Incidence and risk factors of Pneumocystis jirovecii pneumonia in Korean patients with inflammatory bowel disease

Abstract

Background and Aim Little is known whether routine prophylaxis against Pneumocystis jirovecii pneumonia (PJP) is needed in patients with inflammatory bowel disease (IBD) on immunosuppression, especially in Asian populations. We, therefore, sought to investigate the incidence and risk factors of PJP in patients with IBD in Korea. Methods We investigated the incidence of PJP in patients with IBD and compared the characteristics of IBD patients with PJP episodes (IBD‐PJP group) with those of matched controls (IBD‐only group) using a large, well‐characterized referral center‐based cohort. Results Among the 6803 IBD patients (3171 with Crohn's disease and 3632 with ulcerative colitis) enrolled in the Asan IBD Registry between June 1989 and December 2016, six patients (0.09%) were diagnosed with PJP. During the 57 776.0 patient‐years of follow‐up (median 7.2 years per patient), the incidence of PJP was 10.4 cases per 100 000 person‐years, and none of these patients had received PJP prophylaxis. In case–control analysis, the IBD‐PJP group (n = 6) showed significantly higher C‐reactive protein level at diagnosis of IBD (P = 0.006), as well as higher exposure to corticosteroids (P = 0.017), than did controls (n = 24). In addition, the IBD‐PJP group showed higher rates of double (50% vs 12.5%) or triple (33.3% vs 4.2%) immunosuppression than did controls, although these are not statistically significant. Conclusions Although the incidence of PJP in Korean patients with IBD is low, careful monitoring is necessary for the early detection of PJP. In addition to the patients receiving double or triple immunosuppression, PJP prophylaxis should be considered especially in patients with severe disease activities requiring corticosteroids.

Prophylaxis for Pneumocystis jirovecii pneumonia in patients with inflammatory bowel disease: A systematic review

“…Three of the four case series had confirmed PJP diagnoses 49 , 50 , 51 and of the 37 patients with reported PJP diagnoses, nine patients died (24.3%). 53 , 54 , 55 These patients were also older than patients who did not die from PJP (mean age 66.3 years versus 34.5 years). In one case series, the mean total daily dose of corticosteroids (in prednisone equivalents) was 26.7 mg (median 12.5 mg) 50 ; similar results were found in a second case series, where the mean and median dose was 27.5 mg. 51…”

“…A retrospective cohort study concluded that patients who were diagnosed with PJP had a significantly higher C‐reactive protein (CRP) (6.5 mg/dl vs. 0.1 mg/dl, p = 0.006) and were more likely to be receiving corticosteroids (100% vs. 37.5%, p = 0.017) than those who were not diagnosed with PJP. 54 The study found that a higher CRP at time of diagnosis of IBD was a significant risk factor for development of PJP (OR 1.855, 95% confidence interval [CI] 1.065–2.30). 54 Another study found that patients who died from PJP were significantly older than patients who did not die from PCP (69.0 ± 5.4 vs. 58.0 ± 14.0 years, respectively, p = 0.011) and that low serum albumin was a significant risk factor for mortality (OR 0.09, 95% CI 0.01–0.52, p = 0.027).…”

“…Of the four studies that presented mortality data, nine of 47 patients died (24.3%). 4 , 53 , 54 , 55 Only three studies 4 , 53 , 54 reported time from IBD diagnosis to PJP diagnosis, ranging from 2 years to almost 7 years. The majority of patients ( n = 61, 71.2%) were receiving corticosteroids at time of PJP diagnosis 53 , 54 , 55 , 56 ; other common medications included thiopurines ( n = 27, 31.8%) 4 , 53 , 54 , 55 and anti‐TNFs ( n = 17, 20%).…”

“… 4 , 53 , 54 , 55 Only three studies 4 , 53 , 54 reported time from IBD diagnosis to PJP diagnosis, ranging from 2 years to almost 7 years. The majority of patients ( n = 61, 71.2%) were receiving corticosteroids at time of PJP diagnosis 53 , 54 , 55 , 56 ; other common medications included thiopurines ( n = 27, 31.8%) 4 , 53 , 54 , 55 and anti‐TNFs ( n = 17, 20%). 4 , 53 , 54 , 55 Most patients were receiving two immunosuppressive medications at time of PJP diagnosis ( n = 25, 29%), 4 , 53 , 54 , 55 although some were receiving one or three immunosuppressive agents concomitantly ( n = 18, 21.2% and n = 18, 21.2%, respectively).…”

“… 4 , 53 , 54 , 55 Most patients were receiving two immunosuppressive medications at time of PJP diagnosis ( n = 25, 29%), 4 , 53 , 54 , 55 although some were receiving one or three immunosuppressive agents concomitantly ( n = 18, 21.2% and n = 18, 21.2%, respectively). 4 , 53 , 54 , 55 …”