exam 5 - opportunistic infections HIV

Question 1

Drug of choice for MAC treatment

Answer 1

Clarithro 500mg PO BID or Azith 500-600mg PO QD+ Ethambutol 15mg/kg po QD

Question 2

if MAC is severe what 3rd drug can be added on to treatment

Answer 2

Add rifabutin 300mg PO QD

Question 3

if MAC is severe what 4th drug can be added on to treatment

Answer 3

levo 500mg PO QD or moxi 400mg PO QD or
amikacin 10-15mg/kg IV daily or streptomycin 1gm IV or IM daily

Question 4

PJP treatment drug of choice

Answer 4

TMP-SMX 15-20mg/kg/day of TMP IV divided q6-8h x21 days (may switch to PO after clinical improvement)

Question 5

PJP treatment alternative drug therapy options

Answer 5

-Primaquine 30mg PO QD + Clindamycin (600mg IV q6, 900mg IV q8, 450mg PO q6, or 600mg PO q8).
-Pentamidine 4mg/kg IV qd infused over >60 min

Question 6

when can adjunctive treatment be added to PJP

Answer 6

moderate to severe (pO2 < 70)

Question 7

what is adjunctive treatment for mod-sev PJP

Answer 7

prednisone 40mg PO BID x5 days then 40mg PO QD x5 days, then 20mg QD x11 days
(give methylprednisolone 80% if IV)

Question 8

toxoplasmosis acute infection treatment drug of choice

Answer 8

pyrimethamine 200mg PO x1 followed by weight based dosing

Question 9

what is the weight based dosing of pyrimethamine <= 60 kg for TE

Answer 9

pyrimethamine 50mg PO QD + sulfadiazine 1500mg PO q6 + leucovorin 10-25mg PO QD

Question 10

what is the weight based dosing of pyrimethamine > 60kg for TE

Answer 10

pyrimethamine 75mg PO qd + sulfadiazine 1500mg PO q6 + leucovorin 10-25mg PO QD

Question 11

what is the alternative weight based dosing option for TE acute infection

Answer 11

TMP-SMX 5mg/kg (IV or PO) BID

Question 12

what is the duration of treatment for TE acute infection

Answer 12

at least 6 weeks, longer may be needed

Question 13

what are the alternative therapies for TE acute infection

Answer 13

pyrimethamine + leucovorin + clindamycin 600mg IV or PO q6
atovaquone 1500mg PO BID + pyrim + leuco
atovaquone 1500mg PO BID + sulfa
atovaquone 1500mg PO BID

Question 14

do you do prophylaxis for MAC

Answer 14

yes primary and secondary are both recommended

Question 15

primary prophylaxis drug of choice for MAC

Answer 15

Azithromycin 1200mg PO once weekly

Question 16

secondary prophylaxis drug of choice for MAC

Answer 16

Clarithro 500mg PO BID + Ethambutol 15mg/kg PO daily w/wo Rifabutin 300mg PO QD

Question 17

when to stop primary prophylaxis for MAC

Answer 17

once on a fully suppressive ART regimen

Question 18

when to restart primary prophylaxis of MAC

Answer 18

CD4 < 50 and not on fully suppressive ART

Question 19

when to stop secondary prophylaxis treatment for MAC

Answer 19

completed more than 12 months of therapy and there are no s/sxs and a sustained CD4 count > 100 in response to ART

Question 20

when to restart secondary prophylaxis for MAC

Answer 20

fully suppressive ART regimen not possible and CD4 count consistently < 100

Question 21

when to start primary prophylaxis for PJP

Answer 21

CD4 100-200 and RNA above limit or
CD4 < 100

Question 22

prophylaxis drug of choice for PJP

Answer 22

TMP-SMX DS PO QD
TMP-SMX SS PO QD

Question 23

prophylaxis alternative choice for PJP

Answer 23

TMP-SMX DS PO MWF
Dapsone 100mg PO QD
Atovaquone 1500mg PO QD w/ food
Aerosolized or IV pentamidine 300mg/mouth

Question 24

when to stop primary and secondary prophylaxis for PJP

Answer 24

-CD4 >200 for >3 months in response to ART
-CD4 100-200 and RNA below limit for 3-6 months

Question 25

when to restart primary or secondary prophylaxis for PJP

Answer 25

CD4 count < 100 regardless of HIV RNA levels CD4 count 100-200 and HIV RNA levels above detection limits

Question 26

when should prophylaxis be for life in PJP

Answer 26

PJP occurs with CD4 > 200 while on ART

Question 27

when to start primary prophylaxis for TE

Answer 27

CD4 < 100

Question 28

primary prophylaxis drug of choice for TE

Answer 28

TMP-SMX DS PO QD

Question 29

primary prophylaxis alternate therapy for TE

Answer 29

TMP-SMX SS PO QD TMP-SMX DS PO MWF Dap 50 + pyrim 50 + leuco 25 Dap 200 + pyrim 75 + leuco 25 Atovaq 1500 + pyrim 25 + leuco 10

Question 30

when to stop primary prophylaxis for TE

Answer 30

CD4 >200 for >3months and rna below detection due to ART CD4 100-200 if rna below for 3-6 months

Question 31

when to re-start primary prophylaxis for TE

Answer 31

CD4 < 100 CD4 100-200 and rna above detection limit

Question 32

when to stop secondary prophylaxis for TE

Answer 32

completed initial therapy receiving maintenance and free of disease CD4 >200 for >6 months in response to ART

Question 33

secondary prophylaxis drug of choice for TE

Answer 33

pyrimth 25-50 + sulfa 2000-4000 + leuco 10-25 TMP-SMX DS PO BID

Question 34

secondary prophylaxis alternative for TE

Answer 34

clinda 600 + pyrim 25-50 + leuco 10-25 atovaquone 750-1500 + pyrimeth + leuco atovaquone + sulfa atovaquone alone

Question 35

when to restart secondary prophylaxis for TE

Answer 35

CD4 < 200

Question 36

oropharyngeal candidiasis treatment drug of choice

Answer 36

Fluconazole 200mg LD then 100-200mg PO QD x7-14 days

Question 37

fluconazole AEs

Answer 37

n/v/d abdominal pain inc LFTs QTc

Question 38

esophageal candidiasis treatment

Answer 38

fluconazole 200mg LD then 100-200mg PO or IV QD x14-21 days

Question 39

vaginal candidiasis uncomplicated treatment

Answer 39

fluconazole 150mg PO x1 dose topical azoles x3-7 days ibrexafungerp 300mg PO BID x1 day

Question 40

vaginal candidiasis severe treatment

Answer 40

fluconazole 100-200mg PO QD for >7 days topical azoles >7 days

Question 41

vaginal candidiasis recurrent treatment

Answer 41

oteseconazole fluconazole + oteseconazole fluconazole + ibrexafungerp

Question 42

azole refractory vaginal candidiasis

Answer 42

boric acid 600mg vaginal suppository QD x14 days

Question 43

cryptococcal meningitis treatment

Answer 43

Liposomal amphotericin B 3mg/kg IV once daily + flucytosine 25mg/kg PO QID x2 weeks then fluconazole 400-800 x8 weeks then fluconazole 200 for 1 year or longer

Question 44

histoplasmosis mild/moderate treatment

Answer 44

itraconazole 200mg PO TID x3 days then 200mg PO BID >12 months

Question 45

histoplasmosis severe treatment

Answer 45

Liposomal amphotericin B 3 mg/kg IV daily for at least 2 weeks followed by itraconazole 200 mg PO TID x 3 days, then 200 mg PO BID for at least 12 months