Research ArticleArticles

A Survey of Rheumatologists’ Practice for Prescribing Pneumocystis Prophylaxis

DEANNA CETTOMAI, ALLAN C. GELBER and LISA CHRISTOPHER-STINE
The Journal of Rheumatology April 2010, 37 (4) 792-799; DOI: https://doi.org/10.3899/jrheum.090843

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Among 505 rheumatologists who prescribe PCP prophylaxis, the proportions (%) reporting that a given factor was the most important influence in their decision to prescribe prophylaxis. OI: opportunistic infections.

  • Figure 2.
    Figure 2.

    Among 505 rheumatologists who prescribe PCP prophylaxis, the proportion using prophylaxis according to rheumatologic diagnoses (A), medication regimens (B), prednisone doses (C), and other clinical factors (D).

Tables

  • Table 1.

    Questions included in the survey of US rheumatologists. Possible responses are listed in parentheses.

    1.In which region of the country do you practice?
      (Southwest; Northwest; Midwest; Southeast; Mid-Atlantic; Northeast; Alaska/Hawaii; International)
    2.What is your gender?
      (male/female)
    3.In which type of practice do you work?
      (academic; hospital-based; solo private practice; group specialty practice; other)
    4.Including fellowship, for how many years have you been practicing rheumatology?
      (< 5 yrs; 5–10 yrs; 10–15 yrs; 15–20 yrs; > 20 yrs)
    5.On average, approximately how many patients with a rheumatologic diagnosis do you see each week?
      (< 5 pts; 5–10 pts; 10–15 pts; > 20 pts)
    6.Approximately what percentage of the patients you care for are managed on chronic glucocorticoids?
      (< 10%; 10–25%; 25–50%; 50–75%; 75–90%; > 70%)
    7.Approximately what percentage of the patients you care for are managed on other immunosuppressive agents, including cyclophosphamide, methotrexate, azathioprine, and mycophenolate?
      (< 10%; 10–25%, 25–50%; 50–75%; 75–90%; > 90%)
    8.Have any of your patients ever developed Pneumocystis jirovecii pneumonia (PCP)?
      (no; yes; if yes, please specify how many)
    9.Do you prescribe chemoprophylaxis for PCP? If yes, please specify what prophylaxis method you prefer.
      (no; yes – with trimethoprim/sulfamethoxazole once daily; yes – with trimethoprim/sulfamethoxazole 3 times per week; yes – with aerosolized pentamidine; yes – with another prophylactic medication. Please specify)
    10.For which underlying conditions are you most likely to prescribe PCP chemoprophylaxis? (mark all that apply)
      (systemic lupus erythematosus; rheumatoid arthritis; psoriatic arthritis; Wegener’s granulomatosis; polyarteritis nodosa; microscopic polyangiitis; other systemic vasculitides; scleroderma; dermatomyositis; polymyositis; other myositis; other. Please specify; rheumatologic diagnosis does not affect my decision to prescribe or not prescribe PCP chemoprophylaxis; I do not prescribe PCP chemoprophylaxis)
    11.With which treatment regimens are you likely to prescribe PCP chemoprophylaxis? (mark all that apply)
      (prednisone alone; prednisone in combination with another immunosuppressant agent; methotrexate; cyclophosphamide; azathioprine; mycophenolate; TNF-alpha inhibitors; cyclosporine; 6-mercaptopurine; rituximab; other. Please specify; treatment regimen does not affect my decision to prescribe or not prescribe PCP chemoprophylaxis)
    12.At what dose of prednisone are you likely to prescribe PCP chemoprophylaxis?
      (≥ 5 mg/day; ≥ 10 mg/day; ≥ 15 mg/day; ≥ 20 mg/day; ≥ 30 mg/day; ≥ 40 mg/day; ≥ 50 mg/day; other. Please specify; prednisone dosage does not affect my decision to prescribe or not prescribe PCP chemoprophylaxis; I do not prescribe PCP chemoprophylaxis)
    13.What laboratory data do you use when deciding whether to prescribe PCP chemoprophylaxis? (please mark all that apply)
      (peripheral blood absolute lymphocyte count; peripheral blood CD4 T cell count; other. Please specify; laboratory data does not affect my decision to prescribe or not prescribe PCP chemoprophylaxis; I do not prescribe PCP chemoprophylaxis)
    14.What other clinical data not mentioned above makes you more likely to prescribe PCP chemoprophylaxis? (please mark all that apply)
      (history of PCP; history of other opportunistic infection; history of interstitial pulmonary fibrosis; other. Please specify; other clinical data does not affect my decision to prescribe or not prescribe PCP chemoprophylaxis; I do not prescribe PCP chemoprophylaxis)
    15.What is the most important factor in your decision as to whether or not to prescribe PCP chemoprophylaxis?
      (underlying condition; treatment regimen; dose of medication; laboratory data; history of PCP; history of other opportunistic infections; history of interstitial pulmonary fibrosis; other. Please specify; I do not prescribe PCP chemoprophylaxis)
  • Table 2.

