Pneumocystis jirovecii pneumonia (PCP) is an uncommon but potentially severe complication occasionally occurring after liver transplantation (LT). Although 6–12 months of prophylaxis are recommended, data regarding incidence, severity, and PCP prevention in LT recipients remain limited. We aimed to describe the incidence and clinical characteristics of PCP after LT in France, to compare early and late cases, to explore the factors associated with severe respiratory outcomes (including exploratory prognostic analyses), and to evaluate prophylaxis practices across French LT centers.

We conducted a retrospective multicenter study of PCP cases occurring after LT in France between 2010 and 2022; they were identified in hospital discharge diagnosis databases (PMSI). Proven and probable PCP cases according to the EORTC/MSGERC criteria were individually reviewed. Severe respiratory outcome was defined as a need for invasive mechanical ventilation (IMV). In parallel, a structured questionnaire was sent to all French LT centers to evaluate prophylaxis practices.

Fifty-three cases were included: 28 (53%) occurred within six months after LT (early cases) and 25 (47%) later. An additional cause of immunosuppression was more frequent in late cases (36% vs. 7%, p  = 0.016). IMV was required in 15 patients (28%), and in-hospital mortality was 5.7%. In multivariable analysis, high leukocyte count (OR 1.59; p  = 0.015) and low prothrombin ratio (OR 0.88; p = 0.016) were independently associated with IMV. An exploratory score derived from these parameters showed good discrimination (AUC 0.90; NPV 90%). Prophylaxis was systematically prescribed in 7/16 centers (43%).

In this nationwide multicenter study, PCP after LT was infrequent but potentially severe. Prophylaxis practices between centers varied substantially. While the low observed incidence highlights the importance of risk-adapted prevention strategies, exploratory analyses identified a number of biological parameters associated with severe respiratory outcomes.