Guidelines for Prevention and Treatment of Opportunistic Infections in HIVInfected Patients

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Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Patients

• Ernesto J. Lamadrid, MD, AAHIVS
• Director, HIV Services, Alachua County Health
  Department
• Assistant Professor Univ. of Florida College of
  Nursing
• Faculty, Florida/Caribbean AETC

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Disclosure of Financial Relationships
This speaker has no significant financial
relationships with commercial entities to
disclose.
This slide set has been peer-reviewed to ensure
that there areno conflicts of interest
represented in the presentation.
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Opportunistic Infections
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Opportunistic Infections in HIV

• Bacterial/ Mycobacterial
• Mycobacterium Avium Complex (MAC)
• Salmonellosis
• Syphilis
• Tuberculosis
• Bacterial pneumonia
• Fungal
• Candidiasis
• Coccidioidomycosis
• Cryptococcal meningitis
• Histoplasmosis

• Protozoal
• Cryptosporidium
• Pneumocystis carinii Pneumonia (PCP)
• Toxoplasmosis
• Viral
• Cytomegalovirus
• Hepatitis
• Herpes simplex
• Herpes zoster
• Human papiloma virus
• Oral hairy leukoplakia
• Progressive Multifocal Leukoencephalopathy (PML)

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When to Start and Stop Prophylaxis?
Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents National institutes of Health
(NIH), the Centers for Disease Control and
Prevention (CDC), and the HIV Medicine
Association of he Infectious Diseases Society of
America (HIVMA/IDSA) .
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When to Start and Stop Prophylaxis?
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Pneumocystis jirovecii (carinii) Pneumonia
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Pneumocystis jirovecii Pneumonia

• Infection of pulmonary tissue with this fungus.
• Commonly seen when CD4 count is
• Sub-acute presentation may take 2-3 weeks for
  onset of symptoms
• Non-productive cough
• Shortness of breath
• Fever
• Fatigue
• Hypoxemia (low oxygen concentration)

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Pneumocystis jirovecii Pneumonia (PCP)

• Diagnosis
• Chest x-ray-diffuse bilateral interstitial
  infiltrates
• Induced sputum or bronchoalveolar lavage (BAL)
• Silver stain to identify the cyst form of the
  organism
• Complications
• Pneumothorax and respiratory failure
• Prognosis
• Response rates with therapy 60-100

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Chest X-ray Pneumocystis jirovecii Pneumonia
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Silver Stain
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Pneumocystis Treatment-Mild to Moderate

• Able to take PO meds, PaO2 70 mmHg
• First-line
• Trimethoprim/sulfamethoxazole (TMP 15mg/kg/day
  75-100 mg SMX) po TID (round to nearest DS tab,
  ie 160 mg of TMP) or TMP/SMX DS 2 tablets TID
• Alternatives
• Dapsone 100 mg po QD TMP 15 mg/kg po tid
• Clindamycin 300-450 mg PO Q 6-8 hrs primaquine
  15-30 mg (base) PO QD
• Atovaquone 750 mg PO BID with food
• Duration of therapy
• 21 days

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents National institutes of Health
(NIH), the Centers for Disease Control and
Prevention (CDC), and the HIV Medicine
Association of he Infectious Diseases Society of
America (HIVMA/IDSA) .
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Pneumocystis Treatment-Moderate to Severe

• Unable to take PO meds, PaO2
• First-line
• TMP-SMX 15-20 mg/kg/day of TMP component iv
  divided q6-8h
• Alternatives
• Clindamycin 600-900 mg IV Q 6-8h or 300-450 mg PO
  Q 6-8 hrs primaquine 15-30 mg (base) PO QD
• Pentamidine 4 mg/kg IV QD infused over 60
  minutes in D5W
• Duration of therapy
• 21 days

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents National institutes of Health
(NIH), the Centers for Disease Control and
Prevention (CDC), and the HIV Medicine
Association of he Infectious Diseases Society of
America (HIVMA/IDSA) .
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Pneumocystis Treatment-Adjunctive Therapy

• Corticosteroids to inhibit inflammatory response
• Patients with severe infection (i.e. PaO2 mmHg)
• Initiate within 72 hours of anti-PCP therapy
• Prednisone 40 mg po bid days 1-5, 40 mg po qd
  days 6-10, 20 mg po qd days 11-21

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents National Institutes of Health
(NIH), the Centers for Disease Control and
Prevention (CDC), and the HIV Medicine
Association of he Infectious Diseases Society of
America (HIVMA/IDSA) .
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Prophylaxis of P. jirovecii Pneumonia

