Atovaquone versus trimethoprim-sulfamethoxazole as Pneumocystis jirovecii pneumonia prophylaxis following renal transplantation

Pneumocystis pneumonia (PCP) is associated with significant morbidity and mortality in renal transplant recipients (RTR). Trimethoprim–sulfamethoxazole (TMP‐SMZ) is considered the prophylactic agent‐of‐choice. Some patients require an alternative owing to TMP‐SMZ intolerance. This is the first evaluation of full‐dose atovaquone vs. TMP‐SMZ for PCP prevention in RTR. One hundred and eighty‐five RTR were evaluated in this single‐center, retrospective analysis. Patients received either single‐strength TMP‐SMZ daily (group I; n = 160) or 1500 mg/d of atovaquone and of a fluoroquinolone for one month (group II; n = 25). The primary endpoint was the incidence of PCP at 12 months post‐transplant. There were no cases of PCP in either group. There were comparable rates of infections from bacterial pathogens and cytomegalovirus, but rates of BK viremia were significantly higher in group I (22.5%) vs. group II (4%; p = 0.03). The incidence of leukopenia was similar in both groups. Higher mean potassium levels were seen in group I at three months post‐transplant but were comparable at all other time points. The need for dose reduction and/or premature discontinuation of therapy secondary to adverse events was more prevalent in TMP‐SMZ‐treated patients. In our experience, atovaquone appears to be effective in preventing PCP post‐renal transplant and also demonstrates good tolerability.