Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Bacterial Infections Slide Set - PowerPoint PPT Presentation

Loading...

PPT – Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Bacterial Infections Slide Set PowerPoint presentation | free to download - id: 6169ba-MDk3Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

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

Description:

Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Bacterial Infections Slide Set Prepared by the AETC ... – PowerPoint PPT presentation

Number of Views:490
Avg rating:3.0/5.0
Slides: 113
Provided by: CHIe153
Learn more at: http://www.aids-ed.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

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


1
Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and AdolescentsBacterial Infections 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

2
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information could become out of date quickly.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
3
Bacterial Infections
  • Bacterial respiratory infections
  • Bacterial enteric infections
  • Bartonellosis
  • Syphilis

4
Bacterial Infections
  • Bacterial Respiratory Infections

5
Bacterial Respiratory Disease Epidemiology
  • Bacterial pneumonia is a common cause of
    HIV-related morbidity
  • In HIV-infected persons
  • Higher rates of bacterial pneumonia
  • Higher mortality
  • Increased incidence of bacteremia (esp. with S
    pneumoniae)
  • Can occur at any CD4 count or stage of disease
  • Recurrent pneumonia (2 episodes in 1 year) is an
    AIDS-defining condition

6
Bacterial Respiratory Disease Epidemiology (2)
  • Incidence lower with use of ART
  • Risk factors include
  • Low CD4 count (lt200 cells/µL)
  • No or intermittent use of ART
  • Cigarette smoking
  • Injection drug use
  • Chronic viral hepatitis

7
Bacterial Respiratory Disease Epidemiology (3)
  • Organisms
  • S pneumoniae
  • Drug-resistant strains are increasingly common
  • H influenzae
  • P aeruginosa
  • S aureus, including MRSA
  • Atypicals (infrequent)

8
Bacterial Respiratory Disease Clinical
Manifestations
  • Presentation similar to that of HIV uninfected,
    with acute symptoms (fevers, chills, rigors,
    chest pain, productive cough, dyspnea)
  • Subacute illness suggests alternative diagnosis
    (PCP, TB, chronic fungal disease, etc)
  • Physical exam evidence of focal consolidation or
    pleural effusion
  • WBC usually elevated, may see left shift

9
Bacterial Respiratory Disease Clinical
Manifestations (2)
  • Assess disease severity (including signs of
    sepsis) and arterial oxygenation in all patients
  • Pneumonia Severity Index (PSI) appears valid for
    HIV-infected patients

10
Bacterial Respiratory Disease Diagnosis
  • Chest X ray
  • Commonly shows unilateral, focal, segmental, or
    lobar consolidation, but may show atypical
    presentations (multilobar, nodular,
    reticulonodular)

Chest X ray pneumococcal pneumonia showing right
middle lobe consolidation Credit C. Daley, MD
HIV InSite
11
Bacterial Respiratory Disease Diagnosis (2)
  • CAP diagnosis and management guidelines apply to
    HIV-infected as well as HIV-uninfected patients
  • Chest X ray PA and lateral, if possible
  • Consider the possibility of specific pathogens,
    eg
  • TB if compatible clinical and X-ray
    presentation, manage as potential TB, pending
    test results
  • PCP evaluate if clinically indicated (PCP may
    coexist with bacterial pneumonia)
  • P aeruginosa if CD4 50 cells/µL, preexisting
    lung disease, neutropenia, on corticosteroids,
    recent hospitalization, or residence in a health
    care facility
  • S aureus if recent influenza or other viral
    infection, history of injection drug use, or
    severe bilateral necrotizing pneumonia

12
Bacterial Respiratory Disease Diagnosis (3)
  • Microbiologic diagnosis allows targeted treatment
    of specific pathogen(s)
  • Test to identify specific pathogens that would
    significantly alter standard (empirical)
    management decisions, if their presence is
    suspected
  • For patients well enough to be treated as
    outpatient routine testing for etiology is
    optional
  • For hospitalized patients with suspected CAP
    Gram stain and culture of expectorated sputum
    specimen, 2 blood cultures
  • Gram stain and culture of expectorated sputum
    only if good quality specimen as well as good lab
    performance measures
  • Endotracheal aspirate sample for intubated
    patients
  • Consider bronchoscopy with BAL lavage if
    differential includes pathogens such as P jiroveci

