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Sulfamethoxazole (SMX)/trimethoprim (TMP) is the treatment of choice for PCP pneumonia. The IV formulation has been unavailable for almost a year due to shortage. It is contraindicated in patients with sulfa allergy. Here are the alternatives with adverse effects. You'll quickly see why pentamidine should generally be reserved for those with sulfa allergy and G6PD deficiency.
Mild-to-moderate disease:
- Primaquine 15-30 mg PO PLUS Clindamycin 600 mg IV or 300-450 mg PO
- Dapsone 100 mg PO PLUS TMP 5 mg/kg PO
- Atovaquone suspension 750 mg PO
Moderate-to-severe disease:
- Primaquine 15-30 mg PO PLUS Clindamycin 600 mg IV or 300-450 mg PO
- Pentamidine 4 mg/kg IV
Adverse Effects:
- Primaquine: Rash, fever, methemoglobinemia, hemolytic anemia (check for G6PD deficiency)
- Clindamycin: Rash, diarrhea, Clostridium difficile colitis, abdominal pain
- Dapsone: Rash, fever, gastrointestinal upset, methemoglobinemia, hemolytic anemia (check for G6PD deficiency)
- TMP: Rash, gastrointestinal distress, transaminase elevation, neutropenia
- Atovaquone: Rash, fever, transaminase elevation
- Pentamidine: Nephrotoxicity, hyperkalemia, hypoglycemia, hypotension, pancreatitis, dysrhythmias, transaminase elevation
References
Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. MMWR April 10, 2009 / 58(RR04);1-198.