Pneumocystis carinii pneumonia


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PNEUMOCYSTIS CARINII PNEUMONIA: Silver-stained cysts in lung tissue (×400)
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PNEUMOCYSTIS CARINII PNEUMONIA

Pneumocystis carinii pneumonia

Abbreviation: PCP
A subacute opportunistic infection marked by fever, nonproductive cough, tachypnea, dyspnea, and hypoxemia. It is caused by Pneumocystis carinii, the former name of Pneumocystis jiroveci, an organism formerly thought to be a protozoan but now generally accepted as a fungus. The disease is seen principally in immunosuppressed patients, such as those with AIDS or who have received an organ transplant and immunosuppressant drugs. Without treatment, the progressive respiratory failure that the infection causes is ultimately fatal.

Diagnosis

The disease should be suspected in patients with human immunodeficiency virus infection or other risk factors for the disease who present with cough and shortness of breath. Chest x-ray examination may reveal diffuse interstitial infiltrates, upper lobe disease, spontaneous pneumothorax, or cystic lung disease. The diagnosis is confirmed with special stains of sputum, bronchial washings, or lung biopsy specimens. See: illustration

Treatment

Oral trimethoprim-sulfamethoxazole effectively protects against PCP, and is also the drug of choice for active infection. Other drugs that are active against PCP include pentamidine, trimethoprim in combination with dapsone, and atovaquone. Corticosteroids are used as adjunctive therapy when treating markedly hypoxic patients, e.g., those who present with an alveolar-arterial oxygen gradient of more than 35 mm Hg. The introduction of highly active antiretroviral drug cocktails for AIDS patients has markedly reduced the incidence of PCP.

illustration
See also: pneumonia

Pneumocystis carinii pneumonia (PCP)

A lung infection that affects people with weakened immune systems, such as people with AIDS or people taking medicines that weaken the immune system.

Pneumocystis carinii Pneumonia

DRG Category:177
Mean LOS:8.2 days
Description:MEDICAL: Respiratory Infections and Inflammations With Major CC
DRG Category:975
Mean LOS:6.2 days
Description:MEDICAL: HIV with Major Related Conditions With CC

Pneumocystis carinii pneumonia (PCP) is an acute or subacute pulmonary infection that can be fatal. While the term PCP continues in use, the causitive organism has been renamed Pneumocystis jiroveci, named after the scientist (Otto Jirovec) who isolated the organism from humans. It occurs in 5% to 10% of transplant patients; in addition, it is the most common opportunistic infection in people infected with HIV and is the leading cause of death in this population. PCP is viewed as an opportunistic infection because normal cell-mediated immunity protects most humans from infection. With prophylactic medications, an estimated 1% to 20% of people with HIV infection develop PCP at some point in their lifetimes. Epidemiological surveys have found that by age 3 to 4, most humans have been exposed to the pathogen.

Early in the infection, the organisms line up along the alveolar wall near the type I pneumocytes. The alveoli become infiltrated with a fluid that contains proteins, organisms in varying states of development, cellular debris, and surfactant. As the alveoli become clogged with fluid and wastes, gas exchange is impaired. As the disease progresses, alveoli hypertrophy, type I pneumocytes die, and the patient has markedly diminished gas exchange. PCP affects both lungs and can lead to complications such as pulmonary insufficiency, respiratory failure, and death. People infected with HIV have a 10% to 20% mortality rate, whereas other immunocompromised individuals have a 40% mortality rate. Individuals at risk for PCP are immunocompromised and have conditions such as HIV infection or are premature infants. Other vulnerable populations include patients who receive corticosteroid therapy and organ transplantation. PCP used to be common in lung transplant patients, but it is now very rare because of prophylactic treatment.

Causes

Although the causative agent, P. jiroveci, is often classified as a protozoa, its structure and function are closer to a unicellular fungus. Organisms in this family are often found in the lungs of healthy people, and airborne exposure in healthy children occurs globally. PCP occurs when a person become immunocompromised and the fungus multiplies aggressively in the alveoli. Incubation is approximately 4 to 8 weeks.

Genetic considerations

Heritable immune responses could be protective or increase susceptibility.

Gender, ethnic/racial, and life span considerations

Premature infants are at risk for PCP, as are children with immunodeficiency diseases. There are no known differences in the prevalence of PCP in males and females nor among groups with differing ancestries.

