2001 USPHSIDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected With Hu

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2001 USPHS/IDSA Guidelines for the Prevention of
Opportunistic Infections in Persons Infected With
Human Immunodeficiency Virus

• Module 1
• Prophylaxis Core
• A Training Slide Set Prepared by the AETC
  National Resource Center

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Disclaimer

• These slides were developed using the most recent
  treatment guideline information at the time of
  production. However, in the rapidly changing
  field of HIV care this information could become
  out of date quickly. The user is encouraged to
  compare the date of this slide set with the date
  of the most recent guidelines. Also, it is
  intended that these slides be used, as prepared,
  without changes in either content or attribution.
  Users are asked to honor this intent.
• AETC National Resource Center

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Summary of OIs for Which Prevention Is Recommended

• Primary Prophylaxis
• P. carinii
• Tuberculosis
• T. gondii
• M. avium
• Varicella zoster
• S. pneumoniae
• Hepatitis A B
• Influenza

• Secondary Prophylaxis
• P. carinii
• T. gondii
• M. avium
• Cryptococcosis
• Histoplasmosis
• Coccidioidomycosis
• Cytomegalovirus
• Salmonella bacteremia

Standard of care Generally recommended
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OIs for Which Prevention Is Not Routinely
Indicated

• Primary Prophylaxis
• Bacteria (Neutropenia)
• Cryptococcosis
• Histoplasmosis
• Cytomegalovirus

• Secondary Prophylaxis
• Herpes simplex virus
• Candida

Recommended only if subsequent episodes are
frequent or severe
Evidence for Efficacy but Not Routinely
Indicated
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OI Guidelines November, 2001Comparison of
Indications to Discontinue Primary and Secondary
Prophylaxis
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OI Guidelines November, 2001

• OIs for Which Primary and Secondary Prophylaxis
  Is Recommended

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P. carinii Pneumonia

• Primary Prophylaxis
• Indication CD4 lt 200 or thrush
• When stop CD gt 200 for gt 3 mo
• When restart CD4 falls to lt 200
• Secondary prophylaxis
• Same as primary

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P. carinii Pneumonia

• Preferred Regimens
• TMP-SMX DS 1/d
• TMP-SMX SS 1/d
• Alternative Regimens
• Dapsone 100 mg/d
• 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 300 mg/mo
• TMP-SMX DS 3/wk

Adequate for toxoplasmosis (CD4 lt100 pos
serology)
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Toxoplasmosis Primary Prophylaxis

• Indication Pos lgG Toxo CD4 lt 100
• When to stop CD4 gt 200 X 3 mo
• When to restart CD4 falls to lt 100-200

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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 25/wk
• Atovaquone 1500 mg/d Pyrim 25 mg/d leuco10
  mg/d

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ToxoplasmosisSecondary Prophylaxis

• IndicationCompletion of therapy for
  toxoplasmosis unless immune reconstitution occurs
  with HAART.
• When to stop CD4 gt 200 X 6 mo completed
  initial treatment asymptomatic
• When to restart CD4 falls to lt 200

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ToxoplasmosisSecondary Prophylaxis

• Preferred Regimen
• Sulfadiazine 500-1000 mg qid Pyrimethamine
  25-50 mg/d Leucovorin 10-25 mg/d
• Alternative Regimen
• Clindamycin 300-450 mg q 6-8 hr Pyrimethamine
  25-50 mg/d leucovorin10-25 mg/d
• Atovaquone 750 mg q 6-12 hr Pyrimethamine 25
  mg/d leucovorin 10 mg/d

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MACPrimary Prophylaxis

• Indication CD4 lt 50
• When to stop CD4 gt 100 for gt 3 month
• When to restart CD4 falls to lt 50-100

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MACPrimary 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 adjusted for concurrent PI or NNRTI
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MAC Secondary Prophylaxis

• Indication Hx MAC
• When to stop CD4 gt 100 X gt 6 mo and Rx 12 mo
  and asymptomatic
• When to restart CD4 falls to lt 100

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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 adjusted for concurrent PI..NNRTI
Rifabutin reduces levels of clarithromycin by 50
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OI Guidelines November, 2001

• OIs for Which Only Primary Prevention Is
  Generally Recommended

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Tuberculosis Latent Infection

• Screening (5-TU) purified protein derivative
• (PPD) by the Mantoux method
• When HIV infection is first recognized.
• Annual test if TST negative on initial evaluation
  and continued risk.
• Routine evaluation for anergy is not recommended.

