卡氏肺囊虫性肺炎

预防性治疗的首选是甲氧苄啶/磺胺甲恶唑（TMP/SMX），可以口服。证据 C预防：有质量差的证据表明，在减少PCP发病率方面，甲氧苄啶/磺胺甲恶唑（TMP/SMX）可能比雾化喷他脒和氨苯砜（联合或联合乙胺嘧啶）疗效跟高。低质量的观察性（队列）研究或者受试者＜200名且方法学存在缺陷的随机对照临床试验（RCT）。

对无 PCP 症状和体征的 HIV 阳性成人或青少年进行一级预防的指征包括：[43]Centers for Disease Control and Prevention; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. May 2016. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdfCD4 细胞计数＜200 个细胞/μl；口咽念珠菌病；CD4 细胞百分比＜14%；有艾滋病定义性疾病病史；如果无法每 1-3 个月监测 CD4 细胞计数，CD4 细胞计数＞200 个细胞/μl 或小于 250 个细胞/μl。

当患者免疫重建时和连续3个月的CD4细胞计数超过200个细胞/μl要暂停卡氏肺孢子虫肺炎的一级预防。[43]Centers for Disease Control and Prevention; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. May 2016. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf当某些患者服用抗逆转录病毒药物治疗后处于病毒载量抑制期和CD4细胞计数100-200个细胞/μl时，要暂停PCP的一级预防，但这并不被推荐。[44]Opportunistic Infections Project Team of the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE), Mocroft A, Reiss P, et al. Is it safe to discontinue primary Pneumocystis jiroveci pneumonia prophylaxis in patients with virologically suppressed HIV infection and a CD4 cell count <200 cells/microL? Clin Infect Dis. 2010;51:611-619.http://www.ncbi.nlm.nih.gov/pubmed/20645862?tool=bestpractice.com尽管免疫重建，但对于仍有发生PCP危险的患者应在生活中继续进行预防。

在使用氨苯砜之前，如有可能，所有患者都应检查葡萄糖-6-磷酸脱氢酶（G6PD）是否缺乏。

阿托伐醌不应与利福平或利福布丁联合使用。[92]Benfield T, Atzori C, Miller RF, et al. Second-line salvage treatment of AIDS-associated Pneumocystis jiroveci pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008;48:63-67.http://www.ncbi.nlm.nih.gov/pubmed/18360286?tool=bestpractice.com

儿童进行一级预防的指征：1-12个月的HIV阳性或HIV暂不能明确的婴儿；1-5周岁HIV阳性儿童，其CD4细胞计数＜500个细胞/μl或CD4细胞百分比＜15%；6-12周岁HIV阳性儿童，其CD4细胞计数＜200个细胞/μl或CD4细胞百分比＜15%，。[42]National Institutes of Health; Centers for Disease Control and Prevention; HIV Medicine Association of the Infectious Diseases Society of America; Pediatric Infectious Diseases Society; American Academy of Pediatrics. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. 2013. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf

甲氧苄啶/磺胺二甲恶唑可选为预防性用药，没有禁忌证。无法耐受甲氧苄啶/磺胺二甲恶唑，其他选择有氨苯砜、阿托伐醌或雾化喷他脒。

在使用氨苯砜之前，如有可能，所有患者都应检查葡萄糖-6-磷酸脱氢酶（G6PD）是否缺乏。

阿托伐醌不应与利福平或利福布丁联合使用。[92]Benfield T, Atzori C, Miller RF, et al. Second-line salvage treatment of AIDS-associated Pneumocystis jiroveci pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008;48:63-67.http://www.ncbi.nlm.nih.gov/pubmed/18360286?tool=bestpractice.com