Global health considerations

PCP occurs around the globe. In Africa, approximately 80% of infants with HIV infection and pneumonia have pneumocystic organisms present in their lungs. In sub-Saharan Africa, tuberculosis and PCP often are comorbidities. In developed nations with wide availability of antiretroviral therapy, the prevalence of PCP has decreased markedly in the last several decades.

Assessment

History

Patients with PCP often appear acutely ill and weak. They often have pallor, weight loss, and fatigue on exertion and become short of breath even when speaking. Determine if the patient has a history of leukemia, lymphoma, organ transplantation, or HIV infection, all of which compromise the immune system and increase the risk of PCP. Because symptoms of PCP develop over a period of weeks (4 to 8 weeks, generally), initial symptoms may be vague.

Determine if the patient has experienced nonproductive cough or increasing shortness of breath, which are frequent initial symptoms of PCP. Ask about a recent history of anorexia, nausea, vomiting, weight loss, or a low-grade intermittent fever. Note that before PCP prophylaxis in HIV-positive patients, this disease was the first indication of HIV infection in 60% of HIV-positive patients.

Physical examination

Common symptoms include fever, dyspnea on exertion, nonproductive cough, stridor, nasal flaring, and chest tightness. If the patient has a cough, note the type. Examine the patient’s skin, noting its color, turgor, temperature, and whether it is dry and flaky. Check for pallor, flushing, cyanosis, and signs of hypoxemia such as mental status changes and agitation. Note the type, amount, and color of sputum, which is commonly blood-tinged. Observe the patient’s level of consciousness and irritability. Note any muscle wasting or guarding of painful areas. Auscultate the lungs for abnormal breath sounds, crackles, or diminished or absent breath sounds, either unilaterally or bilaterally. Late in PCP, when you percuss the chest, you may hear dullness from lung consolidation.

Psychosocial

PCP is a serious and life-threatening infection; in addition, it may be the defining condition for diagnosis of AIDS, according to the Centers for Disease Control and Prevention. The patient may experience anxiety, depression, or difficulty in coping with the change in health status. Identify the patient’s support system and evaluate its effectiveness. The diagnosis of AIDS presents many complex familial and societal issues.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Lactic dehydrogenase50–150 units/L> 220 units/LReflects onset of infection; 90% of patients with HIV and PCP have elevations
Bronchoscopy and bronchoalveolar lavageNormal pulmonary structures and negative culturesWashings positive for P. carinii on immunofluorescent stainUsed to view the pulmonary structures and obtain bronchoalveolar washings (more sensitive than standard sputum specimens)
Serum immunofluorescent antibodies< 1:16; no organisms observedPresence of organismsUsed to identify antibodies that circulate in blood, formed in response to antigens in protozoan bacterial cell wall
Chest x-rayClear lung fieldsDiffuse bilateral infiltrates; may be normal in early stages of PCPFindings reflect areas of infection and consolidation

Other Tests: High-resolution computed tomography, arterial blood gases, gallium scan, complete blood count

Primary nursing diagnosis

Diagnosis

Risk for infection related to immunosuppression

Outcomes

Immune status; Respiratory status: Gas exchange; Respiratory status: Ventilation; Thermoregulation

Interventions

Infection control; Infection protection; Respiratory monitoring; Temperature regulation

Planning and implementation

Collaborative

Patients require pharmacologic treatment to eradicate the organism. PCP infections may be treated with incentive spirometry, percussion and postural drainage, and humidified oxygen. Some patients may require intubation and mechanical ventilation to maintain gas exchange. If the patient is not intubated and is able to take oral nutrition, a high-calorie, protein-rich diet is recommended. If the patient cannot tolerate large amounts of food, smaller, more frequent meals can be offered. IV fluids and total parenteral nutrition may be needed to maintain fluid balance if the patient cannot tolerate oral enteral feedings.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
Trimethoprim sulfamethoxazole (Bactrim, Septra, TMP/SMX)5 mg/kg IV every 6–8 hrAnti-infectiveKills the organism; used for early cases and for prophylaxis
Antibiotics, anti-infectivesVaries with drugPrimaquine phosphate; trimetrexate and leucovorin; pentamidine isethionate (Nebupent) aerosol treatment; clindamycinKill the organism
Prednisone40 mg PO bid for 5 days and then taperCorticosteroidDecreases pulmonary inflammation; only for patients with severe disease
Antipyretics, antitussives, analgesicsPrescribed as neededOral narcoticsReduce the respiratory rate and control anxiety, thereby improving comfort and gas exchange

Other Drugs: Antipyretics, antitussives, and analgesics are prescribed as needed. Oral narcotics may be given to reduce the respiratory rate and control anxiety, thereby improving comfort and gas exchange.

