Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Bacterial Enteric Disease Slide Set

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Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and AdolescentsBacterial Enteric Disease Slide
Set

• Prepared by the AETC National Resource Center
  based on recommendations from the CDC, National
  Institutes of Health, and HIV Medicine
  Association/Infectious Diseases Society of
  America

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About This Presentation
These slides were developed using recommendations
published in May 2013. The intended audience is
clinicians involved in the care of patients with
HIV. Users are cautioned that, because of the
rapidly changing field of HIV care, this
information could become out of date quickly.
Finally, 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 http//www.aidsetc.org
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Bacterial Enteric Disease Epidemiology

• Higher incidence of gram-negative enteric
  infections among HIV-infected patients
• Risk greatest if CD4 lt200 cells/µL or AIDS
• Risk decreased with ART
• Most commonly cultured bacteria
• Salmonella
• Shigella
• Campylobacter
• E coli
• Clostridium difficile

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Bacterial Enteric Disease Epidemiology (2)

• Source usually ingestion of contaminated food or
  water
• Other risks
• Oral-fecal exposure through sexual activity
  (especially Shigella and Campylobacter)
• HIV-related alterations in mucosal immunity or
  intestinal integrity, gastric acid-blocking
  medications

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Bacterial Enteric Disease Clinical
Manifestations

• Three major clinical syndromes
• Self-limited gastroenteritis
• Diarrheal disease /- fever, bloody diarrhea,
  weight loss, possible bacteremia
• Bacteremia associated with extraintestinal
  involvement, with or without GI illness

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Bacterial Enteric Disease Clinical
Manifestations (2)

• Severe diarrhea 6 loose stools per day, with
  our without other signs/symptoms
• In HIV infection
• Greater risk of more serious illness with greater
  immunosuppression
• Relapses may occur after treatment
• Recurrent Salmonella bacteremia is an
  AIDS-defining illness

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Bacterial Enteric Disease Diagnosis

• History exposures medication review diarrhea
  frequency, volume, presence of blood associated
  signs/symptoms (eg, fever)
• Physical exam including temperature, assessment
  of hydration and nutritional status
• Stool and blood cultures
• Obtain blood cultures in patients with diarrhea
  and fever
• Routine stool culture may not identify non-jejuni
  non-coli Campylobacter species request special
  testingfor these if initial evaluation is
  unrevealing

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Bacterial Enteric Disease Diagnosis (2)

• C difficile toxin or PCR
• If recent or current antibiotic exposure, cancer
  chemotherapy, recent hospitalization, residence
  in long-term care facility, CD4 lt200 cells/µL,
  acid-suppressive medications, moderate-severe
  community-acquired diarrhea
• Endoscopy
• If stool studies and blood culture are
  nondiagnostic, or if treatment for an established
  diagnosis fails
• May diagnose nonbacterial causes (eg, parasites,
  CMV, MAC, noninfectious causes)
• Consider STDs (eg, rectal infections caused by
  lymphogranuloma venereum or N gonorrhoeae)

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Bacterial Enteric Disease Preventing Exposure

• Advice to patients
• Handwashing
• After potential contact with feces, pets or other
  animals, gardening/ contact with soil before
  preparing food, eating before and after sex
• For prevention of enteric infection, soap and
  water preferred over alcohol-based cleansers
  (these do not kill C difficile spores, are partly
  active against norovirus and Cryptosporidium)
• Sex
• Avoid unprotected sexual practices that might
  resultin oral exposure to feces

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Bacterial Enteric Disease Preventing Disease

• Antimicrobial prophylaxis usually not
  recommended, including for travellers
• Risk of adverse reactions, resistant organisms, C
  difficile infection
• Can be considered in rare cases, depending on
  level of immunosuppression and the region and
  duration of travel
• Fluoroquinolone (FQ) or rifaximin
• TMP-SMX may give limited protection (eg, if
  pregnant or already taking for PCP prophylaxis)

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Bacterial Enteric Disease Treatment

• Treatments usually the same as in HIV-uninfected
  patients
• Give oral or IV rehydration if indicated
• Advise bland diet and avoidance of fat, dairy,
  and complex carbohydrates
• Effectiveness and safety of probiotics or
  antimotility agents not adequately studied in
  HIV-infected patients
• Avoid antimotility agents if concern about
  inflammatory diarrhea

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Bacterial Enteric Disease Treatment (2)

• Empiric Therapy
• CD4 count and clinical status guide initiation
  and duration of empiric antibiotics, eg
• CD4 count gt500 cells/µL with mild symptoms only
  rehydration may be needed
• CD4 count 200-500 cells/µL and symptoms that
  compromise quality of life consider short course
  of antibiotics
• CD4 count lt200 cells/µL with severe diarrhea,
  bloody stool, or fevers/chills diagnostic
  evaluation and antibiotics

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Bacterial Enteric Disease Treatment (3)

• Empiric Therapy (cont.)
• Preferred ciprofloxacin 500-750 mg PO (or 400 mg
  IV) Q12H
• Alternative ceftriaxone 1 g IV Q24H or
  cefotaxime 1 g IV Q8H
• Adjust therapy based on study results
• Travelers diarrhea consider possibility of
  antibiotic resistance

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Bacterial Enteric Disease Treatment
(4)Salmonella spp.

• In HIV infection, treatment recommended, because
  of high risk of bacteremia and mortality in
  HIV-infected patients
• Preferred
• Ciprofloxacin 500-750 mg PO (or 400 mg IV) Q12H
• Alternative
• Levofloxacin 750 mg PO or IV Q24H, moxifloxacin
  400 mg PO or IV Q24H
• TMP-SMX PO or IV, if susceptible
• Ceftriaxone (IV) or cefotaxime (IV), if
  susceptible

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Bacterial Enteric Disease Treatment
(5)Salmonella spp. (cont.)

