Clindamycin–primaquine for pneumocystis jiroveci pneumonia in renal transplant patients

Background Trimethoprim/sulfamethoxazole (TMP/SMX) is considered first-line therapy for pneumocystis jiroveci pneumonia (PCP) in renal transplant patients. Alternatives have not been formally studied. Clindamycin–primaquine (C–P) is effective in HIV-associated PCP, but data in renal transplant patients are lacking. Patients and methods Retrospective cohort study of 57 consecutive renal transplant patients who developed PCP and were treated with C–P ( n = 23) or TMP/SMX ( n = 34). Results A non-significantly higher failure rate was observed in patients on C–P due to lack of efficacy (30.4 versus 20.6 %, p = 0.545). The difference was more pronounced in severe PCP (60 versus 37.5 %, p = 0.611) and a significantly lower efficacy of C–P was seen when used as salvage therapy. The two patients who had received C–P after not responding to TMP/SMX failed this regimen, but all seven patients who had failed initial treatment with C–P and had been switched to TMP/SMX were cured ( p = 0.028). No treatment-limiting adverse reactions were reported for patients on C–P while six patients (17.6 %) on TMP/SMX developed possibly related treatment-limiting toxicity ( p = 0.071). However, in only two patients adverse events were definitely related to TMP/SMX (5.9 %). Conclusions Clindamycin–primaquine appears to be safe and well tolerated for treating PCP in renal transplant patients but is probably less effective than TMP/SMX, the standard regimen. However, our data indicates that C–P represents an acceptable alternative for patients with contraindications or treatment emergent toxicities during TMP/SMX use. Notably, TMP/SMX was also acceptably tolerated in most patients. TMP/SMX remains an effective salvage regimen in case of C–P failure.