Pneumocystis Jiroveci, Chest infection in transplant patients.

Background – over the last two or three years, there has been an increase in the number of kidney transplant patients, and other transplant patients, who have been infected with Pneumocystis Jiroveci.

This opportunistic pathogen natural habitat is the lung.

In immuno-suppressed transplant patients it may produce  serious lung infection.

The outbreaks have been noted in transplant units worldwide, and in Australia, particularly in transplant units at Westmead, Royal Prince Alfred Hospitals in NSW, but also in hospitals in Brisbane (Princess Alexandra Hospital), Melbourne (St Vincents Hospital) and also South Australia.

Experience in Canberra

There have been four Canberra kidney transplant patients in the last two and a half years who have suffered Pneumocystis Jiroveci infection.

These patients attend The Canberra Hospital Transplant Unit Out-Patients. The common denominator seems to be contracting the illness when attending large out-patient clinics of sick renal patients, particularly patients who have had organ transplantation. Close proximity allows transmission from a carrier.

My fellow five Physicians and myself have discussed this issue.

The hospital Physicians (Staff Doctors) plan to offer prophylaxis treatment to all of their kidney transplant patients in Canberra.  These patients attend The Canberra Hospital Out-Patients Clinic, and therefore would seem to be at risk.

My patients are in a different situation!

When you attend for review you are not in a crowded waiting room, and rarely exposed to a risk of infection.

My clinics are not associated with a large group of transplant patients congregating in the waiting room. This makes transmission much less likely.

Why not give kidney transplant patient Bactrim prophylaxis?

There is an argument that all transplant patients should go on Bactrim prophylaxis.  However, as indicated , the chances of contracting Pneumocystis Jiroveci not attending the hospital out-patients clinic is not great.  Bactrim may have it’s own problems. Patient’s whose kidney transplant creatinine is > 200 are likely to have worsening kindey function.  There are also issues of Bactrim allergy.  Alternatives could be Dapsone or Pentamidine, but these also have their own intrinsic problems and are not as effective anyway.

What to do?

I have not prescribed Bactrim propylaxis to all of my patients who have had a kidney or kidney/pancreas transplant, but only those who may have to attend a public hospital out-patients clinic. This could either be in Canberra or anywhere in Australia.Over the last six months this program has been very effective and none of my clinic patients have had Pneumocystis Jiroveci.

The incubation period for Pneumocystis Jiroveci is very long (six months), so it is very important that prophylaxis occurs well before exposure. Bactrim prophylaxis has been shown to be excellent.

The  Transplant Society of Australia and New Zealand  has published guidelines and my clinic is using a different approach.

If you disagree with the approach of not being given prophylaxis, and prefer to have continual prophylaxis because of the knowledge that transplant patients around Australia are contracting Pneumocystis Jiroveci, then let me know and I will send you an authority script for Bactrim which will last for about a year.  You would be taking one Bactrim every second day.

If you agree with my proposition that we do not give prophylaxis to every transplant patient because of its risks, then you would need to let me know if you have to attend a public hospital out-patients clinic, particularly if this involves transplant patients, and in advance I will send you a script for Bactrim to be taken before you go to the transplant clinic and a week afterwards.

Bactrim prophylaxis is extremely effective in preventing Pneumocystis Jiroveci.  It is important the medication is taken before exposure, as the incubation period for Pneumocystis Jiroveci is very long (often up to six months).