• Optimal duration of therapy not defined
• Gastroenteritis without bacteremia
• CD4 count 200 cells/µL 7-14 days
• CD4 count lt200 cells/µL 2-6 weeks
• Gastroenteritis with bacteremia
• CD4 count 200 cells/µL14 days, longer if
  persistent bacteremia or complicated infection
• CD4 count lt200 cells/µL 2-6 weeks
• If bacteremia, monitor closely for recurrence
  (eg, bacteremia or localized infection)

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Bacterial Enteric Disease Treatment (6)Shigella
spp.

• Treatment recommended, to shorten duration and
  possibly prevent transmission
• Preferred
• Ciprofloxacin 500-750 mg PO or 400 mg IV Q12H
• Alternative (depending on susceptibilities)
• Levofloxacin 750 mg PO or IV Q24H
• Moxifloxacin 400 mg PO or IV Q24H
• TMP-SMX 106/800 mg PO or IV Q12H for 3-7 days
• Azithromycin 500 mg PO QD for 5 days (not
  recommended if bacteremia)
• High rate of TMP-SMX resistance in infections
  acquired outside the United States

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Bacterial Enteric Disease Treatment (7)
Shigella spp. (cont.)

• Duration of therapy
• Gastroenteritis 7-10 days (5 days for
  azithromycin)
• Bacteremia 14 days
• Recurrent infection up to 6 weeks

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Bacterial Enteric Disease Treatment
(8)Campylobacter spp.

• Optimal treatment in HIV poorly defined
• Culture and susceptibility recommended
  (increasing resistance to FQ)
• Mild disease and CD4 gt200 copies/µL may withhold
  antibiotics unless symptoms persist beyond
  several days
• Mild-moderate disease
• Preferred
• Ciprofloxacin 500-750 mg PO or 400 mg IV Q12H
• Azithromycin 500 mg PO QD for 5 days (avoid if
  bacteremia)
• Alternative (depending on susceptibilities)
• Levofloxacin 750 mg PO or IV Q24H
• Moxifloxacin 400 mg PO or IV Q24H
• Bacteremia ciprofloxacin 500-750 mg PO or 400
  mgIV Q12H aminoglycoside

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Bacterial Enteric Disease Treatment (9)
Campylobacter spp. (cont.)

• Duration of therapy
• Gastroenteritis 7-10 days (5 days for
  azithromycin)
• Bacteremia gt14 days
• Recurrent bacteremic disease 2-6 weeks

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Bacterial Enteric Disease Treatment (10) C
difficile

• Treatment as in HIV-uninfected patients

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Bacterial Enteric Disease Initiating ART

• ART expected to decrease risk of recurrent
  Salmonella, Shigella, and Campylobacter
  infections
• Follow standard guidelines
• Consider patients ability to ingest and absorb
  ARV medications
• Consider prompt ART initiation if Salmonella
  bacteremia, regardless of CD4 count (should not
  be delayed)

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Bacterial Enteric Disease Monitoring and Adverse
Effects

• Monitor closely for treatment response
• Follow-up stool culture not required if clinical
  symptoms and diarrhea resolve
• May be required if public health considerations
  and state law dictate
• IRIS has not been described

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Bacterial Enteric Disease Treatment Failure

• Consider follow-up stool culture if lack of
  response to appropriate antibiotic therapy
• Look for other enteric pathogens including C
  difficile antibiotic resistance
• Consider malabsorption of antibiotics use IV
  antibiotics if patient is clinically unstable

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Bacterial Enteric Disease Preventing Recurrence

• Salmonella
• Secondary prophylaxis should be considered for
  patients with recurrent Salmonella bacteremia
  also might be considered for those with recurrent
  gastroenteritis (with or without bacteremia) and
  in those with CD4 count lt200 cells/µL and severe
  diarrhea
• This approach is not well established weigh
  benefits and risks
• Consider stopping secondary prophylaxis if
  Salmonella infection is resolved, patient is on
  ART with virologic suppression and CD4 count gt200
  cells/µL

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Bacterial Enteric Disease Preventing Recurrence
(2)

• Shigella
• Chronic suppressive therapy not recommended for
  first-time infections
• Recurrent infections extend antibiotic treatment
  for up to 6 weeks
• ART expected to decrease recurrence
• Campylobacter
• Chronic suppressive therapy not recommended for
  first-time infections
• Recurrent infections extend antibiotic treatment
  for 2-6 weeks
• ART expected to decrease recurrence

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Bacterial Enteric Disease Considerations in
Pregnancy

• Diagnosis as with nonpregnant women
• Management as with nonpregnant adults, except
• Expanded-spectrum cephalosporins or azithromycin
  should be first-line therapy for bacterial
  enteric infections (depending on organism and
  susceptibility testing)
• FQs can be used if indicated by susceptibility
  testing or failure of first-line therapy
  (arthropathy in animals no increased risk of
  arthropathy or birth defects in humans after in
  utero exposure)
• Avoid TMP-SMX in 1st trimester (increased risk of
  birth defects)
• Sulfa therapy near delivery may increase risk to
  newborn of hyperbilirubinemia and kernicterus

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Websites to Access the Guidelines

• http//www.aidsetc.org
• http//aidsinfo.nih.gov

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About This Slide Set

• This presentation was prepared by Susa Coffey,
  MD, for the AETC National Resource Center in June
  2013
• See the AETC NRC website for the most current
  version of this presentation
• http//www.aidsetc.org