Research Article|Articles in Press

Rising incidence of Pneumocystis pneumonia: A population-level descriptive ecological study in England

Published:February 10, 2023DOI:



      Pneumocystis pneumonia (PCP) is an opportunistic infection that causes significant morbidity and mortality in the immunocompromised population. This population is growing and diversifying, yet contemporary epidemiology is lacking. We investigated the population-level incidence of PCP over the past decade.


      We conducted a descriptive study of all hospital admissions in England from April 2012 to March 2022. PCP episodes, age, median length of stay, gender and episodes of other respiratory fungal infections were collected. Consumption of Trimethoprim-Sulfamethoxazole was obtained between January 2019 and May 2022.


      The incidence of PCP increased from 2·2–4·5/100,000 population between 2012/2013 and 2019/2020 (p < 0·0001). There was a drop in 2020/2021 to 2·7/100,000 before returning to 3.9/100,000 in 2021/2022. PCP episodes rose as a proportion of all-cause admissions as well as a proportion of episodes due to other fungal infections. The proportion of PCP patients aged 75+ increased from 14% to 26%. The median length of stay was 13.5 days. Consumption of intravenous Trimethoprim-Sulfamethoxazole increased from 0.24 × 100,000 to 0.30 × 100,000 defined daily doses.


      The incidence of PCP is rising rapidly and represents a significant burden to the healthcare system. Further study into who is at risk of PCP is needed to better determine who should be given prophylaxis.


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        • Liu Y.
        • Jiang S.
        • Qu H.
        Risk factors for mortality from pneumocystis carinii pneumonia (PCP) in non-HIV patients: a meta-analysis.
        Oncotarget. 2017; 8: 59729-59739
        • Roblot F.
        • Godet C.
        • Le Moal G.
        • Garo B.
        • Faouzi Souala M.
        • Dary M.
        • et al.
        Analysis of underlying diseases and prognosis factors associated with Pneumocystis carinii pneumonia in immunocompromised HIV-negative patients.
        Eur J Clin Microbiol Infect Dis. 2002; 21: 523-531
        • Sepkowitz K.A.
        Opportunistic infections in patients with and patients without acquired immunodeficiency syndrome.
        Clin Infect Dis. 2002; 34: 1098-1107
        • Dunbar A.
        • Schauwvlieghe A.
        • Algoe S.
        • van Hellemond J.J.
        • Reynders M.
        • Vandecasteele S.
        • et al.
        Epidemiology of Pneumocystis jirovecii pneumonia and (non-)use of prophylaxis.
        Front Cell Infect Microbiol. 2020; 10: 224
        • Nunes J.
        • Issa N.
        • Dupuis A.
        • Accoceberry I.
        • Pedeboscq S.
        Pneumocystis in the era of prophylaxis: do the guidelines have to change?.
        Infection. 2022; 50: 995-1000
        • Rutherford A.I.
        • Patarata E.
        • Subesinghe S.
        • Hyrich K.L.
        • Galloway J.B.
        Opportunistic infections in rheumatoid arthritis patients exposed to biologic therapy: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis.
        Rheumatology. 2018; 57: 997-1001
        • White P.L.
        • Price J.S.
        • Backx M.
        Pneumocystis jirovecii Pneumonia: epidemiology, clinical manifestation and diagnosis.
        Current Fungal Infect Rep. 2019; 13: 260-273
        • Kaplan J.E.
        • Hanson D.L.
        • Navin T.R.
        • Jones J.L.
        Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis.
        J Infect Dis. 1998; 178: 1126-1132
        • Stern A.
        • Green H.
        • Paul M.
        • Vidal L.
        • Leibovici L.
        Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients.
        Cochrane Database Syst Rev. 2014; CD005590
      1. World Health Organisation. Consolidated guidelines on HIV prevention, testing, service delivery and monitoring 2021 [Available from: 〈〉.

