EXAM 5 opportunistic infections Flashcards by Tandrew Nguyen

Opportunistic infections

infections more severe because of HIV mediated immunosuppression (HIV patients sometimes never rebound) may need prophylaxis

Low levels of CD4 cells

can occur in any immunocompromised patients

How well did you know this?

Not at all

Perfectly

Normal CD4 counts

800-1200

How well did you know this?

Not at all

Perfectly

Development of OI CD4 counts

CD4< 500 and especially <200 are associated with development of OIs

How well did you know this?

Not at all

Perfectly

Which opportunistic infection is associated with night sweats?

MAC

How well did you know this?

Not at all

Perfectly

Primary Prophylaxis

administration of anti-infective to prevent first episode of OI in patient living with HIV or at risk bc of CD4 count

How well did you know this?

Not at all

Perfectly

Secondary Prophylaxis

already have had OI, but to prevent further recurrences of a particular OI after successful treatment of OI

How well did you know this?

Not at all

Perfectly

When is starting ART early good?

when there are not good OI treatments
PML
cryptosporidiosis
kaposi’s sarcoma

How well did you know this?

Not at all

Perfectly

Disadvantage of starting ART

Development of IRIS

Overlapping or additive drug toxicities

Drug interactions between AER and OI therapy

How well did you know this?

Not at all

Perfectly

What is IRIS?

Immune reconsitution inflammatory syndrome

Fever, inflammation, worsening clinical manifestations of OI

More likely to occur with CD4<50

Most common within first 4-8 weeks starting ART

How well did you know this?

Not at all

Perfectly

IRIS treatment

Many wait for clinical response to OI therapy, then start ART
Start ART within 2 weeks of starting TB treatment if CD4 <50 or within 8 weeks if higher

Treat OI

Mild: NSAIDs + ICS

Severe: Prednisone

How well did you know this?

Not at all

Perfectly

Oropharyngeal candidiasis

Very common infection

Normal in GI, oropharynx, and female genitalia

Painless, white creamy plaque lesions

How well did you know this?

Not at all

Perfectly

Oropharyngeal candidiasis treatment

Preferred: fluconazole 200mg loading dose followed by 100-200mg PO daily for 7-14 days

Alternative: topical agents for mild to moderate
Nystatin 100,000 5 ml QID for 7-14 days
Clotrimazole 10mg 5times daily for 7-14 days

How well did you know this?

Not at all

Perfectly

Esophageal candidiasis

Fever, retrosternal burning, pain swallowing

How well did you know this?

Not at all

Perfectly

Esophageal candidiasis treatment

Treatment:

Topical not effective

Preferred: fluconazole 200mg loading dose, followed by 100-200mg PO/IV for 14-21 days

How well did you know this?

Not at all

Perfectly

Vulvovaginal candidiasis

Vaginal itching, burning, drainage

How well did you know this?

Not at all

Perfectly

Vulvovaginal candidiasis treatment - Uncomplicated

fluconazole 150 PO x 1 dose

topical azoles for 3-7 days

ibrexafungerp 300mg PO BID

How well did you know this?

Not at all

Perfectly

Vulvovaginal candidiasis treatment - severe

fluconazole 100-200 mg PO daily

topical azoles for 7 days

Vulvovaginal candidiasis treatment - azole refractory c. glabrata vaginitis

boric acid 600mg vaginal suppository

candidiasis prophylaxis

not recommended

only consider for patients with frequent or severe recurrences of esophagitis or vaginitis

Cryptococcal meningitis

headache, fever, neck stiffness, photophobia

Cryptococcal meningitis ART initiation

delayed inhiation of ART for 2 weeks, and sometimes 8 weeks, which is after consolidation

Cryptococcal meningitis treatment

preferred induction:
amphotericin B IV QD + flucytosine for 2 WEEKS

preferred consolidation:
>8 weeks followed by maintenance
Fluconazole 800mg or 400mg in stable patients