    Demographic characteristics of respondents and nonrespondents to the PCP survey.

    CharacteristicSurvey Respondents, n = 727, n (%)Survey Nonrespondents n = 2423, n (%)p
    Geographic region
      Southwest74 (10.2)235 (9.7)< 0.001
      Northwest48 (6.6)133 (5.5)
      Midwest142 (19.5)310 (12.7)
      Southeast119 (16.4)276 (11.3)
      Mid-Atlantic44 (6.0)278 (11.5)
      Northeast152 (20.9)144 (6.0)
      Alaska/Hawaii4 (0.6)2 (0.0)
      International135 (18.6)421 (17.4)
      No response9 (1.2)624 (25.8)
    Sex
      Male460 (63.3)1201 (49.6)< 0.001
      Female255 (35.1)604 (24.9)
      No response12 (1.6)618 (25.5)
    Type of practice
      Acedemic306 (42.1)395 (16.3)< 0.001
      Hospital-based89 (12.2)174 (7.2)
      Solo private83 (11.4)291 (12.0)
      Group specialty206 (28.3)543 (22.4)
      Other36 (5.0)220 (9.1)
      No response7 (1.0)800 (33.0)
    Years in practice*
      < 5129 (17.7)NANA
      5–10109 (15.0)
      10–1581 (11.1)
      15–20125 (17.2)
      > 20271 (37.3)
      No response12 (1.7)

    • ↵* Data not available on nonrespondents. PCP: Pneumocystis pneumonia; NA: not applicable.

  • Table 3.

    Association of demographic characteristics among 727 surveyed rheumatologists with the decision to prescribe PCP prophylaxis.

    Demographic CharacteristicPrescribe PCP Prophylaxis n (%)*Univariate Logistic RegressionMultivariate Logistic Regression
    OR (95% CI)pOR (95% CI)p
    Female191 (74.9)1.47 (1.04, 2.08)0.031.01 (0.68, 1.50)0.97
    Male308 (67.0)
    US-based practice420 (72.0)1.77 (1.20, 2.61)0.0041.97 (1.27, 3.05)0.003
    Internationally based practice80 (59.2)
    Acedemic practice248 (81.0)2.75 (1.94, 3.89)< 0.0011.81 (1.23, 2.66)0.003
    Nonacademic practice252 (60.9)
    ≤ 10 years in practice206 (86.6)4.08 (2.69, 6.18)< 0.0014.13 (2.62, 6.51)< 0.001
    > 10 years in practice292 (61.2)
    ≥ 10% patients on chronic glucocorticoids414 (72.8)2.04 (1.40, 2.96)< 0.0012.11 (1.38, 3.23)0.001
    < 10% patients on chronic glucocorticoids84 (56.8)
    ≥ 10% patients on other immunosuppressants488 (70.5)3.19 (1.48, 6.86)0.0032.26 (0.98, 5.26)0.06
    < 10% patients on other immunosuppresants12 (42.8)
    Caring previously for a patient who developed PCP159 (82.8)2.62 (1.73, 3.98)< 0.0013.04 (1.92, 4.82)< 0.001
    Never caring for a patient who developed PCP345 (64.7)
    ≤ 10 patients with rheumatologic diagnosis under clinical care each week43 (76.8)1.48 (0.78, 2.82)0.23—**—
    > 10 patients with rheumatologic diagnosis under clinical care each week455 (69)

    • ↵* Among survey respondents, the proportion with each characteristic who reported prescribing PCP prophylaxis.

    • ↵** Number of patients with a rheumatologic diagnosis was not included in the final multivariate analysis because this variable did not achieve statistical significance in the univariate analysis.

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