Infectious Diseases - HIV + MRSA Flashcards
Women commencing on cART in pregnancy, when should CD4 cell count be performed?
At initiation of cART and at delivery.
Women commencing on cART in pregnancy, when should a HIV viral load be preformed?
- 2-4 weeks after commencing cART,
- at least once in every trimester
- 36 weeks
- At delivery
Women commencing on cART in pregnancy, when should LFTs be checked?
At invitation of cART
At same time as viral load - each trimester, 36 weeks and delivery
If cART and viral load >50 HIV RNA copies/mL, what interventions are recommended?
Review adherence (including a full exploration of potential impacting factors) and concomitant medication
Perform resistance test if appropriate
Consider therapeutic drug monitoring (TDM)
Optimise to best regimen
Consider intensification.
Women on cART should continue in pregnancy the effective regime except in which cases?
- Non standard regimes for example on protease inhibitor (PI) mono therapy
- Regime’s that have lower pharomokinestics in pregnancy e.g. darunavir/cobicistat and elvitegravir/cobicistat or if absence of data e.g. altegravir 1200 mg once daily (od)
What impact can dolutegravir have on pregnancy? What can be done to minimise this risk?
Neural tube defect
Folic acid 5mg
All pregnant women with HIV should commence ART and continue lifelong treatment.
When should cART be commenced?
Depends on viral load
- <30,000 - as soon as able to in 2nd trimester
- 30,000-100,000 - Immediately 2nd trimester
- > 100,000 +/- CD4 < 200 - 1st trimster
All by 24 weeks
What cART should be started
Tenofovir DF or abacavir
with
emtricitabine or lamivudine
with
efavirenz or atazanavir / ritonavir,
If a women presents late in pregnancy >28 weeks with HIV, what should happen?
Commence cART without delay
If the viral load is unknown or over 100,000 HIV RNA copies/mL, a three- or four-drug regimen that includes raltegravir 400 mg bd or dolutegravir 50 mg od is suggested.
If a women presents in labour without HIV result, what should happen?
Urgent HIV test, if reactive/positive must be acted on to avoid vertical transmission of HIV.
If invasive testing required in pregnancy in HIV patient?
Should not be performed until viral load <50 RNA copies/mL (same with ECV)
If not on cART and testing required and cannot be delayed, commence cART raltegravir and nevirapine 2-4 hrs before procedure
How to decide on mode of delivery for patient with HIV?
Check plasma viral load at 36 weeks
- <50 - planned vaginal delivery
- 50-399 - consider pre-labour CS, consider vital load, trajectory, length of time of Tx, adherence issues, obstetric factors and woman views
- > 400 ELCS
If CS required for HIV 38-39weeks
VD with low viral load, no different but shorted time of SROM
How to manage SROM in HIV +ve woman?
If after >34 weeks deliver within 24hrs
Viral load < 50
- Immediate IOL, low threshold for Tx IP pyrexia
50-399 - consider CS
>400 CS
Give IV Ben Pen if 34-37 weeks
How to manage SROM in HIV women < 34weeks?
Im steroids
Optimise HIV viral load
MDT discussed re timing of delivery
When is IV zidovudine recommended?
- Viral load >1000, who present in labour/SROM or admitted for ELCS
- Untreated women where viral load is not known
Consider if viral load 50-1000 and in labour
For infant post exposure prophylaxis - how is very low risk defined and what is the management?
Very low risk - 2 weeks zidovudine monnotherpay
- cART > 10 weeks
- 2 x viral load < 50, 4 weeks apart
- Viral load < at or after 36 weeks
For infant post exposure prophylaxis - how is low risk defined and what is the management?
Low risk - 4 weeks zidovudine mono therapy
- If very low risk not fulfilled but viral load <50 at or after 36 weeks
- Preterm but most recent viral load < 50
For infant post exposure prophylaxis - how is high risk defined and what is the management?
High risk, viral load no known or likely >50
Neonatal PEP within 4 hours
If baby born preterm with mother with poorly controlled HIV, what additional medication can be given
In preterm labour, if the infant is unlikely to be able to absorb oral medications consider the addition of double-dose tenofovir to further load the baby
Is breastfeeding advised? If mother does breatfeed how should vertical transmission be minimised?
Should not breastfeed (can give cabergoline to suppress lactation)
Maternal cART (rather than infant PrEP)
In non-breast fed babies when should molecular diagnostics be performed fro HIV infection?
- 1st 48hrs & before discharge
- 6 weeks (or 2 weeks after stopping prophylaxis)
- 12 weeks (or 8 weeks after stopping prophylaxis)
- Other occasions if additional risk at at 2 weeks if high risk delivery
When should antibody testing in neonate occur in non breast fed infants?
1st sample of blood if maternal antibody status not known
22-24 months
In breast fed babies when should molecular diagnostics be performed fro HIV infection?
- 1st 48hrs and before discharge
- At 2 weeks
- Monthly throughout breastfeeding
- 4 & 8 weeks after stopping breast feeding
When should antibody testing in neonate occur in breast fed infants?
1st sample of blood if maternal antibody status not known
22-24 months or 8 weeks after stopping breast feeding
How should HIV +ve women be managed postpartum?
Continue cART
Review 4-6 weeks
Consider mental health referral
Contraception (may need to change ART)
Test partner and children
What % of people admitted to hospital are colonised with MRSA?
1-5%
How to eradicate colonisation MRSA
Intranasal or topical mupirocin ointment TDS 5 days
Skin/hair wash with chlorhexadine
What main agents are used in the treatment of MRSA infections?
Vancomycin and teicoplanin
If resistant to those consider linezolid
Why mos vancomycin be given by slow IV infusion?
Red man syndrome