13
Bacterial Respiratory Disease Diagnosis (4)
  • Microbiologic diagnosis
  • Consider blood cultures for all
  • Higher rate of bacteremia in HIV-infected
    patients with CAP
  • Higher risk of drug-resistant pneumococcal
    infection
  • Blood culture has high specificity but low
    sensitivity
  • Consider urinary antigen tests for L pneumophila
    and S pneumoniae
  • Consider diagnostic thoracentesis if pleural
    effusion

14
Bacterial Respiratory Disease Preventing Exposure
  • No effective means of reducing exposure to S
    pneumoniae and H influenzae

15
Bacterial Respiratory Disease Preventing Disease
  • Pneumococcal vaccine
  • Recommended for all with HIV infection,
    regardless of CD4 count
  • 23-valent pneumococcal polysaccharide vaccine
    (PPV23)
  • Multiple observational studies reported benefits
    including reduced risk of pneumococcal bacteremia
  • 13-valent pneumococcal conjugate vaccine (PCV13)
  • Recommended for use in adults with HIV or other
    immunocompromising conditions
  • 7-valent PCV
  • High efficacy against vaccine-type invasive
    pneumococcal disease in one study

16
Bacterial Respiratory Disease Preventing Disease
(2)
  • Pneumococcal vaccination recommendations
  • No previous pneumococcal vaccination
  • Preferred
  • 1 dose PCV13 followed by
  • If CD4 200 cells/µL PPV23 should be given 8
    weeks after PCV13
  • If CD4 lt200 cells/µL, PPV23 can be offered 8
    weeks after PCV13 or can await increase of CD4 to
    gt200 cells/µL
  • Alternative
  • 1 dose PPV23
  • Previous PPV23 vaccination
  • 1 dose of PCV13, to be given 1 year after last
    receipt of PPV23

17
Bacterial Respiratory Disease Preventing Disease
(3)
  • Pneumococcal vaccination recommendations (2)
  • Revaccination
  • Individuals who previously received PPV23
  • Duration of protective effect of PPV23 is not
    known
  • 1 dose PPV23 recommended for age 19-64 years if
    5 years since 1st dose of PPV
  • Another dose of PPV23 for age 65 if 5 years
    since previous PPV23
  • Single dose of PCV13 should be given if 1 year
    since previous PPV23
  • Subsequent doses of PPV23 as above
  • No more than 3 lifetime doses of PPV23

18
Bacterial Respiratory Disease Preventing Disease
(4)
  • Influenza vaccine
  • Recommended annually during influenza season
    (bacterial pneumonia may occur as complication of
    influenza)
  • Live attenuated vaccine is contraindicated and is
    not recommended for HIV-infected persons

19
Bacterial Respiratory Disease Preventing Disease
(5)
  • H influenzae type B vaccine
  • Not usually recommended for adults, unless
    anatomic or functional asplenia (low incidence of
    infection)

20
Bacterial Respiratory Disease Preventing Disease
(6)
  • Antiretroviral therapy reduces risk of bacterial
    pneumonia
  • TMP-SMX and macrolides reduce frequency of
    bacterial respiratory infections when given as
    prophylaxis for PCP or MAC, respectively
  • These should not be prescribed solely to prevent
    bacterial respiratory infections
  • Behavioral interventions
  • Cessation of smoking, injection drug use, alcohol
    use

21
Bacterial Respiratory Infections Treatment
  • Outpatient versus inpatient treatment
  • Severity of disease and CD4 count may both be
    important
  • Mortality higher with higher PSI class, with CD4
    lt200 cells/µL
  • Some offer hospitalization to all CAP patients
    with CD4 lt200 cells/µL and use PSI to guide
    decision in those with CD4 gt200 cells/µL
  • Basic principles of treatment are same as those
    for HIV uninfected

22
Bacterial Respiratory Infections Treatment (2)
  • Target most common pathogens, particularly S
    pneumoniae and H influenzae
  • Empiric treatment should be started promptly
  • Specimens for diagnosis should be collected
    before antibiotics are given
  • Modify treatment, if indicated, based on
    microbiologic and drug susceptibility results
  • Fluoroquinolones should be used cautiously if
    TBsuspected but not being treated (risk of TB
    monotherapy)
  • Empiric macrolide monotherapy cannot be routinely
    recommended (risk of macrolide-resistantS
    pneumoniae)

