Session Information
Session Type: ACR Poster Session C
Session Time: 9:00AM-11:00AM
Background/Purpose: Pneumocystis
pneumonia (PCP) is a potentially devastating opportunistic infection. The
incidence of PCP and the risk of adverse events secondary to prophylactic
medication in children with rheumatic disease are unknown. As a result, healthcare
providers must make the decision about providing prophylaxis on a case by case
basis without formal guidelines. The objective of this study was to
describe current prescribing habits of PCP prophylaxis among pediatric
rheumatologists. We hypothesized that significant variation exists in the
prescribing of PCP prophylaxis.
Methods: We
performed a cross sectional survey of pediatric rheumatologists in the
Childhood Arthritis & Rheumatology Alliance (CARRA). CARRA is an
alliance of pediatric rheumatologists in the United States and Canada. A
questionnaire was administered using REDCAP, a secure web based research
platform. The anonymous survey ascertained basic demographic and PCP
prophylaxis prescribing habits. After approval by the IRB and CARRA, the
questionnaire was piloted and then distributed via an email in May 2015.
A reminder email was sent 2 weeks later to members who had not responded to the
questionnaire. Descriptive analysis was performed using STATA v 13.1
(Stat Corp; College Station TX).
Results: The
questionnaire was sent to 280 pediatric rheumatologists and 76 (27%) responded;
results are shown in Table. Most respondents practice at an academic
medical center (N=74, 97%) and 66 (87%) of pediatric rheumatologists prescribe
PCP prophylaxis. Only nine (12%) report institutional prescribing
guidelines. The most common indications listed for prescribing
prophylaxis were for use of cyclophosphamide (42%) or a diagnosis of
Granulomatosis with Polyangiitis (38%). Trimethoprim-sulfamethoxazole
was the most common first line prophylactic agent prescribed (N=68, 91%).
Indications for initiation of PCP prophylaxis are diverse. Thirty-three
(43%) respondents indicated prescribing in the setting of a specific
medication, thirty-seven (49%) for a specific combination of medications,
twenty-six (34%) a specific laboratory threshold and thirty-one (41%) for a
specific disease.
Conclusion: We
found significant variation in prescribing habits of PCP prophylaxis between
pediatric rheumatologists in the United States and Canada. While most
providers prescribe prophylaxis, we found that 13% do not. Common reasons
given why prophylaxis was not prescribed include a perceived low risk of
infection and that they have never seen a PCP infection before in
practice. Future studies aimed at identifying the incidence of PCP in
children with rheumatic disease and the incidence of adverse events associated
with the prophylactic agents are needed to inform the development of evidence
based guidelines for PCP prophylaxis prescribing.
|
Table. Characteristics of Pediatric Rheumatology Respondents and Responses (n=76)
|
|
|
Characteristic
|
N (%)
|
|
Years in Practice |
|
|
Currently in training – 5 years
|
30 (39%) |
|
6 – 10 years
|
11 (14%) |
|
11 – 20 years
|
15 (20%) |
|
21 – 30 years
|
15 (20%) |
|
30 + years
|
5 (6%) |
|
Average number of patients seen per week |
|
|
0–15
|
24 (32%) |
|
16-30
|
36 (48%) |
|
31-45
|
9 (12%) |
|
46-60
|
5 (7%) |
|
60+
|
1 (1%) |
|
What prompts you to start PCP prophylaxis? |
|
|
Specific medication monotherapy
|
33 (43%) |
|
Specific medication combination
|
37 (49%) |
|
Laboratory value threshold
|
26 (34%) |
|
Specific disease
|
31 (41%) |
|
Which specific monotherapy prompts you to prescribe PCP prophylaxis? |
|
|
Chronic Glucocorticoids > 20 mg daily
|
1 (1%) |
|
Chronic Glucocorticoids ≥ 2 mg/kg daily
|
4 (5%) |
|
Methotrexate
|
1 (1%) |
|
Rituximab
|
7 (9%) |
|
Mycophenolate Mofetil
|
1 (1%) |
|
Cyclophosphamide
|
31 (41%) |
|
Which specific medication combination prompts you to prescribe PCP prophylaxis? |
|
|
TNF Inhibitor and Methotrexate
|
1 (1%) |
|
TNF Inhibitor and Glucocorticoids
|
2 (3%) |
|
TNF Inhibitor and Azathioprine
|
2 (3%) |
|
TNF Inhibitor and Calcineurin Inhibitor
|
2 (3%) |
|
Glucocorticoids and:
|
|
|
Rituximab
|
12 (16%) |
|
Cyclophosphamide
|
33 (43%) |
|
Calcineurin Inhibitor
|
5 (7%) |
|
Methotrexate
|
4 (5%) |
|
Azathioprine
|
4 (5%) |
|
Mycophenolate Mofetil
|
7 (9%) |
|
Anti-IL1 Therapy
|
2 (3%) |
|
Anti-IL6 Therapy
|
3 (4%) |
|
Which laboratory threshold prompts you to prescribe PCP prophylaxis? |
|
|
Absolute Neutrophil Count < 1000 / µL
|
4 (5%) |
|
Absolute Lymphocyte Count < 1000 / µL
|
15 (20%) |
|
CD4 Count < 200 / µL
|
11 (14%) |
|
Which specific disease prompts you to prescribe PCP prophylaxis? |
|
|
Juvenile Dermatomyositis
|
6 (8%) |
|
Systemic Lupus Erythematosus
|
7 (9%) |
|
Juvenile Idiopathic Arthritis
|
1 (1%) |
|
Granulomatosis with Polyangiitis
|
27 (36%) |
|
Other Vasculitis
|
8 (11%) |
|
When do you stop PCP prophylaxis |
|
|
Discontinuation of medication that prompted initiation
|
49 (65%) |
|
Improvement in clinical condition
|
2 (3%) |
|
Improvement in laboratory value that prompted initiation
|
15 (20%) |
|
Legend: Responses from Pediatric Rheumatology physicians describing PCP prophylaxis prescribing habits. PCP, Pneumocystis carinii (jiroveci) Pneumonia; TNF, Tumor Necrosis Factor
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To cite this abstract in AMA style:
Basiaga M, Ogdie-Beatty A. Views and Prescribing Habits of Pneumocystis Prophylaxis in the Pediatric Rheumatology Community [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). https://acrabstracts.org/abstract/views-and-prescribing-habits-of-pneumocystis-prophylaxis-in-the-pediatric-rheumatology-community/. Accessed .« Back to 2015 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/views-and-prescribing-habits-of-pneumocystis-prophylaxis-in-the-pediatric-rheumatology-community/