Echinocandins as alternative treatment for Pneumocystis in HIV-infected patients?

In a Taiwanese study, 34 HIV-positive patients with Pneumocystis
Pneumonia (PCP) who were intolerant (25/34) or who
were unresponsive (9/34) to trimethoprim-sulfamethoxazole
(TMP-SMX) were treated with echinocandins alone or in combination
with other agents. The median CD4 count was 27 cells/
μL and 70.6 % had moderate to severe PCP. Two patients received
only echinocandins during the whole treatment course.
21 patients received monotherapy with echinocandins after
switching from TMP-SMX. The remaining 11 patients had
combination therapy including clindamycin and/or dapsone
or continued TMP-SMX. The median duration of TMP-SMX
before treatment switch was 9 (5-14) days. All cause in-hospital
mortality was 0 % in mild PCP and 29 % in moderate to severe
PCP. The 2 patients who received monotherapy with
echinocandins during the whole treatment course both recovered
and survived. The mortality was similar between those
who were switched to echinocandin monotherapy (17.4 %) and
those who were switched to combination therapy with TMPSMX
(16.7 %).The most commonly used echinocandin was anidulafungin,
followed by caspofungin, and micafungin.

Ref; Huang et al. AIDS 2019;33:1345-1351c

Comment: It is still unclear whether combination therapy with
TMP-SMX and echinocandines is of any benefit compared to
continued TMP-SMX monotherapy in patients with poor response
to treatment. In patients who are intolerant to TMPSMX
echinocandins may be an alternative treatment but further
studies are required to confirm this. It is promising that
two patients who were treated with echinocandin monotherapy
during the whole treatment course both recovered and
survived, but still not enough to recommend echinocandins as
alternative treatment for PCP in HIV infected patients.