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CDM 3 Exam 3 > Lecture 7 - Opportunistic infections > Flashcards

Lecture 7 - Opportunistic infections Flashcards

1
Q

Stage 0 CDC

A

negative test to positive test, < 180 days

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2
Q

Stage 1 CDC

A

> 400 CD4
no AIDS defining illness

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3
Q

Stage 2 CDC

A

200-499 CD4
No AIDS defining illness

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4
Q

Stage 3 CDC = AIDS

A

CD4 < 200 or AIDS defining illness

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5
Q

IRIS

A

mild-to-life threatening inflammatory reaction in response to underlying infection following initiation, re-initiation or change of ART therapy

CD4 < 100 or high viral load = risk

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6
Q

IRIS treatment

A

NSAIDs when symptoms considered moderate-severe

if symptoms persist, then prednisone 20-40mg 4-8weeks

Dont interrupt ART or OI treatments in patients with IRIS unless life threatening

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7
Q

Candidiasis info

A

commonly seen as oropharyngeal or esophageal

caused by Candida albicans usually

CD4 < 200

esophageal higher incidence at lower CD4 counts than oropharyngeal

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8
Q

Candidiasis management

A

prophylaxis not recommended

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9
Q

Oropharyngeal Candidiasis treatment

A

pref = oral fluc 100mg QD for 1x2 weeks
Alternative = itraconazole oral x 7X14 days or posaconazole oral suspension

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10
Q

Esophageal Candidiasis treatment

A

pref = oral fluc 100mg QD for 2x3 weeks
Alternative = isavuconazole 200mg x 1 dose, followed by 50mg QD or 400mg 1 dose followed by 100mg QD

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11
Q

Candidiasis monitoring

A

rapid improvement 48-72hrs of symptoms

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12
Q

For ART-naive pts with CD4 < 50, we start ART when after TB treatment initiation?

A

within 2 weeks

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13
Q

Pneumocystis Pneumonia (PCP) info

A

common pts with CD4 < 200

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14
Q

PCP presentation

A

fever
hypxemia
nonproductive cough
chest discomfort

imaging = V important….Chest X ray = “ground glass”

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15
Q

Mild PCP differences

A

Po2 > 70mmHG
Alveolar-Arterial gradient < 35

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16
Q

Moderate-severe PCP differences

A

< 70 mmHG Po2
Alveolar arterial gradient > 35

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17
Q

Primary PCP prophylaxis if….

A

CD4 < 200
CD4 percentage < 14%
CD4 cell count between 200-250 if ART initiation delayed and CD4 count not possible

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18
Q

Preferred PCP prophylaxis dosing

A

Bactrim double strength (800-160) daily or Single strength (400-80) daily

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19
Q

Alternative PCP prophylaxis dosing

A

Bactrim double strength 800-160 TIW
Dapsone 100mg QD or 50mg BID
Atovaquone 1500mg QD w/ food

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20
Q

When to stop PCP prophylaxis

A

CD4 > 200 for > 3 months in response to ART
CD4 cont between 100-200 and Viral load undetectable for >3-6 months

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21
Q

When to restart PCP prophylaxis

A

CD4 < 100 regardless of viral load
CD4 100-200 and detectable viral load

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22
Q

PCP treatment preferred therapy

A

Bactrim 15-20mg/kg in 3-4 doses per day
or
Bactrim DS 2-3 QD

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23
Q

Alternative mild/moderate PCP treatment

A

Dapsone 100mg + Bactrim 15mg/kg/day in 3 doses

Primaquine 30mg QD + clinda 450 q6 or 600q8h

Atovaquone

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24
Q

Alternative moderate/severe PCP treatment

A

Pentamidine 4mg/kg IV QD

Primaquine 30mg QD + clinda 600 Q6 or 900 Q8 IV (or 450 q6/600q8 PO)

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25
Q

Common Medication pearls of Bactrim, Dapsone, Primaquine

A

Hemolytic anemia in G6PD deficiency

26
Q

Medication pearls of Atovaquone

A

must take w/ food
Bad taste with liquid
$$$$

27
Q

Who are corticosteroids indicated for in PCP?

A

moderate to severe

PaO2 < 70 on room air or > 35 Alveolar-arterial gradient

begin within 72hrs of PCP management

28
Q

Corticosteroids PCP dosing schedule

A

D1-5 = 40mg BID
D6-10 = 40mg QD
D11-21 = 20mg QD

IV Methylpred can be recommended at 75% of prednisone dose

29
Q

what screening dictates Toxoplasma treatment?

A

T.gondii immunoglobulin G screening

30
Q

Toxoplasma presentation

A

Headache, confusion, motor weakness, fever

may lead to seizures,coma, or death if untreated

31
Q

Toxoplasma diagnosis

A

Serologic testing for IgG

culture CSF, urine, blood

Can also use imaging but hard to distinguish

32
Q

Toxoplasma preferred prophylaxis is….

A

Bactrim DS 1QD

33
Q

what’s required to be indicated for toxoplasma prophylaxis

A

< 100 CD4 and + Toxoplasma IgG

34
Q

Alternative toxoplasma prophylaxis treatments….

