Increasing Pneumocystis Pneumonia, England, UK, 2000–2010

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Learning Objectives

Upon completion of this activity, participants will be able to:
• Describe changes in incidence of Pneumocystis jirovecii pneumonia in England from 2000–2010, based on findings of a database study
• Describe changes in risk factors associated with P. jirovecii pneumonia in England from 2000–2010, based on findings of a database study
• Describe the clinical and public health implications of the study findings.

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Authors

Disclosures: Rishma Maini, MBChB; Katherine L. Henderson, MSc; Elizabeth A. Sheridan, MBBS, FRCPath; Theresa Lamagni, MSc, PhD; Gordon Nichols, PhD; Valerie Delpech, MBBS, MPH, FPHM; and Nick Phin, MBChB, LLM, have disclosed no relevant financial relationships.

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Volume 19, Number 3– March 2013

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Increasing Pneumocystis Pneumonia, England, UK, 2000–2010 - Vol. 19 No. 3 - March 2013 - Emerging Infectious Disease journal - CDC

Increasing Pneumocystis Pneumonia, England, UK, 2000–2010

Rishma Maini, Katherine L. Henderson

, Elizabeth A. Sheridan, Theresa Lamagni, Gordon Nichols, Valerie Delpech, and Nick Phin

Author affiliations: Author affiliations: Health Protection Agency, London, UK (R. Maini, K.L. Henderson, E.A. Sheridan, T. Lamagni, G. Nichols, V. Delpech, N. Phin); University of Chester, Chester, UK (N. Phin)

Abstract

After an increase in the number of reported cases of Pneumocystis jirovecii pneumonia in England, we investigated data from 2000–2010 to verify the increase. We analyzed national databases for microbiological and clinical diagnoses of P. jirovecii pneumonia and associated deaths. We found that laboratory-confirmed cases in England had increased an average of 7% per year and that death certifications and hospital admissions also increased. Hospital admissions indicated increased P. jirovecii pneumonia diagnoses among patients not infected with HIV, particularly among those who had received a transplant or had a hematologic malignancy. A new risk was identified: preexisting lung disease. Infection rates among HIV-positive adults decreased. The results confirm that diagnoses of potentially preventable P. jirovecii pneumonia among persons outside the known risk group of persons with HIV infection have increased. This finding warrants further characterization of risk groups and a review of P. jirovecii pneumonia prevention strategies.

Anecdotal reports from clinicians suggest that incidence of Pneumocystis jirovecii pneumonia, previously referred to as P. carinii pneumonia or PCP, among immunosuppressed patients, especially renal transplant recipients, has increased substantially (1). To investigate this claim, we analyzed data for January 2000 through December 2010, using several national data sources: Hospital Episode Statistics, routine laboratory reporting, death certificate data, and HIV surveillance data.
P. jirovecii pneumonia gained notoriety during the AIDS pandemic (2); however, the reservoirs, modes of transmission, and pathogenesis of this organism remain poorly understood (3). Subclinical infection is considered common because studies have shown that anti–P. jirovecii antibodies develop during early childhood (4). Reactivation of latent infection after immunosuppression of the host was thought to be the main pathogenic mechanism (3); however, recent studies indicate that person-to-person spread might cause acute infection in susceptible persons (5).
Although not fully characterized, the known risk factors for P. jirovecii infection include impaired immunity because of HIV infection, hematologic malignancies, and connective tissue disorders (6). Immunosuppressive agents used to treat or prevent graft rejection have been implicated; such agents include corticosteroids, methotrexate, cyclosporine, mycophenolate mofetil, bendamustine, cyclophosphamide (7–11), and, recently, novel immunomodulating drugs, such as tumor necrosis factor–α inhibitors (12).
Prophylactically administered oral trimethoprim–sulfamethoxazole, dapsone, or atovaquone prevent the clinical manifestation of P. jirovecii infection. Also effective for decreasing P. jirovecii infection incidence among HIV-positive patients with a CD4⁺ count <200 a="" administration="" antimicrobial="" drugs="" href="http://wwwnc.cdc.gov/eid/article/19/3/12-1151_article.htm#r13" is="" of="" prophylactic="" routine="" title="13">13
,14). Given the existence of effective chemoprophylaxis, identification of new risk groups might help prevent future increases in P. jirovecii infection incidence. Therefore, we conducted a retrospective analysis of multiple national data sources to examine trends in P. jirovecii infection.
The Health Protection Agency has approval from the National Information Governance Board for Health and Social Care for the collation of surveillance data in accordance with section 251 of the National Health Service Act 2006. No additional ethical approval was required for this study.