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BCPS > HIV & Opportunistic Infections > Flashcards

HIV & Opportunistic Infections Flashcards

1
Q

HIV 4th generation test

A

First step to diagnosing HIV inpatient.

If positive, then will need HIV-1/2 Ab differentiation immunoassay

If negative, then no HIV.

> 99% sensitivity and specificity

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2
Q

HIV-1/2 Ab Immunassay

A

Administer if 4th generation test positive

Differentiates HIV 1 from HIV 2

If positive, diagnosis made

If negative, administer HIV-1 nucleic acid test

> 99% sensitivity and specificity

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3
Q

HIV-1 nucleic acid test

A

Administer if 4th gen HIV test +, HIV-1/2 Ab immunassay negative

Tests for HIV-1

If positive, diagnosis made
If negative, no HIV

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4
Q

Rapid HIV test

A

Can have result in 20 minutes after oral swab or fingerstick

If positive, repeat with another manufacturer test. IF that is positive, then positive . If negative, repeat with another manufacturer’s test.

If negative, no need to retest.

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5
Q

HIV RNA Viral suppression

A

Goal of ART

HIV RNA <20-75 (level of detection of assay)

HIV RNA <200 prevents HIV transmission to sexual partners

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6
Q

HIV RNA testing - when to test

A
  1. Baseline
  2. If not on therapy, every 3-6 months
  3. 2-4 weeks after starting or changing therapy
  4. Then, every 3-4 months while on treatment. Can go to q6 months if suppressed >1yr
  5. Clinical event or decrease in CD4 count
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7
Q

PrEP options

A

Anyone who wants it and recently tested negative for HIV

  1. Tenofovir disoproxil fumarate 300mg + emtricitabine 200mg (truvada)
  2. Tenofovir alafenamide 25mg + emtricitabine 300mg (descovy)
  3. Cabotegravir 600mg months 1 & 2, then q8w
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8
Q

On demand PrEP

A

for MSM, infrequently, can anticipate when. Not FDA approved.

Truvada (tenofovir disoproxil fumarate/emtricitabine):
2 doses 24hrs before sex, 1 dose 24 hrs after first dose, 1 dose 48 hours after first dose

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9
Q

Monitoring parameters for PrEP

A

Baseline:
1. HIV test
2. Renal function (for tenofovir)
3. STI
4. Lipids

Repeat HIV test q3months (or 2 months on cabotegravir)

Repeat renal fxn, STI, lipids q6-12 months

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10
Q

HIV in Pregnancy

A

ALL WOMEN SHOULD BE ON COMBINATION ART ASAP EVEN IN FIRST TRIMESTER

Regimens:
1. A dual nucleoside reverse transcriptase inhibitor (NRTI) combo: abacavair/lamivudine; tenofovir/emtricitabine; tenofovir/lamivudine

  1. Ritonavir-boosted protease inhibitor: darunavir/ritonavir
  2. Integrase strand transfer inhibitor (INSTI): dolutegravir
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11
Q

HIV in labor with HIV RNA >1000

A

Zidovudine IV should be given

Or if HIV RNA unknown

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12
Q

Infant born to HIV + mom, low risk transmission

A

Zidovudine 4mg/kg/dose q12H for 4 weeks.

Start within 6 hours of delivery

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13
Q

Infant born to HIV + mom, high risk of transmission

A

Zidovudine, lamivudine and nevirapine

OR

Zidovudine, lamivudine, and raltegravir

6 weeks

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14
Q

Nonoccupational post-exposure prophylaxis HIV

A

Begin with 72 hours of coming in contact with blood, semen, vaginal secretion, breast milk

Raltegravir twice daily OR dolutegravir daily
+
Tenofovir disoproxil fumarate/emtricitabine daily

Alt: darunavir/ritonavir + tenofovir disoproxil fumarate/emtricitabine

Treat 4 weeks

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15
Q

Occupational PEP HIV

A

Begin ASAP

Raltegravir BID
+
Tenofovir disoproxil fumarate/emtricitabine

Several alts

Continue 4 weeks

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16
Q

Nucleoside/nucleotide reverse transcriptase inhibitors

A

LATTEZ

Lamivurdine
Abacavir
Tenofovir disoproxil fumarate
Tenofovir alafenamide
Emtricitabine
Zidovudine

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17
Q

TAF vs TDF

A

TDF more favorable on lipids

TAF more favorable on bones and kidneys

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18
Q

NRTI renal adjustment needed

A

Emtricitabine
Lamivudine
Zidovudine

TDF do not use <50-70 ml/min
TAF do not use <15 ml/min

TAF has way more drug interactions, mainly with the 3A4 strong inducers

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18
Q

NRTI hepatic adjustment needed

A

Abacavir

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19
Q

Genetic test before abacavir

A

HLA B*5701 to determine if risk for hypersensitivity reaction

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20
Q

Nonnucleoside Reverse Transcriptase Inhibitors (v’s)

