SMX (5.9%).
  
  
  CONCLUSIONS
  Clindamycin-primaquine appears to be safe and well tolerated for treating PCP in renal transplant patients but is probably less effective than TMP/SMX, the standard regimen. However, our data indicates that C-P represents an acceptable alternative for patients with contraindications or treatment emergent toxicities during TMP/SMX use. Notably, TMP/SMX was also acceptably tolerated in most patients. TMP/SMX remains an effective salvage regimen in case of C-P failure.
authors.affiliation: Division of Nephrology and Intensive Care, Department of Internal Medicine, Campus Virchow-Klinikum, Charité-University Medicine Berlin, Berlin, Germany.
authors.forename: P
authors.initials: P
authors.lastname: Nickel
authors.forename: M
authors.initials: M
authors.lastname: Schürmann
authors.forename: H
authors.initials: H
authors.lastname: Albrecht
authors.forename: R
authors.initials: R
authors.lastname: Schindler
authors.forename: K
authors.initials: K
authors.lastname: Budde
authors.forename: T
authors.initials: T
authors.lastname: Westhoff
authors.forename: J
authors.initials: J
authors.lastname: Millward
authors.forename: N
authors.initials: N
authors.lastname: Suttorp
authors.forename: P
authors.initials: P
authors.lastname: Reinke
authors.forename: D
authors.initials: D
authors.lastname: Schürmann
mesh_terms: D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use*; D002981:Clindamycin / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D045363:Pneumocystis carinii / Q000302:isolation & purification*; D011020:Pneumonia, Pneumocystis / Q000188:drug therapy*; D011319:Primaquine / Q000627:therapeutic use*; D012189:Retrospective Studies; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D002981:Clindamycin; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D011319:Primaquine