Preferred maintenance:
 Fluconazole 200mg PO daily

Cryptococcal meningitis prophylaxis

Routine primary prophylaxis is not recommended

secondary prophylaxis is required after induction/consolidation therapy

may discontinue:
completed 1 year
asymptomatic
CD4 > 100 for 3 months on ART

Histoplasmosis treatment consideration

Start ART ASAP after antifungal therapy

less concern for IRIS

histoplasmosis prophylaxis

Primary: CD4 count < 150 and at high risk Use itraconazole 200 QD May stop if taking ART and CD4 > 150 for 6 months Secondary: Itraconazole 200 QD after maintenance complete

Histoplasmosis treatment

mild-mod: itraconazole severe: ampothericin followed by itraconazole

Myocobacterium Avium complex (MAC)

Patients with CD4 count <50, viral replication despite ART Presentation: multi-organ infection, night sweats Physical: enlarged liver, spleen, lymph Diagnosis: culture blood, lymph, bone marrow, tissue

Myocobacterium Avium complex (MAC) treatment considerations

IRIS not a big problem Start ART ASAP, preferably w/ MAC Should include 2 drugs as initial therapy to prevent delay emergence

Myocobacterium Avium complex (MAC) treatment

Clarithromycin 500 PO BID + ethambutol 15mg/kg PO daily Azithromycin 500-600 PO QD + ethambutol 15mg/kg PO daily In severe cases, add rifabutin 300 PO QD In very severe, add 4th drug (levo,moxi, amikacin, streptomycin)

Myocobacterium Avium complex (MAC) prophylaxis

Not recommended who are on ART CD4<50 AND not receiving ART or remaining viremic on ART Preferred: Azithromycin 1200mg once weekly

PJP presentation

Non-productive cough Hypoxemia is most characteristic lab abnormality (O2 down <70mmHg)

PJP diagnosis (physical)

Hypoxemia <70mmHg High Lactate dehydrogenase (LDH) > 500 Ground glass CXR PCR – highly sensitive and specific

PJP treatment - moderate to severe

preferred: TMP-SMX 15-20mg/kg/day of TMP IV q6-8h for 21 days Alternative: primaquine 30mg + clindamycin pentamidine 4mg/kg QD

when are adjunctive corticosteroids used for PJP

use for moderate-severe PJP (PO2 < 70) start within 72 hrs PJP prednisone: 40 PO BID 5days, then 40 PO QD 5 days, then 20mg QD for 11 days

PJP treatment - mild to moderate

preferred: TMP-SMX15-20mg/kg/day of TMP component PO divided 3 doses TMP-SMX, two DS PO TID Alternative: Dapsone 100+ TMP 15 mg/kg/day Primaquine 30mg + clindamycin atovaquone 750mg BID G6PD for Dapsone + primaquine

PJP primary prophylaxis

given to prevent first episode of PJP in all HIV-infected patients with: CD4 count 100-200 if HIV RNA level above detection limits CD4 count < 100 regardless HIV RNA level TMP-SMX DS or SS QD or DS MWF Sulfa allergy: dapsone or atovaquone

PJP secondary prophylaxis

given after completion of treatment for an acute episode for all PJP patients Stop prophylaxis when CD4 count increases from <200 to >200 for >3 months in response to ART Restart if CD4 falls < 100 regardless HIV RNA level TMP-SMX DS or SS QD or DS MWF Sulfa allergy: dapsone or atovaquone

Toxoplasma gondii

Clinical disease almost exclusively occurs because of reactivation of latent tissue cysts Diagnosis: CT scan or MRI of brain reveals one or more ring enhancing lesions in grey matter of cortex/basal ganglia

Toxoplasma gondii treatment - acute infection

preferred: pyrimethamine 200mg PO x1 followed by WBD BW<60 kg: pyrimethamine 50mg + sulfadiazine 1,000mg BW>60kg: pyrimethamine 75mg + sulfadiazine 1,500mg OR Bactrim

Toxoplasma gondii treatment - chronic infection

Preferred: Pyrimethamine 25-50mg + sulfadiazine 2,000-4,000mg + leucovorin 10-25mg OR Bactrim DS PO BID

Toxoplasma gondii primary prophylaxis

needs toxoplasma IgG (+) AND CD4 count <100 Preferred: TMP-SMX DS 1 QD

Toxoplasma gondii secondary prophylaxis

give to all patients after completion of acute treatment Chronic maintenance therapy Can stop if CD4 >200 >6 months in response to ART and completed initial therapy Restart if CD4 count falls <200 regardless