23
Bacterial Respiratory Infections Treatment (3)
  • Outpatient treatment (empiric)
  • Preferred
  • Oral beta-lactam macrolide (azithromycin,
    clarithromycin)
  • Preferred beta-lactams high-dose amoxicillin or
    amoxicillin-clavulanate
  • Alternative beta-lactams cefpodoxime, cefuroxime
  • Fluoroquinolone, especially if penicillin allergy
  • Levofloxacin 750 mg PO QD
  • Moxifloxacin 400 mg PO QD
  • Alternative beta-lactam doxycycline
  • Duration of therapy 7-10 days for most minimum
    5 days
  • Should be afebrile for 48-72 hours, clinically
    stable

24
Bacterial Respiratory Infections Treatment (4)
  • Hospitalized, non-ICU treatment (empiric)
  • Preferred
  • IV beta-lactam macrolide (azithromycin,
    clarithromycin)
  • Preferred beta-lactams ceftriaxone, cefotaxime,
    ampicillin-sulbactam
  • IV fluoroquinolone, especially if penicillin
    allergy
  • Levofloxacin 750 mg IV QD
  • Moxifloxacin 400 mg IV QD
  • Alternative
  • IV beta-lactam doxycycline
  • IV penicillin for confirmed pneumococcal
    pneumonia

25
Bacterial Respiratory Infections Treatment (5)
  • Inpatient, ICU (empiric)
  • Preferred
  • IV beta-lactam IV azithromycin
  • IV beta-lactam (levofloxacin 750 mg IV QD or
    moxifloxacin 400 mg IV QD)
  • Preferred beta-lactams ceftriaxone, cefotaxime,
    ampicillin-sulbactam
  • Alternative
  • Penicillin allergy aztreonam IV IV
    levofloxacin or moxifloxacin as above

26
Bacterial Respiratory Infections Treatment (6)
  • Most CAP pathogens can be treated with the
    recommended regimens
  • Exceptions P aeruginosa and S aureus (including
    community-acquired MRSA)
  • Empiric coverage may be warranted, if either is
    suspected
  • Diagnostic tests (sputum Gram stain and culture)
    likely to be of high yield

27
Bacterial Respiratory Infections Treatment (7)
  • Empiric Pseudomonas treatment
  • Preferred antipneumococcal antipseudomonal
    beta-lactam (ciprofloxacin 400 mg IV Q8-12H or
    levofloxacin 750 mg IV QD)
  • Preferred beta-lactams piperacillin-tazobactam,
    cefepime, imipenem, meropenem
  • Alternative
  • Beta-lactam as above IV aminoglycoside IV
    azithromycin
  • Beta-lactam as above IV aminoglycoside
    (moxifloxacin 400 mg IV QD or levofloxacin 750 mg
    IV QD)
  • Penicillin allergy replace beta-lactam with
    aztreonam

28
Bacterial Respiratory Infections Treatment (8)
  • Empiric S aureus (including community-acquired
    MRSA) treatment
  • Add vancomycin (IV) or linezolid (IV or PO) alone
    to the antibiotic regimen
  • For severe necrotizing pneumonia, consider
    addition of clindamycin to vancomycin (not to
    linezolid), to minimize bacterial toxin production

29
Bacterial Respiratory Infections Treatment (9)
  • When etiology of the pneumonia is identified,
    modify antimicrobial therapy to target that
    pathogen
  • Consider switch from IV to PO therapy when
    improved clinically, able to tolerate PO
    medications, have intact GI function
  • Clinical stability temperature lt37.8C, heart
    rate lt100/minute, respiratory rate lt24/minute,
    SBP 90 mm Hg, room air O2 saturation gt90 or
    PaO2 gt60 mm Hg

30
Bacterial Respiratory Infections Starting ART
  • Initiate ART early in course of bacterial
    pneumonia
  • In one randomized study, early ART in setting of
    OIs (including bacterial infections) decreased
    AIDS progression and death

31
Bacterial Respiratory Infections Monitoring and
Adverse Events
  • Clinical response typically seen within 48-72
    hours after start of appropriate antimicrobial
    therapy
  • Advanced HIV, CD4 lt100 cells/µL, S pneumoniae
    infection prolonged the time to clinical
    stability (gt7 days)
  • Patients on ART had shorter time to clinical
    stability
  • IRIS has not been described

32
Bacterial Respiratory Infections Treatment
Failure
  • If worsening symptoms/signs or no improvement,
    evaluate further for other infectious and
    noninfectious causes
  • Consider possibility of TB