A

ENDER of hiv

Efavirenz
Nevirapine
Doravirine
Etravirine
Rilpivirine

ALL metabolized by CYP 3A4

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21
Q

NNRTI with renal adjustment & hepatic adjustment

A

Nevirapine

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22
Q

Protease inhibitors (-navirs)

A

LARD get this hiv outta me

Lopinavir/ritonavir
Atazanavir
Ritonavir
Darunavir

TAKE ALL WITH FOOD

All metabolized by CYP3A4

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23
Q

Endocrine disturbances with protease inhibitors

A

T2DM
Peripheral fat loss & central fat accumulation
Lipid abnormalities

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24
Q

Protease inhibitor renal adjustment

A

Atazanavir

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25
Q

Protease inhibitor hepatic adjustment

A

Atazanavir
Darunavir

26
Q

Integrase Strand Transfer Inhibitors (-gravirs)

A

C BRED (can take with food)

Cabotegravir (PO and IM)
Bictegravir
Raltegravir
Elvitegravir
Dolutegravir

27
Q

INSTIs with renal adjustment

A

Bictegravir
Elvitegravir

28
Q

INSTIs with hepatic adjustment

A

Bictegravir
Dolutegravir
Elvitegravir

29
Q

Entry Inhibitors

A

FILME at the entry

Fostemsavir
Ibalizumab (IV)
Lenacapavir (PO and SC)
Maraviroc
Enfuvirtide (SC)

30
Q

Entry inhibitors renal adjustment

A

Maraviroc

31
Q

Recommended initial ART therapy

A

2 NRTIs (LATTEZ) + INSTI (-gravirs)

32
Q

Pneumocystitis jiroveci pneumonia (PJP) Preferred Treatment

A

Mod-severe: Bactrim 15-20mg/kg/day TMP dividied q6-8h x21 days - may use IV

Mild-mod: 2 bactrim DS tabs TID

Add steroid taper if severe (A-a gradient >35 or Po2 <70): pred 40mg BID x5d, then 40mg x5d, then 20mg daily for remainder of therapy
steroids decrease mortality

33
Q

PJP prophylaxis

A

Use if CD4 < 200. May D/C if CD4 > 200 for 3 months

Bactrim SS or DS daily

Alt: Bactrim DS 3x/week
Alt: Atovaquone 1500mg daily
Alt: Pentamidine monthly inhalation
Alt: Dapsone 100mg daily or combine with pyrimethamine & leucovorin

34
Q

PJP Alterantive regimens

A
  1. Clindamycin and primaquine
  2. Atovaquone
  3. Pentamidine (IV)
  4. Trimethoprim & Dapsone
35
Q

Pyrimethamine + leucovorin purpose

A

Leucovorin helps prevent myelosuppression. Must be given with pyrimethamine

36
Q

Toxoplasmosis preferred therapy

A

Pyrimethamine 50-75mg/day + Sulfadiazine 1000-1500mg q6h

Add leucovorin 10-25mg/day to reduce bone marrow suppression effect of pyrimethamine

6 weeks at least

Can be used for chronic maintenance

37
Q

Toxoplasmosis alternative therapy

A
  1. Clindamycin + pyrimethamine
  2. Bactrim
  3. Atovaquone + pyrimethamine/leucovorin
  4. Atovaquone + sulfasalazine
  5. Atovaquone alone

Similarly can be used for chronic maintenance therapy, different dosing

38
Q

Toxoplasmosis prophylaxis

A

CD4 <100. Can d/c if CD4 >200 for 3 months

  1. Bactrim DS daily
  2. Dapsone/pyrimethamine/leucovorin
  3. Atovaquone +/- pyrimethamine
39
Q

Oropharyngeal candidiasis treatment

A

Fluconazole 100mg daily

Alt: Itraconazole 200mg solution daily
Alt: Posaconazole suspension 400mg daily
Alt: Miconazole buccal tabs
Alt: Clotrimazole troches
Alt: Nystatin 5ml 4-5x daily

Treat 7-14 days

40
Q

Esophageal candidiasis treatment

A

Fluconazole 100-400mg daily PO or IV
Itraconazole 200mg PO daily

Several alts

Treat 14-21 days

41
Q

Vulvovaginal candidiasis treatment

A

Fluconazole 150mg x1
Topical azoles

Alt: itraconazole 200mg solution daily

Treat 3-7 days

42
Q

Cryptococcal meningitis induction therapy

A

Preferred:

**1. Liposomal amphotericin B 3-4 mg/kg/day PLUS flucytosine 25mg/kg q6h
2. Amphotericin B deoxycholate 0.7-1 mg/kg/day PLUS flucytosine 25mg/kg q6h (renal toxicity)

Several alts. Pick liposomal amp B.