新生儿剂量咨询指导专家。

以下无PCP感染临床症状或体征的HIV阴性患者需要进行一级预防：血液系统恶性肿瘤， 骨髓移植，实质脏器移植，炎症性疾病患者，接受糖皮质激素泼尼松（强的松）每日至少16-20mg治疗，疗程超过1个月。[22]Yale SH, Limper AH. Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy. Mayo Clin Proc. 1996;71:5-13.[45]Stern A, Green H, Paul M, et al. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev. 2014;(10):CD005590.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005590.pub3/fullhttp://www.ncbi.nlm.nih.gov/pubmed/25269391?tool=bestpractice.com[103]Di Cocco P, Orlando G, Bonanni L, et al. A systematic review of two different trimetoprim-sulfamethoxazole regimens used to prevent Pneumocystis jirovecii and no prophylaxis at all in transplant recipients: appraising the evidence. Transplant Proc. 2009;41:1201-1203.http://www.ncbi.nlm.nih.gov/pubmed/19460516?tool=bestpractice.com

这组患者的预防治疗没有指导标准。TMP/SMX是最好的一线抗生素，无法耐受TMP/SMX的患者可进行雾化喷他脒或口服氨苯砜。

在使用氨苯砜之前，如有可能，所有患者都应检查葡萄糖-6-磷酸脱氢酶（G6PD）是否缺乏。

室内空气状态下，当PO2≥70mmHg或肺泡-动脉(A-a)氧分压差≤35mmHg。

治疗选择甲氧苄啶/磺胺甲恶唑（TMP/SMX）。[91]Safrin S, Finkelstein DM, Feinberg J, et al. Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group. Ann Intern Med. 1996;124:792-802.http://www.ncbi.nlm.nih.gov/pubmed/8610948?tool=bestpractice.com证据 A死亡率和治疗失败：高质量的证据表明，甲氧苄啶/磺胺甲恶唑（TMP/SMX）较阿托伐醌能更有效地降低死亡率。TMP/SMX与克林霉素联合伯氨喹、静脉注射喷他脒及甲氧苄氨嘧啶联合氨苯砜在降低死亡率方面的疗效相似。高质量的证据表明，TMP/SMX较阿托伐醌能更有效地防止治疗失败。TMP/SMX与克林霉素联合伯氨喹、静脉注射喷他脒及甲氧苄氨嘧啶联合氨苯砜在防止治疗失败方面的效果类似。系统评价或者受试者＞200名的随机对照临床试验（RCT）。

无法耐受TMP/SMX、无法给予支持治疗和治疗失败的患者可进行替代治疗。[43]Centers for Disease Control and Prevention; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. May 2016. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf替代治疗包括氨苯砜加甲氧苄氨嘧啶，证据 B死亡率和治疗失败：有中等质量的证据表明，甲氧苄氨嘧啶联合氨苯砜降低PCP患者死亡率和防止治疗失败的疗效与克林霉素联合伯氨喹相似。受试者＜200名的随机对照临床试验（RCT）、受试者＞200名且方法学存在缺陷的随机对照临床试验（RCT）、方法学存在缺陷的系统评价或者高质量的观察性（队列）研究。克林霉素加伯氨喹啉证据 A死亡率和治疗失败：有高质量的证据表明，克林霉素联合伯氨喹降低PCP患者的死亡率和预防治疗失败的疗效与甲氧苄啶/磺胺甲恶唑（TMP/SMX）相似。系统评价或者受试者＞200名的随机对照临床试验（RCT）。或阿托伐醌。证据 A死亡率和治疗失败：有高质量的证据表明，对于PCP患者，阿托伐醌降低死亡率的效果较甲氧苄啶/磺胺甲恶唑（TMP/SMX）小，且较TMP/SMX相比，不能更有效地防止治疗失败。然而，目前共识认为，对于不能使用TMP/SMX患者，给予阿托伐醌可以使其受益。系统评价或者受试者＞200名的随机对照临床试验（RCT）。

在使用伯氨喹或氨苯砜之前，如有可能，所有患者都应检查葡萄糖-6-磷酸脱氢酶（G6PD）是否缺乏。

阿托伐醌不应与利福平或利福布丁联合使用。[92]Benfield T, Atzori C, Miller RF, et al. Second-line salvage treatment of AIDS-associated Pneumocystis jiroveci pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008;48:63-67.http://www.ncbi.nlm.nih.gov/pubmed/18360286?tool=bestpractice.com