33
Bacterial Respiratory Infections Preventing
Recurrence
  • 23-valent pneumococcal vaccine, as above
  • Influenza vaccine during influenza season
  • Antibiotic prophylaxis generally not recommended
    to prevent bacterial respiratory infections
    (potential for drug resistance and toxicity)

34
Bacterial Respiratory Infections Considerations
in Pregnancy
  • Diagnosis as in nonpregnant adults (abdominal
    shielding during radiographic procedures)
  • Management as in nonpregnant adults, except
  • Clarithromycin not recommended as first-line
    agent (birth defects in animals) azithromycin
    recommended when macrolide is indicated
  • Quinolones may be used for serious infections
    when indicated (no arthropathy or birth defects
    reported in exposed human fetuses)
  • Doxycycline not recommended (hepatoxicity,stainin
    g of fetal teeth and bones)

35
Bacterial Respiratory Infections Considerations
in Pregnancy (2)
  • Management
  • Beta-lactams no known teratogenicity or
    increased toxicity
  • Aminoglycosides theoretical risk of fetal renal
    or eighth nerve damage, but not documented in
    humans except with streptomycin, kanamycin
  • Linezolid limited data not teratogenic in
    animal studies

36
Bacterial Respiratory Infections Considerations
in Pregnancy (3)
  • Increased risk of preterm labor and delivery
  • If pneumonia after 20 weeks of gestation, monitor
    for contractions
  • Pneumococcal and influenza vaccines can be
    administered
  • Influenza vaccine recommended for all pregnant
    women during influenza season
  • During pregnancy, vaccines should be administered
    after ART has been initiated, to minimize
    transient HIV RNA increases that may be caused by
    vaccine

37
Bacterial Infections
  • Bacterial Enteric Infections

38
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

39
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

40
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

41
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

42
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

43
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)

44
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

45
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)

46
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

47
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

48
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

49
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

50
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)

51
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

52
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

53
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

54
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

55
Bacterial Enteric Disease Treatment (10) C
difficile
  • Treatment as in HIV-uninfected patients

56
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)

57
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

58
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

59
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

60
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

61
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

62
Bacterial Infections
  • Bartonellosis

63
Bartonellosis Epidemiology
  • Bartonella spp. cause variety of infections,
    including cat-scratch disease, retinitis, trench
    fever, relapsing bacteremia, endocarditis
  • In immunocompromised also bacillary angiomatosis
    (BA) and peliosis hepatis
  • BA usually caused by B henselae or B quintana
  • Typically occurs late in HIV infection median
    CD4 count lt50 cells/µL
  • B henselae linked to cat scratches from cats
    infested with fleas, cat fleas
  • B quintana associated with louse infestation

64
Bartonellosis Clinical Manifestations
  • In HIV-infected persons, symptoms often chronic
    (months-years)
  • May involve nearly any organ system
  • BA of the skin papular red vascular lesions,
    subcutaneous nodules may resemble Kaposi sarcoma
    or pyogenic granuloma
  • Osteomyelitis (lytic lesions)
  • Peliosis hepatica (B henselae)
  • Endocarditis
  • Systemic symptoms of fever, sweats, weight loss,
    fatigue, malaise

65
Bartonellosis Clinical Manifestations (2)
Skin lesions of Bartonella
Credits Left P. Volberding, MD, UCSF Center
for HIV Information Image Library Right G.
Beatty, MD A. Lukusa, MD, HIV InSite
66
Bartonellosis Diagnosis
  • Tissue biopsy histopathologic examination
  • Serologic tests (available through the CDC and
    some state health labs)
  • Up to 25 of patients with advanced HIV infection
    and positive blood cultures for Bartonella may
    not develop antibodies
  • Antibody levels can indicate resolution and
    recrudescence of infection
  • Blood culture
  • PCR not widely available

67
Bartonellosis Preventing Exposure
  • If CD4 count lt100 cells/µL, high risk of severe
    disease if infected by B quintana or B henselae
  • Advice to patients
  • B quintana
  • Consider risks of contact with cats
  • If acquiring a cat cat should be gt1 year of age,
    in good health, free of fleas
  • Avoid cats with fleas, stray cats
  • Avoid cat scratches
  • Avoid contact with flea feces
  • Control fleas
  • B henselae
  • Eradicate body lice, if present

68
Bartonellosis Preventing Disease
  • Primary chemoprophylaxis not recommended
  • Macrolide or rifamycin was protective in a
    retrospective case-control study

