Exam 5 - Opportunistic Infections (Erdman) Flashcards
Normal CD4 count in adults?
500 - 1200 cells/mm3
without ART therapy a patient with HIV will have a ______ decline in CD4 cells per year
50 - 100
when CD4 cell counts are < ______ and especially < ______ are associated with development of opportunistic infections
< 500 and < 200
When CD4 counts are < 500 pts may develop OIs such as what 5 infections/diseases?
bacterial pneumonia vaginal candidiasis thrush shingles oral leukoplakia
When CD4 counts are < 200 pts may develop OIs such as what 7 infections/diseases?
PCP Kaposi Sarcoma CMV MAC Lymphoma Cryptococcal meningitis Cryptospordium diarrhea
why avoid starting ART with an acute OI?
IRIS!! (immune reconstitution inflammatory syndrome)
worsening clinical manifestations (because body is getting better immune system really starts attacking the infection)
IRIS will typically develop within the first ______ weeks of initiation of ART if it is going to occur
4 - 8 weeks
Oropharyngeal cadidiasis/thrush:
use topical therapy when?
if INITIAL, mild or moderate episodes only
Oropharyngeal cadidiasis/thrush:
what are the topical options?
nystatin susp
Clotrimazole troches
miconazole buccal tab
Oropharyngeal cadidiasis/thrush:
topical or systemic is superior?
systemic fo sho
Oropharyngeal cadidiasis/thrush:
when you absolutely must use systemic therapy?
if concomitant candida esophagitis
Symptoms of esophageal candidiasis
retrosternal burning pain/discomfrot
dysphagia
odynophagia
Treatment of choice for esophageal candidiasis
fluconazole 100 mg PO IV or QD x 14 - 21 days
IV when having issues swallowing for sure — at least initially the move to PO!
Options for Vulvovaginitis Cadidia infection:
topical azoles if skin involvement
PO fluconazole
(do longer fluconazole treatment regimens if severe/recurrent episodes)
Primary Prophylaxis for candida infections?
NOT RECOMMENDED!!
only do daily secondary prophylaxis if severe/frequent esophagitis or vaginitis
Cryptococcous Meningitis:
Sxs?
menigitis things: fever, HA, malaise..
Diagnosis of Cryptococcus meningitis done how?
lumber punctures/CSF analysis….
Cryptococcus Pneumonia
________ be excluded in AIDS patients
concomitant meningitis
Treatment of Cryptococcus Meningitis:
Overall into what different phases?
3 phases:
induction –> consolidation –> maintenance
Treatment of Cryptococcus Meningitis:
what does induction phase consist of?
IV liposomal amphotericin B + PO flucytosine x 2 weeks
Treatment of Cryptococcus Meningitis:
what does consolidation phase consist of?
PO fluconazole x 8 weeks
Treatment of Cryptococcus Meningitis:
what does maintenance phase consist of?
fluconazole x 1 yr
Treatment of Cryptococcus Meningitis:
When to do primary or secondary prophylaxis
priamary – almost like never
secondary is like maintenance therapy…secondary prophylaxis CAN be stopped at some point..
what is PCP
pneumocystis jirovecii/carnii Pneumonia
main symptoms seen with PCP?
CHF like symptom of progressive dyspnea on exertion
annnnd
a NON-productive cough
Hypoxemia: deemed as pO2 < ______ mmHg
70
DOC regimen for PCP?
SMZ-TMP: HIGH DOSE x 21 days
possible adjunctive therapy for PCP?
prednisone
when to add prednisone for PCP?
when pO2 < 70 mmHg
also best to start with INITIATION of PCP therapy
should you do Primary prophylaxis for PCP?
YES! ALL HIV PTs start when CD4 count is less than 200
should you do Secondary prophylaxis for PCP?
must do it!
can you ever stop prophylaxis for PCP?
yes only when CD4 count has been above 200 for 3 consistent months
what infection can be affected by lifestyle choices a lot (can come from shell fish, raw/undercooked meat or soil or cat feces exposure)
toxoplasma gondii
main treatment for Toxoplasma?
pyrimethamine and sulfadiazine x 6 weeks and leucovorin
what is leucovorins role in toxoplasma treatment
it help minimize bone marrow suppression from pyrimethamine
what are the adjunctive therapy options for toxoplasma treatment and when to use them?
steroids - use for patients with mass effect from focal lesions or assoc. edema and
anticonvulsants - if history of of seizures (only to use during acute treatment)
when to do primary prophylaxis for toxoplasma?
when pt is seroPOSITIVE and do it when CD4 is < 100
Washing hands (after soil or cat liter handling) and fruits is important what type of patient?
Toxo IgG seroNEGATIVE toxoplasma
what does MAC stand for
mycobacterium avium complex
MAC occurs most when CD4 count is below what?
50!
MAC Symptoms:
Gradual onset or hit them like a train?
gradual onsest
Treatment of MAC should involve at least 2 or more __________ drugs
antimycobacterial
what are the main drugs used for treating MAC
Clarithromycin and Ethambutol
maybe rifabutin
treat disseminated MAC for how long?
> 12 months
If pt with disseminated MAC is not on ART..when do you start ART?
preferably as soon as ART is started
when treating MAC: watch out for drug interactions b/w rifabutin or clarithromycin and the use of what 2 specific ARTs mainly?
Protease inhibitors
and NNRTIs
when to do primary prophlaxis for MAC?
only do it it pts are NOT on fully suppressive ART and have CD4 count < 50
do secondary prophylaxis for who and how long after MAC?
everyone gets it for a year
DOC for oropharyngeal cadidiasis
fluconazole PO QD 7 - 14 days
Monitor ________ periodically during prolonged azole therapy
LFTs
Azoles can cause ______ or ______ as side effects
GI upset
hepatoxicity
Side effects of IV amphotericicin?
NEPHROtoxicity (BUN/SCr monitoring)
Hypokalema (electrolyte monitoring)
hypomagnesemia (electrolyte monitoring)
Infusion related reactions
Side effects of Flucytosine/monitor what?
Bone marrow suppression (CBC once or twice weekly)
T or F: you do not need to renal adjust flucytosine
false you hella do need to adjust
Alt. Therapy options for PCP?
Atovaquone
Primaquine
DAPSONE + TMP
SMX-TMP:
Side effects?
some reason a lot higher in pts with AIDS
Rash, fever, leukopenia/thrombocytopenia/ hepatitis, HYPERKALEMIA
Monitor what when giving SMX-TMP?
CBC/SCr and K (2 - 3 times per week)
what two drugs do you need to test for G6PD deficiency (because risk of methemoglobinemia/hemolysis)
Dapsone and Primaquine
relevant to PCP
ADEs of ethambutol?
optic neuritis
hepatoxicity
ADEs of rifabutin?
red/orange colored body fluids
hepatoxicity
uveitis
DOC for PCP prophylaxis?
BACTRIM DS PO QD
DOC for Toxoplasma primary prophylaxis?
BACTRIM DS PO QD
For Primary prophylaxis:
Dapsone alone is ok to cover PCP or Toxoplasma?
Dapsone is only ok alone for PCP;
Dapsone needs to be given with pyrimethamine if want to cover Toxoplasma
For secondary prophylaxis for Toxoplasma:
do what drugs?
(same as treatment)
pyrimethamine and sulfadiazine and leucovorin
drug of choice for MAC primary prophylaxis
Azithromycin once WEEKLY
drug of choice for MAC secondary prophylaxis
Clarithromycin/Ethambutol +/- rifabutin