治疗持续21天。

室内空气状态下，当PO2＜70mmHg或肺泡-动脉(A-a)氧分压差＞35mmHg。

患者临床检查出现呼吸功能不全症状，应立即送入医院，如果需要送入ICU进行机械通气。

治疗选择甲氧苄啶/磺胺甲恶唑（TMP/SMX）静脉注射。替代治疗包括克林霉素加伯氨喹啉或静脉注射喷他脒。证据 B死亡率和治疗失败：有中等质量的证据表明，静脉注射喷他脒降低PCP患者死亡率和防止治疗失败的疗效与甲氧苄啶/磺胺甲恶唑（TMP/SMX）相似。受试者＜200名的随机对照临床试验（RCT）、受试者＞200名且方法学存在缺陷的随机对照临床试验（RCT）、方法学存在缺陷的系统评价或者高质量的观察性（队列）研究。

无法耐受TMP/SMX、无法给予支持治疗和治疗失败的患者可进行替代治疗。[43]Centers for Disease Control and Prevention; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. May 2016. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf

喷他脒较克林霉素加伯氨喹联合治疗更有效，但患者对后者的耐受性一般更好。一些证据表明，联合克林霉素和伯氨喹可能是最有效的挽救疗法，但尚未在经历 TMP/SMX 治疗失败患者的前瞻性临床试验中获得证实。[43]Centers for Disease Control and Prevention; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. May 2016. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf

在使用伯氨喹之前，如有可能，所有患者都应检查葡萄糖-6-磷酸脱氢酶（G6PD）是否缺乏。

治疗持续21天。

针对经选择患者组全部患者的治疗推荐

所有患者都应该给于皮质类固醇，越早越好，最好在头 72 小时内用药。[99]Ewald H, Raatz H, Boscacci R, et al. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV infection. Cochrane Database Syst Rev. 2015;(4):CD006150.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006150.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/25835432?tool=bestpractice.com证据 A疗效：高质量的证据表明，在中-重度肺囊虫肺炎（PCP）应用糖皮质激素辅助治疗有助于减少1-3个月死亡率和机械通气的使用。[102]Briel M, Bucher HC, Boscacci R, et al. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection. Cochrane Database Syst Rev. 2006(3):CD006150.http://www.ncbi.nlm.nih.gov/pubmed/16856118?tool=bestpractice.com系统评价或者受试者＞200名的随机对照临床试验（RCT）。

室内空气状态下，当PO2≥70mmHg或肺泡-动脉(A-a)氧分压差≤35mmHg。

治疗选择甲氧苄啶/磺胺甲恶唑（TMP/SMX）。[42]National Institutes of Health; Centers for Disease Control and Prevention; HIV Medicine Association of the Infectious Diseases Society of America; Pediatric Infectious Diseases Society; American Academy of Pediatrics. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. 2013. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf

如果儿童不能耐受TMP/SMX或治疗5-7天后临床治疗失败，可选用替代治疗。[42]National Institutes of Health; Centers for Disease Control and Prevention; HIV Medicine Association of the Infectious Diseases Society of America; Pediatric Infectious Diseases Society; American Academy of Pediatrics. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. 2013. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf然在氯林可霉素和氨苯砜在儿童中应用尚缺乏数据。

在使用伯氨喹或氨苯砜之前，如有可能，所有患者都应检查葡萄糖-6-磷酸脱氢酶（G6PD）是否缺乏。

阿托伐醌不应与利福平或利福布丁联合使用。[92]Benfield T, Atzori C, Miller RF, et al. Second-line salvage treatment of AIDS-associated Pneumocystis jiroveci pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008;48:63-67.http://www.ncbi.nlm.nih.gov/pubmed/18360286?tool=bestpractice.com