69
Bartonella Infection Treatment
  • No randomized controlled trials in HIV-infected
    patients
  • BA, peliosis hepatica, bacteremia, osteomyelitis
  • Preferred
  • Doxycycline 100 mg PO or IV Q12H
  • Erythromycin 500 mg PO or IV Q6H
  • Alternative
  • Azithromycin 500 mg PO QD
  • Clarithromycin 500 mg PO BID
  • Duration at least 3 months

70
Bartonella Infection Treatment (2)
  • CNS infections
  • Preferred doxycycline 100 mg PO or IV Q12H /-
    rifampin 300 mg PO or IV Q12H
  • Endocarditis (confirmed Bartonella)
  • Doxycycline 100 mg IV Q12H gentamicin 1 mg/kg
    IV Q8H x 2 weeks, then doxycycline 100 mg IV or
    PO Q12H
  • If renal insufficiency doxycycline 100 mg IV
    Q12H rifampin 300 mg IV or PO Q12H x 2 weeks,
    then doxycycline 100 mg PO Q12H
  • Other severe infections
  • Doxycycline 100 mg PO or IV Q12H rifampin 300
    mg PO or IV Q12H
  • Erythromycin 500 mg PO or IV Q6H rifampin 300
    mg PO or IV Q12H

71
Bartonellosis Starting ART
  • Bartonella CNS or ophthalmic lesions if not on
    ART, probably should treat with doxycycline a
    rifamycin for 2-4 weeks before initiating ART

72
Bartonellosis Monitoring and Adverse Effects
  • Check Bartonella IgG titer at diagnosis and (if
    positive) every 6-8 weeks until 4-fold decrease
  • Oral doxycycline risk of pill-associated
    ulcerative esophagitis
  • Rifamycins have significant interactions with
    many ARVs some combinations must be avoided
  • IRIS has not been described

73
Bartonellosis Treatment Failure
  • Consider alternative second-line regimens (above)
  • If positive or increasing Ab titer, treat until a
    4-fold decrease

74
Bartonellosis Preventing Recurrence
  • Secondary prophylaxis
  • In case of relapse after 3 months of treatment,
    long-term suppression is recommended while CD4
    count lt200 cells/µL doxycycline or macrolide
  • Discontinuing suppressive therapy
  • After 3-4 months of therapy and CD4 count gt200
    cells/µL for 6 months some also require a
    4-fold decrease in Bartonella titers

75
Bartonellosis Considerations in Pregnancy
  • No data on Bartonella infections during pregnancy
    in HIV-infected women in HIV-negative women, B
    bacilliformis associated with increased
    complications and risk of death
  • Diagnosis as in nonpregnant women
  • Treatment erythromycin recommended avoid
    tetracyclines (hepatotoxicity and staining of
    fetal teeth)
  • Alternative 3rd-generation cephalosporins (1st-
    and 2nd-generation cephalosporins not effective
    against Bartonella)

76
Bacterial Infections
  • Syphilis

77
Syphilis Epidemiology
  • Caused by Treponema pallidum
  • Associated with increased risk of HIV sexual
    acquisition and transmission
  • Increased incidence in men who have sex with men
  • HIV infection may somewhat alter diagnosis,
    natural history, and management of syphilis, but
    principles of management are the same with or
    without HIV infection

78
Syphilis Clinical Manifestations
  • HIV may make clinical lesions more apparent and
    accelerate progression of syphilis
  • Primary syphilis
  • Painless nodule at site of contact, rapidly
    ulcerates (chancre)
  • In HIV-infected patients, may see multiple or
    atypical chancres, or no primary lesion

79
Syphilis Clinical Manifestations (2)
Chancres of primary syphilis
Credit Centers for Disease Control and Prevention
80
Syphilis Clinical Manifestations (3)
  • Secondary syphilis (2-8 weeks after primary
    inoculation)
  • Protean symptoms, may involve almost any organ
    system and include
  • Rash (macular, maculopapular, papulosquamous, or
    pustular) or condyloma lata
  • Generalized lymphadenopathy
  • Constitutional symptoms (fever, malaise,
    anorexia, arthralgias, headache)
  • CNS symptoms
  • Symptoms last days-weeks
  • In advanced HIV infection, may be more severe or
    progress more rapidly
  • Distinguish from primary HIV infection