• Preferred Regimens
• TMP-SMX DS 1/d
• TMP-SMX SS 1/d
• Alternative Regimens
• Dapsone 100 mg/d can be given as 50 mg BID
• Dapsone 50 mg/d Pyrim 50 mg/wk Leucovorin 25
  mg /wk
• Dapsone 200 mg/wk Pyrim 75 mg/wk Leuco 25
  mg/wk
• Atovaquone 1500 mg/d
• Aerosol pentamidine in sterile water 300 mg/mo
  via Respirgard II nebulizer
• TMP-SMX DS 3/wk

Adequate for toxoplasmosis (CD4 serology)
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Prevention of Opportunistic Infections
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Tuberculosis
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Tuberculosis

• Pulmonary and extrapulmonary infection caused by
  Mycobacterium tuberculosis.
• Transmission airborne after a prolonged exposure
  to the bacilli
• Increased risk of transmission in closed
  environments with poor circulation of air.
• Immunocompromised patients are at increased risk
  of infection if exposed to MTB.

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Symptoms of Pulmonary TB

• Period of incubation is 2-12 weeks, but can be
  longer.
• Symptoms
• Productive cough
• Hemoptysis
• Fever
• Night sweats
• Fatigue
• Weight loss

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Diagnosis

• Chest X-ray
• Sputum culture
• Acid fast bacilli smear and culture
• Collect a sample every morning X three
  consecutive days
• Smear result available in 24-46 hours
• Nucleic acid amplification result available in
  48-72 hours
• TST not a diagnostic tool, only for screening

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X-ray
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Laboratory
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Toxoplasma gondii encephalitis
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Toxoplasmic encephalitis (TE)

• Toxoplasma gondii
• Intracellular parasite that infects various
  warm-blooded animals
• Infection from humans usually from ingestion of
  undercooked meat or exposure to cat feces
• Can infect any organ but most commonly infects
  the brain and eye

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Toxoplasmic encephalitis (TE)

• Clinical presentation
• Fever, headache, seizures, mental status changes
• Diagnosis
• Presumptive CT Scan of head showing
  ring-enhancing lesions in patient with positive
  Toxoplasma IgG
• Definitive brain biopsy required (rarely done)

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CT scan with contrast
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Toxoplasmosis-Treatment

• First-line
• Pyrimethamine 200 mg PO x 1 then 50 (if or 75 mg (if 60 kg) PO QD sulfadiazine 1 (if
  
  leucovorin 10-25 mg PO QD for at least 6 weeks
• Alternatives
• TMP-SMX (TMP 5 mg/kg/day SMX 25 mg/kg/day) PO
  or IV BID
• Pyrimethamine leucovorin as in first-line
  regimen one of the following
• Clindamycin 600 mg IV OR po q6 hrs
• Azithromycin 900-1200 mg PO QD

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents National Institutes of Health
(NIH), the Centers for Disease Control and
Prevention (CDC), and the HIV Medicine
Association of he Infectious Diseases Society of
America (HIVMA/IDSA) .
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Toxoplasmosis-Treatment

• Preferred Chronic Maintenance
• Pyrimethamine 25-50 mg po qd Sulfadiazine 2-4 g
  po qd (in 2-4 divided doses) plus leucovorin 10
  25 mg po qd
• Alternative Chronic Maintenance
• Clindamycin 600mg PO q 8 h pyrimethamine
  2550mg PO qd leucovorin 1025 PO qd should
  add additional agent to prevent PCP or
• Atovaquone 750mg PO q 612 h /- (pyrimethamine
  25mg PO qd leucovorin 10mg PO qd) or
  sulfadiazine 2-4 g PO daily

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Toxoplasmosis Primary Prophylaxis

• Preferred Regimen
• TMP-SMX DS 1/d po
• Alternative Regimen
• TMP-SMX SS 1/d
• Dapsone 50 mg/d Pyrim 50 mg/wk Leuco 25mg/wk
• Dapsone 200 mg/wk Pyrim 75 mg/wk Leuco
  25mg/wk
• Atovaquone 1500 mg/d Pyrim 25 mg/d Leuco 10
  mg/d

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Prevention of Opportunistic Infections
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Mucosal Candidiasis
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Oral Candidiasis

• Fungal infection of the oral cavity
• Can be seen at any stage of the disease, most
  common in advanced illness
• Symptoms white oral lesions, change in taste,
  tenderness of oral cavity
• May progress to esophagitis causing heartburn and
  chest pain

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Oral Thrush
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Esophageal Candidiasis
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Treatment

