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Echinocandins as alternative treatment for HIV-infected patients with Pneumocystis pneumonia

Huang, Yu-Shana; Liu, Chun-Engb; Lin, Shih-Pingc; Lee, Chen-Hsiangd; Yang, Chia-Juie,f; Lin, Chi-Yingg; Tang, Hung-Jenh; Lee, Yi-Chieni,j; Lin, Yi-Chunk; Lee, Yuan-Til,m; Sun, Hsin-Yuna; Hung, Chien-Chinga,n on behalf of the Taiwan HIV Study Group

doi: 10.1097/QAD.0000000000002207

Objectives: Treatment with trimethoprim-sulfamethoxazole for Pneumocystis pneumonia (PCP) is often associated with adverse effects. Echinocandins, by inhibiting the cyst form of Pneumocystis jirovecii, may be an alternative therapy for PCP. However, clinical experience with echinocandins in the treatment of PCP remains limited among HIV-infected patients.

Methods: From August 2013 to April 2018, data of HIV-infected patients with confirmed PCP who received echinocandins as alternative treatment because of intolerance or unresponsiveness to trimethoprim-sulfamethoxazole were retrospectively reviewed to assess the effectiveness and safety of echinocandins alone or in combination with other agents.

Results: In total, 34 patients were included, with a median CD4+ count of 27 cells/μl [interquartile range (IQR), 20–93). Twenty-four patients (70.6%) presented with moderate-to-severe PCP. The most common adverse effects leading to withdrawal of trimethoprim-sulfamethoxazole were hepatotoxicity (29.4%), gastrointestinal upset (23.5%), and rash (17.6%). Nine patients (26.5%) were switched to echinocandins after failure of trimethoprim-sulfamethoxazole. The median interval before switch from trimethoprim-sulfamethoxazole to echinocandins was 9.0 days (IQR 5.0–14.0). The all-cause and PCP-related in-hospital mortality rate of patients receiving echinocandins as alternative therapy was 20.6% (7/34) and 14.7% (5/34), respectively. The all-cause in-hospital mortality was 0% in mild PCP cases and 29% (7/24) in moderate-to-severe PCP cases. Patients who had failed to respond to first-line trimethoprim-sulfamethoxazole treatment tended to have a higher in-hospital mortality rate than those without first-line trimethoprim-sulfamethoxazole failure (44.4% versus 12.0%, P = 0.06).

Conclusion: Echinocandin therapy might serve as an alternative option for HIV-infected patients with PCP who are intolerable to trimethoprim-sulfamethoxazole.

aDepartment of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei

bDepartment of Internal Medicine, Changhua Christian Hospital, Changhua County

cDepartment of Internal Medicine, Taichung Veterans General Hospital, Taichung

dDepartment of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine

eDepartment of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City

fSchool of Medicine, National Yang-Ming University, Taipei

gDepartment of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County

hDepartment of Internal Medicine, Chi Mei Medical Center, Tainan

iDepartment of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City

jDepartment of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City

kDepartment of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan

lDepartment of Internal Medicine, Chung Shan Medical University Hospital

mSchool of Medicine, Chung Shan Medical University, Taichung

nDepartment of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan.

Correspondence to Hsin-Yun Sun, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei. Tel: +886 2 23123456 x66096; fax: +886 2 23822172; e-mail:

Received 22 December, 2018

Revised 20 February, 2019

Accepted 22 February, 2019

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