81
Syphilis Clinical Manifestations (4)
Rash of secondary syphilis
Credit Centers for Disease Control and Prevention
82
Syphilis Clinical Manifestations (5)
  • Latent syphilis no overt signs/symptoms (but
    serologic evidence of syphilis), though relapse
    of manifestations of secondary syphilis may occur
  • Late syphilis cardiovascular syphilis, gummatous
    syphilis or slowly progressive disease in any
    organ system

83
Syphilis Clinical Manifestations (6)
  • Neurosyphilis May occur at any stage of
    syphilis, with various symptoms
  • Cranial nerve dysfunction, stroke, meningitis,
    acute or chronic mental status change, loss of
    vibration sense, auditory or ophthalmic
    abnormalities, similar in HIV-uninfected patients
  • Concomitant uveitis and meningitis more common in
    HIV-positive patients

84
Syphilis Diagnosis
  • Direct detection of T pallidum
  • Darkfield microscopy of mucocutaneous lesion,
    DFA-TP, biopsy with silver stain
  • Presumptive serologic diagnosis tests
  • Nontreponemal serologic tests (VDRL, RPR)
  • Treponemal tests (eg, FTA-ABS, TP-PA, EIAs,
    chemiluminescence immunoassays)

85
Syphilis Diagnosis (2)
  • Testing algorithms
  • Traditional screening for nontreponemal
    antibodies confirmation of reactive tests by
    treponemal assay
  • Newer screening with treponemal test (EIA or
    CIA), with reflex nontreponemal test if positive
  • May identify previously treated syphilis
    infection more often than untreated infection
  • If positive treponemal screening test and
    negative reflex nontreponemal test second
    treponemal test should be done (using different
    antigens) to confirm
  • If second treponemal test is positive assess
    risk factors and prior syphilis treatment
  • If suspected primary syphilis treat empirically,
    retest with nontreponemal test in several weeks
    to confirm diagnosis
  • If no evidence of primary syphilis treat for
    late-latent syphilis (unless past treatment can
    be confirmed)
  • If second treponemal test is negative no
    treatment indicated

86
Syphilis Diagnosis (3)
  • Early-stage disease
  • Nontreponemal serologic tests (VDRL, RPR) may
    show atypical responses (higher, lower, or
    delayed) in HIV-infected patients
  • False-negative tests possible (as in
    HIV-uninfected patients) pursue other diagnostic
    tests if high suspicion of syphilis (eg, repeat
    serology, biopsy, DFA of lesion material exclude
    prozone phenomenon)

87
Syphilis Diagnosis (4)
  • Latent syphilis
  • Serologic tests positive but no clinical
    manifestations
  • Early latent evidence of infection lt1 year
  • Late latent evidence of infection gt1 year or
    duration is not known

88
Syphilis Diagnosis (5)
  • Late-stage disease
  • Cardiovascular and gummatous same as for
    HIV-uninfected patients

89
Syphilis Diagnosis (6)
  • Neurosyphilis
  • All with syphilis (regardless of stage) should be
    evaluated for clinical evidence of CNS or ocular
    involvement
  • CSF exam should be done for any patient with
  • Neurologic, auditory, or ophthalmic symptoms or
    signs
  • Tertiary syphilis
  • Treatment failure (on basis of serologic tests)
  • CSF abnormalities (elevated protein, mononuclear
    pleocytosis) common in early syphilis and in HIV,
    without neurologic symptoms no evidence that
    clinical and prognostic significance is different
    in HIV-infected and HIV-uninfected with early
    syphilis

90
Syphilis Diagnosis (7)
  • Neurosyphilis
  • No single test used to diagnose instead, various
    combinations of reactive serologic tests, CSF
    cell count and protein, and reactive CSF-VDRL
    with or without clinical manifestations support
    the diagnosis

91
Syphilis Diagnosis (8)
  • Neurosyphilis
  • CSF examination
  • Mild mononuclear pleocytosis (6-200 cells/µL),
    normal or mildly elevated protein
  • CSF VDRL
  • Specific not sensitive (reactive test
    establishes neurosyphilis nonreactive test does
    not exclude it)
  • CSF FTA-ABS
  • Highly sensitive less specific (reactive test
    does not establish the diagnosis nonreactive
    test excludes neurosyphilis)
  • PCR-based methods not recommended

