Pneumocystis jirovecii pneumonia prophylaxis in patients with glioma receiving concurrent chemoradiation: a systematic review and meta-analysis.
systematic_review · Level I
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- Record sourced from PubMed, PMID 41542224.
- Also identified by DOI 10.1016/j.eclinm.2025.103715 and PMC identifier 12803824.
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Abstract
Routine antibiotic prophylaxis against <i>pneumocystis jirovecii</i> pneumonia (PJP) is recommended during concurrent temozolomide and radiotherapy (TMZ-RT) for glioma based on early small studies. However, true PJP risk may be far lower, raising questions about the value and harms of universal prophylaxis. We conducted a systematic review (PROSPERO: CRD42021292396) of studies reporting PJP incidence among glioma patients treated with TMZ-RT. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to May 1, 2025. Outcomes included overall PJP incidence and rates stratified by prophylaxis, corticosteroid exposure, and lymphopenia. Of 3791 records, 35 studies (13,637 patients, 12,301 received TMZ-RT) met eligibility criteria. Across 24 studies confirming PJP, 71 cases occurred among 12,056 TMZ-RT patients-a pooled incidence of 0.74% (95% CI, 0.59-0.93%) with minimal heterogeneity (Q = 23.3, p = 0.44; I<sup>2</sup> = 1.4%). Seventeen studies detailed prophylaxis: 55.1% (2942/5341) of patients received it; PJP incidence was 0.8% (14/1765) with versus 0.3% (9/2719) without prophylaxis. Baseline corticosteroid exposure was reported in 13 studies (n = 5908: median 49.5%, range 27.3%-82.3%), and grade 3-4 lymphopenia in 15.2% (319/2102) of TMZ-RT patients. Incomplete study-level reporting precluded robust risk factor-adjusted analyses. Across heterogeneous populations and study designs, the pooled PJP incidence associated with TMZ-RT was 0.74% (95% CI, 0.59-0.93%). Due to the heterogeneity in study populations and designs, lack of standardized diagnostic confirmation, and incomplete reporting of steroid administration, this finding should be interpreted with caution. Currently available evidence suggests the risk of PJP is lower than the commonly cited 3.5% threshold for prophylaxis. Well-designed prospective studies are needed to clarify true infection risk and inform prophylaxis decisions. The Deanship of Graduate Studies and Scientific Research at Qassim University provided financial support for the article processing charge (APC) of this manuscript.