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P114 Risk factors and clinical characteristics for Pneumocystis jirovecii pneumonia in Japanese patients with ulcerative colitis

T. Sato1, R. Koshiba*1, K. Kojima1, K. Fujimoto1, M. Kawai1, K. Kamikoduru1, Y. Yokoyama1, T. Takagawa1, M. Uchino2, N. Hida1, K. Watanabe1, H. Miwa3, H. Ikeuchi2, S. Nakamura1

1Hyogo College of Medicine, Division of Internal Medicine, Department of Inflammatory Bowel Disease, Nisinomiya, Hyogo, Japan, 2Hyogo College of Medicine, Division of Surgery, Department of Inflammatory Bowel Disease, Nisinomiya, Hyogo, Japan, 3Hyogo College of Medicine, Division of Gastroenterology, Department of Internal Medicine, Nisinomiya, Hyogo, Japan

Background

Pneumocystis jirovecii pneumonia (PJP) is usually classified into two types: PJP with HIV (HIV-PJP) and PJP without HIV (non-HIV-PJP: NH-PJP). Respiratory failures progress more rapidly and require more artificial respiratory control, falling in poor prognosis in NH-PJP than in HIV-PJP.1–3 There is no consensus in the approach to prophylaxis against NH-PJP in patients with ulcerative colitis (UC) despite prophylaxis with sulfamethoxazole/trimethoprim (TPM-SMX) reduces NH-PJP infections.4 The purpose of this study was to determine the clinical characteristics and risk factors for NH-PJP in patients with UC treated with immunosuppressants.

Methods

Of the 3927 patients with UC between April 2007 and March 2017 received immunosuppressive drugs. Seventy patients experienced pneumonia, including nine patients with NH-PJP. A retrospective case–control study was conducted in these patients, with an NH-PJP group (n = 9) and a non-NH-PJP group (n = 36). The Lichtiger clinical activity index (LCI) was compared between the initiation of treatment and the onset of NH-PJP. The day of NH-PJP onset after immunosuppressant therapy was calculated with the Kaplan–Meier estimator.

Results

Two patients in the NH-PJP group died. The median LCI (range) at the initiation of treatment was 13 (8–17), whereas that at NH-PJP onset was 2 (1–8) (p = 0.016)

Comparison of Lichtiger clinical activity index before treatment and at the onset of PJP. Median score 13 (range 8–17) before treatment decreased significantly to 2 (1–8) at the onset of PCP. *Wilcoxon’s signed-rank test.

The median period to NH-PJP onset was 83 days from the beginning of immunosuppressive treatment. Age and the dose of prednisolone (PSL; mg/day) were significantly greater (p = 0.02 and p = 0.002, respectively), three immunosuppressants were used significantly more frequently (p = 0.004), and the lymphocyte counts during treatment were significantly lower (p < 0.01) in the NH-PJP group than in the non-NH-PJP group. The cut-off value, sensitivity, and specificity for the lowest lymphocyte count to predict NH-PCP during treatment were 570/μl, 0.81, and 0.89, respectively, according to a receiver-operating characteristic curve.

Conclusion

NH-PJP occurred when the symptoms of UC were stabilising, when the immunosuppressive drugs were reduced. Senior age, a higher dose of PSL (mg/day), and lower lymphocyte counts during treatment are risk factors for NH-PJP. Prophylactic treatment with TPM-SMX should be used for UC patients with these risk factors.

References

1. Thomas CF Jr, Limper AH. Pneumocystis pneumonia: clinical presentation and diagnosis in patients with and without acquired immune deficiency syndrome. Semin Respir Infect 1998;13:289–95.

2. Sato T, Inokuma S, Maezawa R. Clinical characteristics of Pneumocystis carinii pneumonia in patients with connective tissue diseases. Mod Rheumatol 2005;15:191–7.

3. Iikuni N, Kitahama M, Ohta S, et al. Evaluation of Pneumocystis pneumonia infection risk factors in patients with connective tissue disease. Mod Rheumatol 2006;16:282–8.

4. Rahier JF, Magro F, Abreu C, et al. Second European evidence-based consensus on the prevention, diagnosis and managementof opportunistic infections in inflammatory bowel disease. J Crohns Colitis 2014;8:443–68.