92
Syphilis Diagnosis (9)
  • Neurosyphilis testing, considerations
  • Reactive CSF VDRL plus CSF WBC 10 cells/µL
    supports diagnosis of neurosyphilis
  • Mild mononuclear CSF pleocytosis (6-15 cells/µL)
    may be associated with HIV infection itself and
    may complicate diagnosis of neurosyphilis using
    cutoff of gt20 cells/µL may improve specificity of
    neurosyphilis diagnosis in HIV-infected patients
  • Elevated CSF protein concentration should not be
    used as sole diagnostic criterion

93
Syphilis Preventing Exposure
  • Risk screening should be routine
  • Client-centered risk-reduction messages give
    specific actions to reduce risk of acquiring STIs
    and for transmitting HIV
  • Routine serologic testing for syphilis at least
    annually Q 3-6 months if multiple partners,
    unprotected intercourse, injection drug or
    methamphetamine use, or partners with risks
  • Consider referral for behavioral intervention
  • Evaluate for other STIs

94
Syphilis Preventing Disease
  • For persons exposed sexually to someone with
    syphilis evaluate clinically and serologically
    and treat presumptively
  • Persons exposed within the 90 days preceding
    diagnosis of primary, secondary, or early-latent
    syphilis in a sex partner may be infected even if
    tests are seronegative treat presumptively
  • Persons exposed gt90 days before diagnosis of
    primary, secondary, or early-latent syphilis in a
    sex partner treat presumptively if serologic
    test results are not available immediately and
    follow-up is uncertain

95
Syphilis Treatment
  • Management similar to that for HIV-uninfected
    persons, but rates of serologic treatment failure
    and neurologic complications may be higher in HIV
    infection closer follow-up is recommended
  • Penicillin is treatment of choice
  • Patients with penicillin allergy whose compliance
    or follow-up cannot be ensured desensitize and
    treat with penicillin
  • Use alternatives to penicillin only with close
    clinical and serologic monitoring
  • Azithromycin resistance and treatment failure
    especially in men who have sex with men (MSM)

96
Syphilis Treatment (2)
  • Early stage (primary, secondary, early-latent)
  • Preferred
  • Benzathine penicillin G 2.4 million units IM,
    single dose
  • Alternative (for penicillin-allergic patients
    monitor closely)
  • Doxycycline 100 mg PO BID for 14 days
  • Ceftriaxone 1 g IM or IV QD for 10-14 days
  • Azithromycin 2 g PO for 1 dose (note reports of
    treatment failure and resistance should not be
    used in MSM or pregnant women)

97
Syphilis Treatment (3)
  • Late-latent (no signs of neurosyphilis)
  • Preferred
  • Benzathine penicillin G 2.4 million units IM
    weekly for 3 weeks
  • Alternative (for penicillin-allergic patients)
  • Doxycycline 100 mg PO BID for 28 days (not
    thoroughly evaluated in HIV-infected patients
    monitor closely)
  • Late-stage (cardiovascular or gummatous)
  • CSF examination consult ID specialist
  • Preferred Benzathine penicillin G 2.4 million
    units IM weekly for 3 weeks

98
Syphilis Treatment (4)
  • Neurosyphilis, otic syphilis, ocular syphilis
  • Preferred
  • Aqueous crystalline penicillin G, 18-24 million
    units daily, as 3-4 million units IV Q4H or
    continuous infusion for 10-14 days
  • Consider addition of benzathine penicillin 2.4
    million units IM weekly for 3 weeks after
    completion of IV therapy
  • Alternative
  • Procaine penicillin G 2.4 million units IM QD
    probenecid 500 mg PO QID for 10-14 days
  • Consider addition of benzathine penicillin 2.4
    million units IM weekly for 3 weeks after
    completion of above
  • Patients with sulfa allergy should not receive
    probenecid, so this regimen is not recommended
    for them
  • Penicillin allergy
  • Desensitization to penicillin is preferred if
    not feasible, ceftriaxone 2 g IM or IV QD for
    10-14 days

99
Syphilis Starting ART
  • No special considerations, no evidence that ART
    should be delayed until after treatment for
    syphilis
  • IRIS is uncommon
  • Use of ART associated with
  • Decreased risk of serologic failure of syphilis
    treatment
  • Lower risk of neurosyphilis
  • Normalization of CSF parameters after treatment