新生儿剂量咨询指导专家。

治疗持续21天。

室内空气状态下，当PO2＜70mmHg或肺泡-动脉(A-a)氧分压差＞35mmHg。

儿童出现呼吸急促应住院，可能需要转入ICU并进行机械通气。

无法耐受甲氧苄啶/磺胺甲恶唑（TMP/SMX）或TMP/SMX治疗5-7天失败的患者可进行替代治疗。[42]National Institutes of Health; Centers for Disease Control and Prevention; HIV Medicine Association of the Infectious Diseases Society of America; Pediatric Infectious Diseases Society; American Academy of Pediatrics. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. 2013. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf

在使用伯氨喹之前，如有可能，所有患者都应检查葡萄糖-6-磷酸脱氢酶（G6PD）是否缺乏。

阿托伐醌不应与利福平或利福布丁联合使用。[92]Benfield T, Atzori C, Miller RF, et al. Second-line salvage treatment of AIDS-associated Pneumocystis jiroveci pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008;48:63-67.http://www.ncbi.nlm.nih.gov/pubmed/18360286?tool=bestpractice.com

新生儿剂量咨询指导专家。

治疗持续21天。

针对经选择患者组全部患者的治疗推荐

所有患者都应该给于皮质类固醇，越早越好，最好在头 72 小时内用药。[42]National Institutes of Health; Centers for Disease Control and Prevention; HIV Medicine Association of the Infectious Diseases Society of America; Pediatric Infectious Diseases Society; American Academy of Pediatrics. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. 2013. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf

患者出现呼吸功能损害应住院，可能需要转入ICU并进行机械通气。

HIV阴性患者发生PCP首选治疗也是TMP/SMX或静脉注射喷他脒。替代治疗类似于HIV阳性患者。

无法耐受甲氧苄啶/磺胺甲恶唑（TMP/SMX）或TMP/SMX治疗4-8天失败的患者可进行替代治疗。[20]Gilmartin GS, Koziel H. Pneumocystis carinii pneumonia in adult non-HIV disorders. J Intensive Care Med. 2002;17:283-301.

在使用伯氨喹或氨苯砜之前，如有可能，所有患者都应检查葡萄糖-6-磷酸脱氢酶（G6PD）是否缺乏。

阿托伐醌不应与利福平或利福布丁联合使用。[92]Benfield T, Atzori C, Miller RF, et al. Second-line salvage treatment of AIDS-associated Pneumocystis jiroveci pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008;48:63-67.http://www.ncbi.nlm.nih.gov/pubmed/18360286?tool=bestpractice.com

治疗持续14-21天。

针对经选择患者组全部患者的治疗推荐

HIV阴性PCP患者使用糖皮质激素辅助治疗一直存在争议，一项回顾性报告显示免疫抑制成人患者随着糖皮质激素应用增加，其恢复也更快。[21]Pareja JGR, Garland R, Koziel H. Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia. Chest. 1998;113:1215-1224.http://www.ncbi.nlm.nih.gov/pubmed/9596297?tool=bestpractice.com

PCP患者中已经接受治疗或无症状者需要进行二级预防，治疗方案与一级预防每组患者相同。

HIV阳性患者感染PCP时需要进行二级预防，应与PCP治疗同时进行，并在治疗停止后仍继续预防，当进行抗逆转录病毒疗法重建免疫时，可暂停二级预防。[42]National Institutes of Health; Centers for Disease Control and Prevention; HIV Medicine Association of the Infectious Diseases Society of America; Pediatric Infectious Diseases Society; American Academy of Pediatrics. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. 2013. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf[43]Centers for Disease Control and Prevention; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. May 2016. http://aidsinfo.nih.gov/guidelines (last accessed 5 June 2016).http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf[101]Benson CA, Kaplan JE, Masur H, et al. Treating opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine. Clin Infect Dis. 2005;40:S131.http://cid.oxfordjournals.org/content/40/Supplement_3/S131.full

当患者免疫重建且CD4细胞计数连续3个月超过200个细胞/μl时，可停止二级预防。尽管免疫重建，但对于仍有发生PCP危险的患者应在生活中继续进行预防。