Infectious Diseases - HIV + MRSA

Question 1

Women commencing on cART in pregnancy, when should CD4 cell count be performed?

Answer 1

At initiation of cART and at delivery.

Question 2

Women commencing on cART in pregnancy, when should a HIV viral load be preformed?

Answer 2

• 2-4 weeks after commencing cART,
• at least once in every trimester
• 36 weeks
• At delivery

Question 3

Women commencing on cART in pregnancy, when should LFTs be checked?

Answer 3

At invitation of cART
At same time as viral load - each trimester, 36 weeks and delivery

Question 4

If cART and viral load >50 HIV RNA copies/mL, what interventions are recommended?

Answer 4

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.

Question 5

Women on cART should continue in pregnancy the effective regime except in which cases?

Answer 5

1. Non standard regimes for example on protease inhibitor (PI) mono therapy
2. 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)

Question 6

What impact can dolutegravir have on pregnancy? What can be done to minimise this risk?

Answer 6

Neural tube defect
Folic acid 5mg

Question 7

All pregnant women with HIV should commence ART and continue lifelong treatment.

When should cART be commenced?

Answer 7

Depends on viral load

1. <30,000 - as soon as able to in 2nd trimester
2. 30,000-100,000 - Immediately 2nd trimester
3. > 100,000 +/- CD4 < 200 - 1st trimster

All by 24 weeks

Question 8

What cART should be started

Answer 8

Tenofovir DF or abacavir
with
emtricitabine or lamivudine
with
efavirenz or atazanavir / ritonavir,

Question 9

If a women presents late in pregnancy >28 weeks with HIV, what should happen?

Answer 9

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.

Question 10

If a women presents in labour without HIV result, what should happen?

Answer 10

Urgent HIV test, if reactive/positive must be acted on to avoid vertical transmission of HIV.

Question 11

If invasive testing required in pregnancy in HIV patient?

Answer 11

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

Question 12

How to decide on mode of delivery for patient with HIV?

Answer 12

Check plasma viral load at 36 weeks

1. <50 - planned vaginal delivery
2. 50-399 - consider pre-labour CS, consider vital load, trajectory, length of time of Tx, adherence issues, obstetric factors and woman views
3. > 400 ELCS

If CS required for HIV 38-39weeks
VD with low viral load, no different but shorted time of SROM

Question 13

How to manage SROM in HIV +ve woman?

Answer 13

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

Question 14

How to manage SROM in HIV women < 34weeks?

Answer 14

Im steroids
Optimise HIV viral load
MDT discussed re timing of delivery

Question 15

When is IV zidovudine recommended?

Answer 15

1. Viral load >1000, who present in labour/SROM or admitted for ELCS
2. Untreated women where viral load is not known

Consider if viral load 50-1000 and in labour

Question 16

For infant post exposure prophylaxis - how is very low risk defined and what is the management?

Answer 16

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

Question 17

For infant post exposure prophylaxis - how is low risk defined and what is the management?

Answer 17

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

Question 18

For infant post exposure prophylaxis - how is high risk defined and what is the management?

Answer 18

High risk, viral load no known or likely >50

Neonatal PEP within 4 hours

Question 19

If baby born preterm with mother with poorly controlled HIV, what additional medication can be given

Answer 19

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

Question 20

Is breastfeeding advised? If mother does breatfeed how should vertical transmission be minimised?

Answer 20

Should not breastfeed (can give cabergoline to suppress lactation)

Maternal cART (rather than infant PrEP)

Question 21

In non-breast fed babies when should molecular diagnostics be performed fro HIV infection?

Answer 21

1. 1st 48hrs & before discharge
2. 6 weeks (or 2 weeks after stopping prophylaxis)
3. 12 weeks (or 8 weeks after stopping prophylaxis)
4. Other occasions if additional risk at at 2 weeks if high risk delivery

Question 22

When should antibody testing in neonate occur in non breast fed infants?

Answer 22

1st sample of blood if maternal antibody status not known
22-24 months

Question 23

In breast fed babies when should molecular diagnostics be performed fro HIV infection?

Answer 23

1. 1st 48hrs and before discharge
2. At 2 weeks
3. Monthly throughout breastfeeding
4. 4 & 8 weeks after stopping breast feeding

Question 24

When should antibody testing in neonate occur in breast fed infants?

Answer 24

1st sample of blood if maternal antibody status not known
22-24 months or 8 weeks after stopping breast feeding

Question 25

How should HIV +ve women be managed postpartum?

Answer 25

Continue cART
Review 4-6 weeks
Consider mental health referral
Contraception (may need to change ART)
Test partner and children

Question 26

What % of people admitted to hospital are colonised with MRSA?

Answer 26

1-5%

Question 27

How to eradicate colonisation MRSA

Answer 27

Intranasal or topical mupirocin ointment TDS 5 days
Skin/hair wash with chlorhexadine

Question 28

What main agents are used in the treatment of MRSA infections?

Answer 28

Vancomycin and teicoplanin

If resistant to those consider linezolid

Question 29

Why mos vancomycin be given by slow IV infusion?

Answer 29

Red man syndrome