100
Syphilis Monitoring and Adverse Events
  • Monitor clinical and serologic response to
    treatment assure at least 4-fold decline from
    titer done at time of treatment
  • Early stage at 3, 6, 9, 12, 24 months
  • Late-latent at 6, 12, 18, 24 months
  • Consider treatment failure persistence or
    recurrence in clinical signs and symptoms or
    sustained 4-fold increase in nontreponemal test
    titer
  • Neurosyphilis if CSF pleocytosis present
    initially, repeat CSF exam at 6 months also
    repeat if symptoms recur or nontreponemal titer
    increases by 4-fold
  • Consider retreatment if no decrease in CSF WBC by
    6 months or if WBC not normal by 2 years

101
Syphilis Monitoring and Adverse Events (2)
  • After successful treatment, nontreponemal tests
    may remain serofast, ie, reactive at stable
    titer, usually low (18)
  • Sustained 4-fold increase in titer indicates
    reinfection

102
Syphilis Monitoring and Adverse Events (3)
  • Jarisch-Herxheimer reaction may occur in the
    first 24 hours after start of syphilis treatment
  • Fever, headache, myalgia
  • Manage symptoms with antipyretics
  • Most frequent in those with early syphilis, high
    nontreponemal titers, and prior penicillin
    treatment

103
Syphilis Treatment Failure
  • Early stage
  • Consider CSF evaluation and retreatment if
  • 4-fold decrease in serum nontreponemal test
    titer 6-12 months after therapy, or
  • Sustained 4-fold increase in titer after initial
    4-fold reduction after treatment, or
  • Persistent or recurring signs or symptoms of
    syphilis
  • Reinfection is difficult to document and
    treatment failure is difficult to rule out
  • If no appropriate titer response after CSF
    evaluation and retreatment, management is unclear
  • gt15 of early syphilis patients (HIV infected and
    uninfected) do not have 4-fold decline in titer
    after treatment

104
Syphilis Treatment Failure (2)
  • Early stage
  • Retreatment benzathine penicillin G, 2.4 million
    units weekly for 3 weeks (if neurosyphilis
    present, treat for that)

105
Syphilis Treatment Failure (3)
  • Late-latent stage
  • Repeat CSF exam and retreat if
  • Clinical signs or symptoms of syphilis, or
  • Sustained 4-fold increase in titer after initial
    reduction after treatment, or
  • 4-fold decrease in serum nontreponemal test
    titer within 12-24 months after therapy
  • Treatment benzathine penicillin G, 2.4 million
    units weekly for 3 weeks (if neurosyphilis
    present, treat for that)

106
Syphilis Treatment Failure (4)
  • Neurosyphilis
  • Consider retreatment if
  • CSF WBC count has not decreased 6 months after
    completion of treatment, or
  • CSF WBC count is not normal 2 years after
    treatment

107
Syphilis Preventing Recurrence
  • Secondary prevention and maintenance therapy not
    indicated

108
Syphilis Considerations in Pregnancy
  • Screening
  • At 1st prenatal visit in all women in
    high-prevalence areas or high-risk women, repeat
    early in 3rd trimester and at delivery
  • Transmission to the fetus and adverse pregnancy
    outcomes highest with early-stage syphilis
  • Pregnancy does not alter the clinical course or
    diagnostic test results of syphilis in adults
  • Syphilis associated with increased risk of
    perinatal HIV transmission to infants

109
Syphilis Considerations in Pregnancy (2)
  • Use penicillin, if possible, as in nonpregnant
    HIV-infected adults
  • Penicillin is effective for preventing syphilis
    transmission to the fetus and for treatment of
    fetal infection
  • Optimal penicillin regimen is not clear
  • In early syphilis, consider second injection of
    benzathine penicillin G 1 week after first dose
  • No alternatives to penicillin proven effective
    and safe for treatment of syphilis during
    pregnancy or prevention of fetal infection
  • Pregnant women with syphilis and history of
    penicillin allergy should undergo desensitization
    and treatment with penicillin

110
Syphilis Considerations in Pregnancy (3)
  • Jarisch-Herxheimer reaction in 2nd half of
    pregnancy may precipitate preterm labor or fetal
    distress
  • In 2nd half of pregnancy, sonographic evaluation
    for fetal or placental syphilis
  • Consult with OB specialists
  • After treatment, repeat serologic titers in 3rd
    trimester and at delivery
  • Insufficient data on serologic responses after
    therapy
  • Treatment likely inadequate if delivery 30 days
    of treatment, if woman has sign of infection at
    delivery, or if maternal titer is 4-fold higher
    than pretreatment titer

111
Websites to Access the Guidelines
  • http//www.aidsetc.org
  • http//aidsinfo.nih.gov

112
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
About PowerShow.com