A

Bactrim DS TIW
Bactrim SS daily
Dapsone 50mg/200mb QD + pyrimethamine/leucov weekly
Atovaquone 1500mg QD

35
Q

When to stop Toxoplasma prophylaxis….

A

CD4 > 200 for > 3 months in response to ART

CD4 100-200 and Viral load is undetectable for atleast 3-6 months

36
Q

Toxoplasma preferred treatment

A

< 60kg = pyrimethamine 200mg PO, then 50mg QD + sulfadiazine 1000mg q6h + leucovorin 10-25mg qd

> 60kg = pyrimethamine 200mg, then 75mg qd + sulfadiazine 1500 q6h + leucovorin 10-25mg qd

duration 6 weeks

continue maintenance therapy once complete therapy

37
Q

Toxoplasma alternative treatment

A

pref: Bactrim 5mg/kg

pyrimethamine + leucovorin + clinda

Atovaquone 1500mg QD + sulfadiazine or pyrimethamine & leucovorin or neither

38
Q

Toxoplasma maintenance treatment

A

Pref: pyrimethamine 25-50 QD + sulfadiazine 2-4g QD + leucovorin 10-25mg

alternative:
Clinda + pyrimethamine + leucovorin
Bactirm DS QD/BID
Atovaquone 750-1500mg BID + sulfadiazine or pyrimethamine & leucovorin

39
Q

When are corticosteroids recommended for Toxoplasma adjunctive treatments?

A

HIV-infected children with CNS toxoplasmosis if….
CSF protein > 1000 or focal lesions with substantial mass effect or edema

40
Q

Who should get anticonvulsants with Toxoplasmosis ?

A

Pts with history of seizure, not indicated as prophylaxis

41
Q

When to D/c maintenance therapy for toxoplasmosis

A
  1. successfully completed initial therapy
  2. asymptomatic of signs and symptoms of TE
  3. CD4 count > 200 for > 6 months
42
Q

Cryptococcosis info

A

90% in pts with CD4 < 100

43
Q

Cryptococcosis presentation

A

Fever
Malaise
Headache
Neck stiffness
Photophobia

44
Q

Cryptococcosis diagnosis

A

CSF analysis
CSF pressure > 25
Antigen test

45
Q

Cryptococcosis prophylaxis

A

not recommended, doesn’t occur often

46
Q

Cryptococcosis treatment phases

A

induction > 2 weeks
consolidation > 8 weeks
Maintenance > 1yrs

47
Q

Induction preferred regimen Cryptococcosis

A

Luposomal Ampho 3-5mg/kg + flucytosine 25mg/kg

Ampho deoxycholate 0.7-1.0mg/kg + flucytosine 25mg/kg

2 weeks

48
Q

Induction alternative Cryptococcosis

A

Ampho B lipid complex 5mg/kg IV + flucytosine or fluc 800

Ampho B alone
Fluc + flucytosine
Fluc 1200 QD IV/PO

2 weeks

49
Q

Preferred Consolidation Cryptococcosis therapy

A

Fluc 800mg QD > 8 weeks

can reduce to 400mg QD if 2 week CSF cultures are negative

50
Q

Alternative consolidation cryptococcosis therapy

A

Itraconazole 200mg PO BID > 8 weeks

51
Q

Maintenance Cryptococcosis therapy

A

Fluc 200mg QD for at least 1 year

52
Q

When to d/c maintenance cryptococcosis therapy

A

complete 2 earlier phases, and maintenance for atleast 1 year

Asymptomatic of signs/symptoms of cryptococcal infections

CD4 > 100 for > 3 months with suppressed viral load

53
Q

MAC presentation and diagnosis

A

Fever
diarrhea
night sweats
fatigue, weight loss

Diagnosis: isolation of MAC from sterile fluid/tissue culture

54
Q

MAC prophylaxis

A

not recommended for adults/adolescent who immediately initiate ART

55
Q

Who should get MAC prophylaxis

A

Viremic pts, not receiving or no option for ART, CD4 < 50

Rule out disseminated MAC disease before starting

56
Q

Preferred MAC prophylaxis

A

Azithromycin 1200 QW
Clarithromycin 500 BID
Azithromycin 600 BIW

Alternative: Rifabutin 300 QD

57
Q

MAC treatment

A

Clarithromycin 500 BID + ethambutol 15mg/kg
Azithromycin 500-600 QD + ethambutol 15mg/kg

to prevent/delay resistance

58
Q

When can you add 3rd or 4th drug for MAC treatment?

A

People with HIV w/ CD4 < 50, high mycobacterial loads, absence of ART

Rifabutin 300 QD
Fluoroquinolone ( Levo 500 or moxi 400)
inject AGs (amikacin or streptomycin)

59
Q

MAC monitoring

A

improvement within 2-4 weeks after start therapy
dec mycobacteria

failure = no response 4-8 weeks, then test for resistance

60
Q

When to D/c MAC maintenance therapy

A
  1. successfully completed at least 12 months therapy
  2. no signs and symptoms of MAC disease
  3. CD4 > 100 for 6 months in response to ART

CDM 3 Exam 3 (9 decks)

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