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Tuberculosis Treatment of Latent Infection

• Indications
• PPD gt 5 mm induration at 48-72h
• Hx PPD no Rx
• TB contact (D/C if PPD neg at 12 wks)
• All PPD positives should be evaluated for
  active TB including chest x-ray.

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Treatment of Latent TB Infection CDC/ATS
Guidelines, August 2001

• Recommended Regimens
• No HIV INH X 9 mo.
• HIV INH X 9 mo. (if compliance assured)
• RIF-PZA X 2 mo.
• Alternative RIF/RBT alone X 4 mo.

Am J Resp Crit Care 2001 1641319
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Treatment of Latent TB Infection CDC/ATS
Guidelines, August 2001

• Rationale for RIF-PZA in HIV Co-infection
• Compliance risk of active disease.
• Risk of ? ALT greater with INH vs RIF-PZA in HIV
  co-infected.
• 21 reported cases severe RIF-PZA hepatotoxicity,
  none had HIV.
• Well tolerated in HIV co-infected patients.

Am J Resp Crit Care 2001 1641319
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Treatment of Latent TB Infection CDC/ATS
Guidelines, August 2001

• RIF-PZA Regimen
• HAART Use RBT dose adjustment
• Admonitions
• Not recommended Liver disease or hx INH
  hepatotoxicity
• Caution Other hepatotoxic drugs or EtOH
• Prescription Only 2 week supply

Am J Resp Crit Care 2001 1641319
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Treatment of Latent TB Infection CDC/ATS
Guidelines, August 2001

• RIF-PZA Regimen
• Monitoring
• Clinical at 2,4,6, 8 weeks.
• Lab ALT Bili at baseline, 2,4, 6 weeks.
• Discontinue 1) Sx ? ALT
• 2) ALT gt 5X ULN, or
• 3) ? Bili.

Am J Resp Crit Care 2001 1641319
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Tuberculosis Treatment of Latent Infection -
Regimens

• HAART/No HAART
• INH 300 mg/d pyridoxine 50 mg/d X 9 mo (270
  doses)
• INH 900 mg pyridoxine 100 mg 2 X wk X 9 months
  (76 doses

Assuming completion of treatment can be assured.
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Tuberculosis Treatment of Latent Infection -
Regimens

• HAART
• Rifabutin daily X 4 months
• Rifabutin Pyrazinamide 20 mg/kg/d X 2 months
  (60 doses)
• No HAART
• Rifampin 600 mg/d X 4 months
• Rifampin 600 mg/d Pyrazinamide 20 mg/kg/d X 2
  months (60 doses)

Dose adjusted for PI or NNRTI
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Tuberculosis Treatment of Latent Infection

• When to restart patients previously treated for
  TB infection or TB disease do not require
  retreatment based upon diminished immune function
  alone. Patients with known exposure or suspected
  of acquiring TB infection may need retreatment.
  In these instances consultation with experts is
  strongly recommended.

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Rifabutin Dose Modifications With ART Agents
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Tuberculosis Prophylaxis Therapeutic Monitoring
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Varicella-Zoster Virus Disease

• Varicella vaccine contraindicated in HIV-infected
  adults.
• Varicella zoster immune globulin (VZIG) for
  susceptible HIV-infected children and adults.
  Give ASAP but ? 96 hours after close contact with
  a person who has chickenpox or shingles.
• No preventive measures are currently available
  for shingles.

