A Quality Improvement Initiative to Standardize Pneumocystis jirovecii Pneumonia Prophylaxis in Pediatric Patients With Solid Tumors

Abstract

Background: Pediatric patients with extracranial solid tumors (ST) receiving chemotherapy are at an increased risk for Pneumocystis jirovecii pneumonia (PJP). However, evidence guiding prophylaxis practices in this population is limited. A PJP-related fatality at our institution highlighted inconsistent prescribing approaches and concerns about prophylaxis-related toxicity, prompting the development of a quality improvement (QI) initiative to standardize PJP prophylaxis for patients with ST. Procedure: Our quality improvement (QI) initiative aimed to increase PJP prophylaxis initiation rates in pediatric patients (0–18 years) with newly diagnosed extracranial ST (excluding osteosarcoma) to over 90%, without associated chemotherapy delays or significant prophylaxis-related toxicity. The initiative was designed using the Model for Improvement with monthly Plan–Do–Study–Act cycles. Interventions included regular stakeholder engagement, education, and electronic health record (EHR)-integrated prophylaxis prescriptions. Balancing measures, including discontinuation rates of prophylaxis, related toxicity, and chemotherapy delays, were assessed through clinician surveys and chart review. Kotter's 8-Step Change Model secured engagement during planning and implementation of this 6-month (April–September 2024) initiative across inpatient and outpatient settings in a tertiary oncology center. Results: PJP prophylaxis was initiated in 100% (n = 20) of eligible patients, an 88.7% relative improvement in coverage, compared to initiation rates of 53% in a historical cohort (n = 16/30). No chemotherapy delays or discontinuations of prophylaxis due to toxicity were reported. Conclusion: A universal approach to PJP prophylaxis can be safely and effectively implemented in pediatric patients with ST without significant toxicity. Our experience highlights how change management models can effectively support the implementation of QI initiatives in pediatric oncology.