Title: Guidelines for Prevention and Treatment of Opportunistic Infections in HIVInfected Patients
1Guidelines 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
2Disclosure 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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4Opportunistic Infections
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6Opportunistic 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)
7When 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) .
8When to Start and Stop Prophylaxis?
9Pneumocystis jirovecii (carinii) Pneumonia
10Pneumocystis 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)
11Pneumocystis 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
Orrick, J. Opportunistic Infections in HIV/AIDS
12Chest X-ray Pneumocystis jirovecii Pneumonia
13 Silver Stain
Orrick, J. Opportunistic Infections in HIV/AIDS
14Pneumocystis 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) .
15Pneumocystis 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) .
16Pneumocystis 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) .
17Prophylaxis 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)
Montero JA 16th annual FAETC Conference
Prevention of Opportunistic Infections
18Tuberculosis
19Tuberculosis
- 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.
20Symptoms of Pulmonary TB
- Period of incubation is 2-12 weeks, but can be
longer. - Symptoms
- Productive cough
- Hemoptysis
- Fever
- Night sweats
- Fatigue
- Weight loss
21Diagnosis
- 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
22X-ray
23Laboratory
24Toxoplasma gondii encephalitis
25Toxoplasmic 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
Orrick, J. Opportunistic Infections in HIV/AIDS
26Toxoplasmic 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)
Orrick, J. Opportunistic Infections in HIV/AIDS
27CT scan with contrast
28Toxoplasmosis-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) .
29Toxoplasmosis-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
30Toxoplasmosis 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
Montero JA 16th annual FAETC Conference
Prevention of Opportunistic Infections
31Mucosal Candidiasis
32Oral 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
33Oral Thrush
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35Esophageal Candidiasis
36Treatment
- 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) .
37Alternative 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) .
38Fluconazole-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)
39Cryptococcal meningitis
40Cryptococcal 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
Orrick, J. Opportunistic Infections in HIV/AIDS
41Cryptococcal 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
Orrick, J. Opportunistic Infections in HIV/AIDS
42Mycobacterium avium Infections
43Mycobacterium 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
Orrick, J. Opportunistic Infections in HIV/AIDS
44MAC-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
Orrick, J. Opportunistic Infections in HIV/AIDS
45MAC-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
Orrick, J. Opportunistic Infections in HIV/AIDS
46MAC 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
Montero JA 16th annual FAETC Conference
Prevention of Opportunistic Infections
47MAC 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
Montero JA 16th annual FAETC Conference
Prevention of Opportunistic Infections
48MAC 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
Montero JA 16th annual FAETC Conference
Prevention of Opportunistic Infections
49Summary
- 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.
50Questions ?
Office (352) 334-7985 enplamadrid_at_hotmail.com
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