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VACCINES ROUTINE USE
Risk IDU, MSM, hemophilia, chronic HBV or HCV
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VACCINES OTHER

• Give if indicated
• Cholera, Japanese encephalitis, Lyme disease,
  Tetanus-diptheria, Typhoid inactivated (Typhim V1)

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VACCINES OTHER

• Contraindicated (live virus)
• Varicella, Yellow Fever, Typhoid live (Ty21a),
  Measles, Vaccinia

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OI Guidelines November, 2001

• OIs for Which Only Secondary Prevention Is
  Generally Recommended

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Cytomegalovirus Disease

• Chronic maintenance therapy following induction
• Preferred Regimen
• Ganciclovir IV or PO
• Foscarnet IV
• Ganciclovir implant PO (for retinitis)
• Alternative Regimen
• Cidofovir IV probenecid PO
• Fomivirsen injection in vitreous
• Valganciclovir PO
• When to stop CD4 gt100-150 X 6 mo no active
  disease negative ophthal exam.
• When to restart CD4 lt 100-150

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Prophylaxis Summary Fungal Agents
Consider if CD4 lt 100 endemic area (gt10
cases/100 pts-yrs) CD4 gt 100-200 X 6 mo
complete initial therapy asymptomatic
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Cryptococcosis

• Chronic Maintenance Therapy
• Regimen Preferred Fluconazole (AI). Alternate
  Amphotericin B, itraconazole
• When to stop completed initial treatment
  asymptomatic CD4 gt100 - 200 X 6 mo on HAART
• When to restart CD4 falls to lt 100 - 200

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Histoplasmosis

• Lifelong Suppressive Therapy
• Indication Completion of therapy for
  histoplasmosis
• Agents itraconazole (200 mg twice a day).
• When to stop Insufficient data (? CD4 gt100
  cells/µL)

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Coccidioidomycosis

• Lifelong Suppressive Therapy
• Indication Completion of therapy for
  coccidioidomycosis
• Regimen fluconazole PO or itraconazole.
• Patients with meningeal disease require
  consultation with an expert.
• When to stop Insufficient data (? CD4 gt100
  cells/µL )

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Salmonella

• Prevention of Reccurrence
• Indication Salmonella septicemia
• Regimen Preferred Fluoroquinolones
  (ciprofloxacin) for susceptible organisms.
• Other Management Household contacts should be
  evaluated for carriage so that hygienic measures
  and/or antimicrobial therapy can be instituted
  and recurrent transmission prevented. (Optional)

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OI Guidelines November, 2001

• Infections Requiring Other Management Strategies

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Hepatitis C Virus Infection

• Prevention of Disease
• Recommend screening-if positive do RIBA/ HCV
  PCR, then
• Avoid excessive amounts of alcohol
• Vaccinate against hepatitis A
• Evaluated for chronic liver disease and for the
  possible need for treatment.
• Monitor liver enzymes on patients on HAART.
• HAART should not be routinely withheld from
  patients co-infected with HIV and HCV

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Human Papillomavirus Infection

• Prevention of Disease
• Genital Epithelial Cancers in HIV-infected Women
• Pelvic exam PAP X 2 in first year after HIV Dx.
• If normal, repeat PAP annually
• If abnormal, follow Interim Guidelines for
  Management of Abnormal Cervical Cytology (NCI)
• Prevention of Recurrence
• Careful follow-up and monitoring after treatment
• No specific therapy recommended.

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OI Guidelines November, 2001

• Cost Considerations

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Drug Costs Of PCP Prophylaxis
Administration costs need to be considered.
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VACCINE COSTS
Average Wholesale Price
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Drug Costs Exceeding 10,000/yr
Average Wholesale Price
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For Additional Information

• Sources of Complete Guidelines
• AETC Resource Center www.aids-etc.org
• AIDS Treatment Information Service
  www.hivatis.org

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• OI Guideline Slides
• December 2001
• Author John G. Bartlett, M.D.
• Editor Richard W. Dunning, M.H.S.
• Reviewers
• Renslow Sherer, M.D.
• Caroline Teter, PAC, M.P.H.