Pneumocystis jiroveci pneumonia (PJP) is a feared opprtunistic infection in the renal transplant population. The unicellular fungus is ubiquitous in the environment but has an untreated mortality of 90–100% in immunocompromised HIV-negative patients [1]. This falls to 35% with treatment [2]. Many, but not all, transplant centres routinely prescribe PJP prophylaxis. Current European Best Practice Guidelines recommend at least 4 months of PJP prophylaxis post-renal transplantation [3], while KDIGO guidelines suggest 3–6 months [4]. Both guidelines advocate additional prophylaxis during and following the treatment of acute rejection [3, 4].

The World Health Organization classifies a disease outbreak as the occurrence of cases of disease in excess of what would normally be expected in a defined community. By this definition, there are six recent reports of outbreaks of PJP in renal transplant recipients.

In Tokyo, there were 27 confirmed cases of PJP in 12 months followed by 6 in the next 36 months in a centre that had seen only three cases in 28 years. Twenty-two affected recipients were >12 months post-transplantation and 6 were more than a decade from the date of their transplant [5]. Over a similar 12-month period, 22 cases of PJP were identified in renal transplant patients in Leiden, with 11 affected individuals >1 year post-transplant [6], and recently the Royal Liverpool University Hospital reported 18 cases of PJP in their renal transplant population [7]. There had been a solitary confirmed case of PJP in the Liverpool population in the last 10 years [7]. A Swiss centre had a cluster of 19 PJP cases in recipients of donor kidneys [8] and there was a second Japanese outbreak involving 10 renal transplant patients [9]. In both these groups, the majority of patients developed PJP beyond the suggested period for prophylaxis [8, …

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