Induction is 2 weeks

43
Q

Cryptococcal meningitis consolidation therapy

A

Fluconazole 800mg daily (may decrease to 400mg if CSF negative, ART started)

At least 8 weeks

44
Q

Cryptococcal meningitis maintenance therapy

A

Fluconazole 200mg daily x1 year.

May d/c after a minimum of a year if CD4 > 100 for 3 months

45
Q

When to start ART with cryptococcal meningitis

A

AFter 2-10 weeks of treatment.
Risk of IRIS

46
Q

Cryptococcal meningitis prophylaxis

A

Not indicated

47
Q

MAC preferred therapy

A

Clarithromycin 500mg BID PLUS ethambutol 15mg/kg/day

Can use azithromycin 500-600mg in place of clarithromycin if drug interactions or intolerance

Treat for 12 months minimum

48
Q

Add on therapy to MAC preferred therapy

A

If CD4 <50, high mycobaterial load, or no ART

  1. Rifabutin 300mg/day
  2. FQ (levo 500, moxi 400)
  3. Aminoglycoside (amikacin 10-15 mg/kg IV or streptomycin 1g IV/IM)
49
Q

MAC prophylaxis

A

CD4 <50 and not on ART. If immediately started on ART, not needed.
Use a macrolide

50
Q

Cytomegalovirus retinitis, sight threatening lesions

A

Can progress to blindness or retinal detachment

Valganciclovir 900mg BID x14-21 days, then 900mg daily.
May add on intravitreal injections of ganciclovir or foscarnet

Alt: ganciclovir IV
Alt: Foscarnet IV
Alt: Cidofovir IV

51
Q

Cytomegalovirus retinitis, peripheral lesions

A

Valganciclovir 900mg BID x14-21 days, then 900mg daily for 3-6 months until ART induced immunity

52
Q

Cytomegalovirus esophagitis, colitis, pneumonitis, neuro

A

Use ganciclovir, foscarnet, or valganciclovir

53
Q

CMV prophylaxis

A

Not indicated

54
Q

Positive TB skin test

A

Ranges from >=5 to >=15 depending on risk factors

55
Q

Latent TB regimens, non HIV

A
  1. Rifapentine 900mg + isoniazid 900mg weekly for 12 weeks
  2. Rifampin 600mg daily x4 months
  3. Rifampin 600mg daily + isoniazid 300mg daily x3 months
  4. Isoniazid 300mg daily or 900mg twice weekly for 6-9 months
56
Q

Latent TB treatment, with HIV

A
  1. Rifapentine 900mg daily + isoniazid 15mg/kg + pyridoxine 50mg daily weekly for 12 weeks
  2. Isoniazid 300mg + rifampin 600mg + pyridoxine 25-50mg daily x3 months

Can still do rifampin 600mg daily x4 months

If rifampin drug interactions concerning, then isoniazid 300mg daily + pyridoxine 25-50mg daily x6-9 months

57
Q

First line active TB agents

A

Rifampin
Isoniazid
Pyrazinamide
Ethambutol

58
Q

Intensive & continuation phase for TB, no HIV

A

Intensive: RIPE x2 months (daily or 5x weekly)

Continuation: isoniazid + rifampin x4 months (daily or 5x weekly)

If TB isolate susceptible to isoniazid, rifampin, then can exclude ethambutol

59
Q

Intensive, continuation phase for TB, HIV +

A

Intensive: RIPE daily x2 months (may use rifabutin instead of rifampin)

Continuation: isoniazid + rifampin or rifabutin daily x4 months

60
Q

When to extend continuation phase of TB treatment

A

nonHIV: positive sputum and xray after intensive phase

HIV: if not on ART

increase from 4 to 7 months

61
Q

Purpose of pyridoxine in RIPE therapy

A

Prevent neuropathy caused from isoniazid

62
Q

When to use rifabutin over rifampin for HIV + on ART

A

ART contains protease inhibitor

ART contains TAF

Dose adjustment to ART needed if contain INSTIs

Need washout period after rifampin of 2 weeks before restarting PIs, elvitegravir, or NNRTI

63
Q

Rifabutin + ART

A

May need to increase dose to 450-600mg daily if in combo with NRTI and NNRTIs

Do not give with TAF

If PI boosted with ritonavir, decrease rifabutin dose

Avoid elvitegravir and bictegravir with rifabutin

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