Background: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection associated with lymphopenic conditions including HIV/AIDS, hematologic malignancy1, organ transplantation2, and lymphocyte-suppressive therapies such as high dose glucocorticoids3,4. PJP prophylaxis, which is highly effective, is indicated when the incidence of PJP exceeds the rate of adverse events due to prophylaxis.4,7 Guidelines from the American Thoracic Society (ATS) suggest PJP prophylaxis is indicated among patients on prolonged high-dose steroid therapy. However, there is a paucity of data regarding 1) PJP incidence among immunosuppressive disease states that require high-dose steroid therapy and 2) practice patterns among providers who prescribe PJP prophylaxis. As part of a quality improvement initiative, we assessed provider prescription practices of PJP prophylaxis and conducted a retrospective chart review of PJP cases from 6/2012-11/2018 to identify potentially preventable PJP in the setting of high-dose steroids at Michigan Medicine.
Methods: We surveyed all practicing faculty at Michigan Medicine within the departments of Gastroenterology, Pulmonology, and Rheumatology. Participants were queried regarding the steroid dose threshold for the initiation of PJP prophylaxis, preferred prophylactic regimen, and knowledge of existing guidelines. We then reviewed all encounters from June 2012 to November 2018 with a positive PJP PCR test from sputum or bronchoalveolar lavage samples. Each encounter was individually reviewed with attention given to presenting symptoms, clinical data, consultation to Infectious Diseases and Pulmonology, and steroid exposure within the prior 3 months. High-dose steroid therapy was defined as any steroid dose equal to or greater than prednisone 20 mg for more than four weeks. Prophylaxis was defined as the appropriate prescription of trimethoprim-sulfamethoxazole, atovaquone, dapsone, or aerosolized pentamidine prior to the encounter.
Results: Our cross-sectional survey (30% response rate, n=43) showed most clinicians used their own clinical judgement rather than published guidelines when determining indications for PJP prophylaxis (65% of respondents). The majority used the steroid equivalent of prednisone 20 mg daily as their threshold for prophylaxis prescription. Our subsequent chart review of 306 encounters with a non-negative PJP PCR from 6/2012-11/2018 identified 214 unique clinical diagnoses of PJP as supported by clinical data and specialist evaluation during each encounter. Forty-five cases, or 21% of all PJP cases at our institution, occurred in the setting of recent high-dose steroid exposure without appropriate prophylaxis prescription. Of these forty-five cases, nine (9) deaths occurred with PJP as a major contributing factor. Indications for high-dose steroid therapy among the 45 cases of steroid-related PJP were primarily oncologic (44%), rheumatologic (22%), or hematologic (16%) in nature.
Conclusions: Despite existing national guidelines, our work demonstrates wide provider variability in PJP prophylaxis prescription and a significant number of preventable PJP cases among patients on high-dose steroid therapy at our institution. Subsequent root-cause analysis indicates several interventions in the areas of clinician education, electronic medical record reminders and best practice advisories, and publication of institutional guidelines as ways to reduce harm.