Short-term Steroid Therapy in Patients With P. Jirovecii Pneumonia Due to HIV / AIDS
Short-term Steroid Therapy in Patients With P. Jirovecii Pneumonia Due to HIV / AIDS
The treatment guidelines for Pneumocystis pneumonia (PCP) suggest adding 40mg of prednisone
 (or its equivalent in methylprednisolone) twice per day on days 1 through 5, 40 mg days 6
 through 10, and 20 mg daily on days 11 through 21 in subjects with moderate and serious PCP.
 Steroids have shown to improve clinical outcome and reduction in mortality in HIV-infected
 patients the effectiveness of adjuvant steroid treatment for PCP has been observed if it
 starts within the first 24 to 48 hours. Possibly, there is a long-term benefit with their use
 in the recovery of function and limitation of chronic pulmonary complications; recently,
 benefits have been observed in decreasing the incidence of Inflammatory Immune Reconstitution
 Syndrome (IRIS) due to Mycobacterium tuberculosis. On the other hand, steroids could increase
 the morbidity related to adverse reactions as well as paradoxical worsening of associated
 herpes virus infection, which are attributed to IRIS or as a result of immunosuppression
 generated by their use. Recently, it has been shown that gradually steroids withdrawal is not
 necessary in patients who have received less than 21 days of treatment.

 This non-inferiority work aims to confirm the null hypothesis that a reduced steroid scheme
 in patients with moderate PCP (8 days) and severe pneumonia (14 days) is sufficient to limit
 long-term ventilatory complications and acute postinflammatory syndrome, compared to the
 conventional 21-day scheme. It also has been hypothesized that it could be associated with
 fewer cases of IRIS due to herpes virus type 1,2,3 and 8.
The investigators selected hospitalized subjects with confirmed or suspected moderate or
 severe PCP: the diagnostic certainty will be based on the following criteria:

 Proved PCP. Defined as cases with presence of P. jirovecii cysts in bronchial alveolar lavage
 (BAL) exams or lung biopsy.

 Possible PCP. Defined by the following two criteria: 1) the presence of three of four items:
 cough, fever, dyspnea and compatible radiological or tomographic findings 2) associated
 clinical improvement after the onset of trimethoprim/sulfamethoxazole (TMP / SMX).

 Probable PCP. Defined as the presence of one of the two previous criteria, without other
 identified microorganisms.

 The radiological or tomographic findings compatible with PCP are: presence of bilateral
 reticular infiltrate, ground glass, crazy paving pattern and presence of bullae, cysts or
 spontaneous pneumothorax.

 The microbiological findings will be the identification of cysts in the Grocott stain or a
 positive immunofluorescence test (IFA).

 Patients will be classified as moderate PCP when the partial pressure of oxygen (PaO2) is
 less than 70 mmHg and the alveolar arterial difference (Da-a) is greater than 35 mmHg and
 severe PCP when it is greater than 45 mmHg.

 The sample size was calculated for non-inferiority tests to a tail with an estimated
 mortality of 16% for both groups; using a Z alpha in 1.65 and Z beta in 1.645, with a
 non-inferiority margin of 0.6; resulting in 98 subjects per group.

 After obtaining the informed consent, patients will be randomized accordingly to their CD4+ T
 cell count (less or more than 50 cells/mm3 and assigned to each group:

 -  Group A or Conventional Steroids use (CoSt).patients will receive 21 days of steroid
 treatment.

 -  Group B or Shortened Steroids use (SSt). Subjects with moderate PCP will receive 8 days
 of steroids and subjects with severe PCP 14 days of steroids.

 The equivalent prednisone doses of systemic steroids will be recorded, as well as the
 duration of their administration since it could be modified according to the criteria of the
 treating physicians; demographic data, the start date of ART (Antiretroviral Therapy), and
 the presence of other opportunistic, nosocomial and co-infections will also be recorded.

 The laboratory data that will be recorded at the time of diagnostic suspicion of PCP will be:
 CD4+ T cell count, HIV viral load, lactate dehydrogenase (LDH), C-reactive protein (PCRe),
 pAO2, Da-aO2.

 Once the patient has been discharged, the patient will be scheduled to continue ambulatory,
 conventional follow-up at 90, 180 and 360 days after starting the ART and to evaluate
 secondary outcomes.

 Once 50% of the sample size has completed 30 days of follow-up, a preliminary analysis will
 be conducted to assess safety and efficacy; if differences in the mortality are observed, the
 study will be terminated.
Inclusion Criteria:

 -  Older than 18 years

 -  To have a gasometry at the admission that confirms moderate or severe PCP.

 -  Patients receiving trimethoprim / sulfamethoxazole in doses of 15 to 20 mg / kg per
 day from the first 24 hours after admission.

 -  Patients who have begun adjuvant treatment with steroids in the first 48 hours after
 admission.

 -  No history of chronic pulmonary disease.

 -  APACHE at hospitalization less than 20 points.

 Exclusion Criteria:

 -  Allergic to TMP/SMX, who have not tolerated desensitization.

 -  History of inflammatory, infectious, autoimmune or neoplastic diseases except Kaposi's
 sarcoma, which merit the chronic use of steroids.

 -  Pleural or pericardial effusion and meningitis from any cause.

 -  Septic shock not related to PCP.

 -  Subjects who during the hospitalization have been diagnosed with any neoplasia (except
 Kaposi´s sarcoma)