792 The Journal of Rheumatology 2010; 37:4; doi:10.3899/jrheum.090843 Personal non-commercial use only.The Journal of Rheumatology Copyright © 2010. All rights reserved. A Survey of Rheumatologists’ Practice for Prescribing Pneumocystis Prophylaxis DEANNACETTOMAI,ALLANC.GELBER,andLISACHRISTOPHER-STINE ABSTRACT. Objective. Pneumocystis pneumonia (PCP) occurs in immunocompromised hosts, in both the pres- enceandabsenceofhumanimmunodeficiencyvirus(HIV)infection,withsubstantialmorbidityand a heightened mortality. We assessed practice patterns among rheumatologists for prescribing PCP prophylaxis. Methods. Invitations to an online international survey were e-mailed to 3150 consecutive members of theAmerican College of Rheumatology. Results. Completed surveys were returned by 727 (23.1%) members. Among respondents, 505 (69.5%) reported prescribing prophylaxis. Factors associated with significantly higher frequency of prescribing PCP prophylaxis included female gender (OR 1.47, p = 0.03), US-based (OR 1.77, p = 0.004), academic-based (OR 2.75, p < 0.001), in practice less than 10 years (OR 4.08, p < 0.001), having previously treated PCP (OR 2.62, p < 0.001), and in a practice with a higher proportion of patients maintained on chronic glucocorticoids (OR 2.04, p < 0.001) or other immunosuppressant medications(OR3.19,p=0.003).Inmultivariateanalysis,rheumatologistsearlyintheircareersand thosewithacademicandUS-basedpracticesweremorelikelytoprescribeprophylaxis.Amongpre- scribers, the most important determinants for issuing prophylaxis were treatment regimen (68.6%), rheumatologic diagnosis (9.3%), and medication dosage (8.3%). Conclusion. Nearly one-third (30%) of the rheumatologists surveyed reported that they never pre- scribedPCPprophylaxis.Whilethepatientcharacteristicsforwhichprophylaxiswasprescribedvar- iedwidely,physiciandemographicswerestronglypredictiveofPCPprophylaxisuse.Thesefindings suggest that development of consensus guidelines might influence clinical decision-making regard- ing PCPprophylaxis in HIV-negative patients with rheumatologic diagnoses. (First Release March 1 2010; J Rheumatol 2010;37:792–9; doi:10.3899/jrheum.090843) Key Indexing Terms: PNEUMOCYSTIS PROPHYLAXIS PNEUMOCYSTIS PNEUMONIA IMMUNE SYSTEM HUMAN IMMUNODEFICIENCYVIRUS From the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. D. Cettomai, BS;A.C. Gelber, MD, MPH, PhD; L. Christopher-Stine, MD, MPH, Department of Medicine, Johns Hopkins University School of Medicine. Address correspondence to Dr. L. Christopher-Stine, Johns Hopkins University School of Medicine, Mason F. Lord Building, Center Tower, Suite 4100, Room 409, 5200 Eastern Ave., Baltimore, MD 21224, USA. E-mail: lchrist4@jhmi.edu Accepted for publication November 11, 2009. Pneumocystis jirovecii (formerly P. carinii) pneumonia (PCP) is an opportunistic infection that occurs in immuno- compromised persons and is the most prevalent opportunis- ticinfectioninpatientswithhumanimmunodeficiencyvirus (HIV) 1 . The occurrence of PCP among HIV-negative per- sons with immunocompromised states of other origins has beenincreasinglyrecognized 2-8 .Therearenumerousreports ofPCPoccurringinpatientswithunderlyingrheumatologic diagnoses 9-20 . Overall, the incidence of PCP appears to be increasing 4 , a rise attributed to the increasing number of patients undergoing immunosuppressive treatment for a growing number of indications 21 . WhilethemortalityofPCPinpatientsinfectedwithHIV is 10%–20%, it is substantially higher, estimated to be 30%–60%,inpersonswithoutHIV,whooftenpresentmore acutely and with more severe respiratory compromise than patients infected with HIV 1 . Effective antibiotic prophylax- isforPCPisavailableandrecommendedforpatientsathigh risk of infection, although the frequency with which pro- phylactictherapyisusedisunknown.Consensusguidelines are well established for the use of PCP prophylaxis in HIV-infectedindividuals 22 , but no such guidelines exist for prescribing PCP prophylaxis in HIV-negative populations. Further, a recent Cochrane review assessed the use of pro- phylaxis only in persons with hematologic malignancies, bone marrow transplants, and solid organ transplants 23 . We intended to review the evidence for PCP prophylaxis in HIV-uninfected persons chronically treated with cortico- steroids for a variety of conditions, including rheumatolog- ic disorders. However, no relevant studies were found addressinguseofprophylaxisinthisclinicalcontext,among patients with rheumatologic diagnoses. We surveyed an international sample of rheumatologists See related editorial in this issue. www.jrheum.org Downloaded on April 20, 2021 from