        • Kaplan J.E.
        • Hanson D.
        • Dworkin M.S.
        • Frederick T.
        • Bertolli J.
        • Lindegren M.L.
        • et al.
        Epidemiology of human immunodeficiency virus-associated opportunistic infections in the United States in the era of highly active antiretroviral therapy.
        Clin Infect Dis. 2000; 30: S5-14
        • Bitar D.
        • Lortholary O.
        • Le Strat Y.
        • Nicolau J.
        • Coignard B.
        • Tattevin P.
        • et al.
        Population-based analysis of invasive fungal infections, France, 2001-2010.
        Emerg Infect Dis. 2014; 20: 1149-1155
        • Pereira-Diaz E.
        • Moreno-Verdejo F.
        • de la Horra C.
        • Guerrero J.A.
        • Calderon E.J.
        • Medrano F.J.
        Changing trends in the epidemiology and risk factors of Pneumocystis pneumonia in Spain.
        Front Public Health. 2019; 7: 275
        • Maini R.
        • Henderson K.L.
        • Sheridan E.A.
        • Lamagni T.
        • Nichols G.
        • Delpech V.
        • et al.
        Increasing Pneumocystis pneumonia, England, UK, 2000-2010.
        Emerg Infect Dis. 2013; 19: 386-392
        • Kolbrink B.
        • Scheikholeslami-Sabzewari J.
        • Borzikowsky C.
        • von Samson-Himmelstjerna F.A.
        • Ullmann A.J.
        • Kunzendorf U.
        • et al.
        Evolving epidemiology of pneumocystis pneumonia: findings from a longitudinal population-based study and a retrospective multi-center study in Germany.
        Lancet Reg Health Eur. 2022; 18100400
      2. Office for National Statistics. Population Estimates 2022 [Available from: 〈〉.

        • Gronseth S.
        • Rogne T.
        • Hannula R.
        • Asvold B.O.
        • Afset J.E.
        • Damas J.K.
        Epidemiological and clinical characteristics of immunocompromised patients infected with Pneumocystis jirovecii in a twelve-year retrospective study from Norway.
        BMC Infect Dis. 2021; 21: 659
        • Scott I.C.
        • Whittle R.
        • Bailey J.
        • Twohig H.
        • Hider S.L.
        • Mallen C.D.
        • et al.
        Rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis epidemiology in England from 2004 to 2020: An observational study using primary care electronic health record data.
        Lancet Reg Health Eur. 2022; 23100519
        • Freeman K.
        • Ryan R.
        • Parsons N.
        • Taylor-Phillips S.
        • Willis B.H.
        • Clarke A.
        The incidence and prevalence of inflammatory bowel disease in UK primary care: a retrospective cohort study of the IQVIA Medical Research Database.
        BMC Gastroenterol. 2021; 21: 139
      3. Statistics OfN. Cancer registration statistic, England 2017. 2017.

        • Zhao M.
        • Sall Jensen M.
        • Knudsen T.
        • Kelsen J.
        • Coskun M.
        • Kjellberg J.
        • et al.
        Trends in the use of biologicals and their treatment outcomes among patients with inflammatory bowel diseases – a Danish nationwide cohort study.
        Aliment Pharmacol Ther. 2022; 55: 541-557
        • de la Torre B.G.
        • Albericio F.
        The pharmaceutical industry in 2021. An analysis of FDA drug approvals from the perspective of molecules.
        Molecules. 2022; 27
      4. UKHSA. HIV testing, new HIV diagnoses, outcomes and quality of care for people accessing HIV services: 2021report. 2021.

      5. Public Health England. Microbiology Diagnostic Standards 2015 [Available from: 〈〉.

        • Kingston A.
        • Robinson L.
        • Booth H.
        • Knapp M.
        • Jagger C.
        • MODEM Project
        Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model.
        Age Ageing. 2018; 47: 374-380
      6. Excellence NIfHCa. Technology appraisal: Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed. 2021.

      7. NHS Improvment. National prices and national tariff workbook 2020 [Available from: 〈〉.

        • Herbert A.
        • Wijlaars L.
        • Zylbersztejn A.
        • Cromwell D.
        • Hardelid P.
        Data resource profile: hospital episode statistics admitted patient care (HES APC).
        Int J Epidemiol. 2017; 46: 1093
        • Burns E.M.
        • Rigby E.
        • Mamidanna R.
        • Bottle A.
        • Aylin P.
        • Ziprin P.
        • et al.
        Systematic review of discharge coding accuracy.
        J Public Health. 2012; 34: 138-148