A trial of caspofungin salvage treatment in PCP pneumonia

Pneumocystis jirovecii pneumonia (PCP) remains a major cause of mortality in patients with HIV; we read with enormous interest the recent PCP mortality prediction rule stratifying 451 patients by mortality at the time of illness presentation.1 The first-line treatment for this infection, cotrimoxazole, is associated with a number of adverse effects, including rash, leucopenia, thrombocytopenia and interstitial nephritis.2 Therefore, treatment with cotrimoxazole significantly adds to the morbidity associated with this condition and we note in this study that this was the main treatment used. One of the identifying characteristics of P jirovecii is the presence of (1,3)-β-d-glucan in its cell wall.3 As the cell wall of this organism does not contain ergosterol (the target of azoles and polyenes), echinocandins, which target the synthesis of (1,3)-β-d-glucan, are likely to be the only effective antifungals for PCP.4 Caspofungin was the first echinocandin licensed for empiric antifungal treatment in candidiasis and aspergillosis. In animal …