ID Pt2

Question 1

Preferred ART for HIV+ pregnant women

Answer 1

dual NRTI + ritonavir boosted PI (atazanavir or darunavir) or an INSTI (raltegravir)

Question 2

PCP/PJP prophylaxis (preferred)

Answer 2

CD4 < 200

Bactrim DS daily
Bactrim SS daily
Bactrim DS three times weekly

Question 3

PCP/PJP preferred treatment

Answer 3

Bactrim: 2 DS tabs TID or 15-20mg/kg/day trimethoprim divided q6-8h for 21 days IV

Question 4

PCP/PJP prophylaxis alternative

Answer 4

atovaquone 1500 mg once daily OR dapsone 100 mg daily OR dapsone 50 mg weekly + leucovorin and pyrimethamine weekly

Question 5

PCP/PJP alternative treatment regimens

Answer 5

Clindamycin & primaquine: 600 mg q6h or 900mg q8h IV + primaquine 30 mg daily.

Pentamidine: 4mg/kg/day IV for 21 days (more severe disease)

Trimethoprim + dapsone: trimethoprim 15 mg/kg/day divided q8h + dapsone 100 mg daily for 21 days

Atovaquone (Mepron): 750 mg BID for 21 days with high fat meal (mild/moderate)

Question 6

PCP/PJP Primary & Secondary prophylaxis initiation/discontinuation

Answer 6

Primary: CD4 < 200 to initiate
Secondary: Post PCP/PJP if CD4 < 200

D/C when CD4 > 200 for more than 3 months OR 100-200 with undetectable viral load for 3-6 months

Question 7

Cryptococcosis preferred treatment - induction

Answer 7

liposomal amphotericin B 3-4 mg/kg/day + flucytosine 25 mg/kg q6h OR amphotericin B 0.7-1mg/kg/day + flucytosine 25 mg/kg q6h

duration: 2 weeks (need negative CSF)

Question 8

cryptococcosis consolidation therapy

Answer 8

fluconazole 400 mg daily for 8 weeks

Question 9

cryptococcosis maintenance therapy and secondary prophylaxis

Answer 9

fluconazole 200 mg daily.

Can DC after 1 year if CD4 > 100

No primary prophylaxis

Question 10

MAC treatment

Answer 10

macrolide + ethambutol for 12 months

clarithromycin 500 mg BID or azithro 500-600 mg daily + ethambutol 15 mg/kg/day.

May add rifabutin, fluoroquinolone, or aminoglycoside if CD4 < 50.

Question 11

MAC Primary Prophylaxis

Answer 11

Indicated if CD4 < 50 who are not on ART. Not recommended if on ART.

Consider clarithromycin 500 mg BID or azithro 1200 mg weekly or 600 mg BID. Alternative is rifabutin 300 mg daily

Question 12

MAC Secondary Prophylaxis

Answer 12

DC treatment after 12 months if CD 4 > 100 for 6 months, asymptomatic, and on ART. Restart if CD4 < 100.

Question 13

CMV retinitis treatment

Answer 13

Valganciclovir 900 mg PO BID for 14-21 days, followed by 900 mg PO daily + injections of ganciclovir or foscarnet for 1-4 doses over 10 days.

Continue until CD4 > 100 for 3-6 months

Question 14

CMV esophagitis or colitis treatment

Answer 14

ganciclovir 5 mg/kg IV q12h then valganciclovir 900 mg PO BID when tolerated

Continue until CD4 > 100 for 3-6 months

Question 15

CMV prophylaxis

Answer 15

No primary prophylaxis

Secondary - continue treatment until CD4 > 100 for 3-6 months.

Question 16

Toxoplamosis primary prophylaxis

Answer 16

If prophylaxis for PCP, then covering toxoplasmosis. Initiate if CD4 < 100 - Bactrim DS daily.

Can DC if CD4 > 200 for 3 months. If viral load undetectable for 3-6 months and CD4 100-200 can also DC.

Question 17

Toxoplasmosis treatment

Answer 17

Pyrimethamine 50-75 mg/day (loading dose of 200 mg) + sulfadiazine 1000 – 1500 mg every 6 hours plus leucovorin

ADE: thrombocytopenia, granylocytopenia, add leucovorin 10-25 mg/day to reduce bone marrow effects from pyrimethamine.

Alternative: clindamyacin 600 mg IV or PO q6h + pyrimethamine (use in sulfa allergy) + leucovirin. Also consider Bactrim or atovaquone.

Question 18

Toxoplamosis secondary prophylaxis

Answer 18

DC if CD4 > 200 for 6 months or longer

Lower dose tx:

Pyrimethamine 25-50 mg/day + leucovorin 10-25 mg/day + sulfadiazine 2-4 g/day

Question 19

Latent TB Treatment - non-HIV

Answer 19

Isoniazid 300 mg daily or 900 twice weekly for 9 months, or rifampin 600 mg daily for 4 months

Question 20

Latent TB Treatment - HIV

Answer 20

Isoniazid 300 mg daily for 9 months or DOT isoniazid 900 mg twice weekly for 9 months

Question 21

Active TB treatment: non-HIV

Answer 21

Intensive Phase: Isoniazid, rifampin, pyrazinamide, ethambutol for 2 months.

Can drop ethambutol if cultures are sensitive to isoniazid and rifampin.

Continuation phase: isoniazid + rifaminpin for 4 months

Add pyridoxine (vit b6) to isoniazid to reduce neuropathy

Question 22

Active TB treatment: HIV

Answer 22

Intensive Phase: Isoniazid, rifampin /rifabutin, pyrazinamide, ethambutol for 2 months.

Can drop ethambutol if cultures are sensitive to isoniazid and rifampin.

Continuation phase: isoniazid + rifampin/rifabutin for 4 months

Question 23

TB - Rifampin HIV drug considerations

Answer 23

• Do no use with PI’s or NNRTI’s (except efavirenz or nevirapine)
• If using rifabutin (pt’s on PI’s or NNRTI’s): dose increase for NNRTI and dose decrease for PI’s
• Cannot use rifabutin with elvitegravir or bictegravir
• Only use rifapentine if on efavirenz or raltegravir regimen

Question 24

TB - resistance to isoniazid

Answer 24

Intensive phase: Replace isoniazid with moxifloxacin or levofloxacin for 2 months
Continuation phase: rifampin + ethambutol + moxi/levo for 7 months

Question 25

TB - resistance to rifampin

Answer 25

Administer Isoniazid, pyrazinamide, ethambutol for 9-12 months. Can add streptomycin to first 2 months to reduce total duration to 9 months.

Question 26

TB treatment durations

Answer 26

TB - 6 months
If still positive after 2 months of treatment, then 9 months
If CNS or bone/joint involvement: 9 months

Question 27

Histoplasmosis

Answer 27

Amp B lipid for 1-2 weeks then intraconazole for total of 12 weeks.

Question 28

Coccidioidomycosis

Answer 28

Fluconazole or itraconazole for 3-6 months. If severe, use amph B + intraconazole for 1 year

Don’t treat non-immunocompromised

Question 29

Blastomycosis

Answer 29

Itraconazole for 6 months

Amph b + itraconazole 6-12 months

Question 30

Aspergillosis

Answer 30

Voriconazole IV or PO

Isavuconazole or amph B - tx 6-12 weeks