• Esophageal Candidiasis
• Fluconazole 100mg (up to 400mg) PO or IV daily
  (AI)
• Oral Candidiasis initial episodes (714 day
  treatment)
• Fluconazole 100mg PO daily (AI) or
• Clotrimazole troches 10mg PO 5 times daily (BII)
• Nystatin suspension 46 mL QID or 12 flavored
  pastilles 45 times daily (BII)

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents National Institutes of Health
(NIH), the Centers for Disease Control and
Prevention (CDC), and the HIV Medicine
Association of he Infectious Diseases Society of
America (HIVMA/IDSA) .
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Alternative Therapy

• Itraconazole oral solution 200mg PO daily (BI)
• or
• Posaconazole oral solution 100mg PO BID x 1, then
  100mg daily (BI)

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents National Institutes of Health
(NIH), the Centers for Disease Control and
Prevention (CDC), and the HIV Medicine
Association of he Infectious Diseases Society of
America (HIVMA/IDSA) .
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Fluconazole-refractory oropharyngeal candidiasis

• Itraconazole oral solution 200mg PO daily (AII)
• Posaconazole oral solution 400mg PO BID (AII)
• Amphotericin B deoxycholate 0.3mg/kg IV daily
  (BII)
• Anidulafungin 100mg IV x 1, then 50mg IV daily
  (BII)
• Caspofungin 50mg IV daily (CII)
• Micafungin 150mg IV daily (CII)
• Voriconazole 200mg PO or IV BID (CIII)

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Cryptococcal meningitis
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Cryptococcal Meningitis

• Fungal infection caused by Cryptococcus
  neoformans
• Clinical Presentation
• Presentation may be subtle
• Headache, fever, malaise
• Mental status changes, focal nuerologic signs
  (minority of patients)
• Papular rash
• Diagnosis
• Serum and cerebrospinal fluid testing for
  cryptococcal antigen (titer 18)
• Identification of Cryptococcus neoformans on
  India ink stain of CSF, culture

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Cryptococcal Meningitis Treatment

• Acute treatment
• Induction
• Amphotericin B 0.7 mg/kg/day IV flucytosine
  (5-FC) 25 mg/kg/dose po q6h x 2 weeks
• Consolidation (after at least 2 weeks of
  successful induction -defined as significant
  clinical improvement negative CSF culture)
• fluconazole 400 mg po qd x 8 weeks or until CSF
  cultures negative
• Maintenance therapy
• Fluconazole 200 mg po qd

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Mycobacterium avium Infections
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Mycobacterium avuim Complex (MAC)

• AKA Mycobacterium intracellulare (MAI)
• Commonly found in food, water, and soil
• Clinical presentation
• High fevers nocturnal spikes
• Diarrhea, night sweats, malaise
• Diagnosis
• Culture of organism from infected site
• Fast-growing mycobacteria

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MAC-Treatment

• First-line
• Clarithromycin 500 mg po bid ethambutol 15
  mg/kg po qd rifabutin 300 mg po qd
• Consider adding rifabutin if severely
  immunocompromised (i.e. CD4 cell count 50
  cells/mm3) or not on effective CART
• Caution drug interactions between rifabutin and
  ARVs

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MAC-Treatment

• Alternative
• Azithromycin 600 mg po qd ethambutol 15 mg/kg
  po qd rifabutin 300 mg po qd
• Ciprofloxacin, ofloxacin, or amikacin should be
  added to regimen in patients not responding to
  2-4 weeks of treatment

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MAC Primary Prophylaxis

• Preferred Regimen
• Azithromycin 1200 mg/wk or
• Clarithromycin 500 mg bid
• Alternative Regimen
• Rifabutin 300 mg/d or
• Azithromycin 1200 mg/wk Rifabutin 300 mg/d

Dose adjust for concurrent PI or NNRTI
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Prevention of Opportunistic Infections
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MAC Secondary Prophylaxis

• Indication history of MAC
• When to stop
• CD4 100 for 6 months Rx 12 months
  asymptomatic
• When to restart CD4 falls below 100

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Prevention of Opportunistic Infections
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MAC Secondary Prophylaxis

• Preferred Regimen
• Clarithromycin 500 mg bid Ethambutol 15 mg/kg/d
  Rifabutin 300 mg/d
• Alternative Regimen
• Azithromycin 500 mg/d Ethambutol 15 mg/kg/d
  Rifabutin 300 mg/d

Dose adjust for concurrent PI or NNRTI
Rifabutin reduces levels of clarithromycin by 50
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Prevention of Opportunistic Infections
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Summary

• Correctional nurses are the frontline of care of
  all inmates are you must be aware of the multiple
  diseases that may affect their life.
• If you dont think of a diagnosis, you will miss
  it.

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Questions ?
Office [phone] enplamadrid_at_hotmail.com
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