Independent

Patients with PCP infection are often weak and debilitated. They may become short of breath even when speaking, and their dyspnea is severe. Discuss your concerns with the physician if the patient remains uncomfortable. Alterations in the medication regimen may be necessary. Position the patient so that he or she is comfortable and breathes with as little effort as possible. Usually, if you elevate the bed and support the patient’s arms on pillows, the respiration eases. A major nursing responsibility is to coordinate periods of activity and rest. Schedule diagnostic tests and patient care activities with ample rest periods between them. As the patient gains strength, encourage coughing and deep-breathing exercises and teach him or her how to perform incentive spirometry. Evaluate the patient’s gait, and if it is steady, encourage periods of ambulation interspersed with periods of rest.

Reduce the patient’s anxiety by providing a restful environment, including diversionary activities. Teach the patient guided imaging or relaxation techniques for nonpharmacologic relief of discomfort. Provide time each day to allow the patient to ask questions and explore fears. Include the family and significant others in all teaching activities as appropriate.

Evidence-Based Practice and Health Policy

Crozier, F. (2011). Pneumocystis carinii pneumonia prophylaxis: current therapies and recommendations. Journal of Pediatric Oncology Nursing, 28(3), 179–184.

  • Children being treated with regimens that include chemotherapy, steroids, or stem cell transplant have a particularly increased risk for developing PCP.
  • Clinician experts propose the use of PCP prophylaxis for a period of 3 to 6 months or until immune function is restored for anyone who is neutropenic.
  • Experts also highlight the critical role that nurses and other primary care providers play in educating families about the importance of preventing PCP, encouraging prophylactic medication adherence, ensuring proper medication administration, and monitoring for potential side effects of therapy.

Documentation guidelines

  • Physical changes: Breath sounds, breathing patterns, sputum production
  • Nutritional status: Appetite, body weight, food tolerance
  • Complications, changes in oxygen exchange or airway clearance
  • Response to medications
  • Tolerance to activity, level of fatigue, ability to sleep at night

Discharge and home healthcare guidelines

Advise the patient to quit smoking, rest, avoid excess alcohol intake, maintain adequate nutrition, and avoid exposure to crowds and others with upper respiratory infections. Teach the patient appropriate preventive measures, such as covering the mouth and nose while coughing when in contact with susceptible individuals. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Teach the patient to recognize symptoms, such as dyspnea, chest pain, fatigue, weight loss, fever and chills, and productive cough, that should be reported to healthcare personnel.

References in periodicals archive ?
Pneumocystis carinii pneumonia in human immunodeficiency virus (HlV)-positive and HIV-negative immunocompromised patients.
Cytomegalovirus and Pneumocystis carinii pneumonia in children with acquired immunodeficiency syndrome.
Non-invasive diagnosis of Pneumocystis carinii pneumonia by PCR on oral washes.
Utility of lactate dehydrogenase vs radiographic severity in the differential diagnosis of Pneumocystis carinii pneumonia.
They found that men were twice as likely as women to receive either zidovudine or Pneumocystis carinii pneumonia prophylaxis when the recipient was not a drug user.
Approved June 23,1981 for the treatment of Pneumocystis carinii pneumonia (PCP)
After a few years of infection persons begin to lose T-helper cells, then begin to develop outward manifestations of immune dysfunction such as oral candidiasis, then begin to suffer life-threatening diseases such as pneumocystis carinii pneumonia.
Annie visited every day while Donetta was recovering from Pneumocystis carinii pneumonia.
SMT is a widely used antibiotic used to treat infections such as urinary tract infections, bronchitis, ear infections (otitis), traveler's diarrhea, and Pneumocystis carinii pneumonia.
Pneumocystis carinii pneumonia as a complication of bendamustine monotherapy in a patient with advanced progressive breast cancer.
We are developing treatments for fungal infections, malaria, tuberculosis, cancer, diabetes, Pneumocystis carinii pneumonia ("PcP") and tropical diseases, including African sleeping sickness (trypanosomiasis) and leishmaniasis.
SAN FRANCISCO -- More clinicians will need to start or restart prophylactic therapy for Pneumocystis carinii pneumonia in HIV-infected patients in order to reach the Healthy People 2010 target of prophylaxis in 95% of eligible patients, Dr.