Lecture 7 - Opportunistic infections Flashcards
Stage 0 CDC
negative test to positive test, < 180 days
Stage 1 CDC
> 400 CD4
no AIDS defining illness
Stage 2 CDC
200-499 CD4
No AIDS defining illness
Stage 3 CDC = AIDS
CD4 < 200 or AIDS defining illness
IRIS
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
IRIS treatment
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
Candidiasis info
commonly seen as oropharyngeal or esophageal
caused by Candida albicans usually
CD4 < 200
esophageal higher incidence at lower CD4 counts than oropharyngeal
Candidiasis management
prophylaxis not recommended
Oropharyngeal Candidiasis treatment
pref = oral fluc 100mg QD for 1x2 weeks
Alternative = itraconazole oral x 7X14 days or posaconazole oral suspension
Esophageal Candidiasis treatment
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
Candidiasis monitoring
rapid improvement 48-72hrs of symptoms
For ART-naive pts with CD4 < 50, we start ART when after TB treatment initiation?
within 2 weeks
Pneumocystis Pneumonia (PCP) info
common pts with CD4 < 200
PCP presentation
fever
hypxemia
nonproductive cough
chest discomfort
imaging = V important….Chest X ray = “ground glass”
Mild PCP differences
Po2 > 70mmHG
Alveolar-Arterial gradient < 35
Moderate-severe PCP differences
< 70 mmHG Po2
Alveolar arterial gradient > 35
Primary PCP prophylaxis if….
CD4 < 200
CD4 percentage < 14%
CD4 cell count between 200-250 if ART initiation delayed and CD4 count not possible
Preferred PCP prophylaxis dosing
Bactrim double strength (800-160) daily or Single strength (400-80) daily
Alternative PCP prophylaxis dosing
Bactrim double strength 800-160 TIW
Dapsone 100mg QD or 50mg BID
Atovaquone 1500mg QD w/ food
When to stop PCP prophylaxis
CD4 > 200 for > 3 months in response to ART
CD4 cont between 100-200 and Viral load undetectable for >3-6 months
When to restart PCP prophylaxis
CD4 < 100 regardless of viral load
CD4 100-200 and detectable viral load
PCP treatment preferred therapy
Bactrim 15-20mg/kg in 3-4 doses per day
or
Bactrim DS 2-3 QD
Alternative mild/moderate PCP treatment
Dapsone 100mg + Bactrim 15mg/kg/day in 3 doses
Primaquine 30mg QD + clinda 450 q6 or 600q8h
Atovaquone
Alternative moderate/severe PCP treatment
Pentamidine 4mg/kg IV QD
Primaquine 30mg QD + clinda 600 Q6 or 900 Q8 IV (or 450 q6/600q8 PO)
Common Medication pearls of Bactrim, Dapsone, Primaquine
Hemolytic anemia in G6PD deficiency
Medication pearls of Atovaquone
must take w/ food
Bad taste with liquid
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Who are corticosteroids indicated for in PCP?
moderate to severe
PaO2 < 70 on room air or > 35 Alveolar-arterial gradient
begin within 72hrs of PCP management
Corticosteroids PCP dosing schedule
D1-5 = 40mg BID
D6-10 = 40mg QD
D11-21 = 20mg QD
IV Methylpred can be recommended at 75% of prednisone dose
what screening dictates Toxoplasma treatment?
T.gondii immunoglobulin G screening
Toxoplasma presentation
Headache, confusion, motor weakness, fever
may lead to seizures,coma, or death if untreated
Toxoplasma diagnosis
Serologic testing for IgG
culture CSF, urine, blood
Can also use imaging but hard to distinguish
Toxoplasma preferred prophylaxis is….
Bactrim DS 1QD
what’s required to be indicated for toxoplasma prophylaxis
< 100 CD4 and + Toxoplasma IgG
Alternative toxoplasma prophylaxis treatments….
Bactrim DS TIW
Bactrim SS daily
Dapsone 50mg/200mb QD + pyrimethamine/leucov weekly
Atovaquone 1500mg QD
When to stop Toxoplasma prophylaxis….
CD4 > 200 for > 3 months in response to ART
CD4 100-200 and Viral load is undetectable for atleast 3-6 months
Toxoplasma preferred treatment
< 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
Toxoplasma alternative treatment
pref: Bactrim 5mg/kg
pyrimethamine + leucovorin + clinda
Atovaquone 1500mg QD + sulfadiazine or pyrimethamine & leucovorin or neither
Toxoplasma maintenance treatment
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
When are corticosteroids recommended for Toxoplasma adjunctive treatments?
HIV-infected children with CNS toxoplasmosis if….
CSF protein > 1000 or focal lesions with substantial mass effect or edema
Who should get anticonvulsants with Toxoplasmosis ?
Pts with history of seizure, not indicated as prophylaxis
When to D/c maintenance therapy for toxoplasmosis
- successfully completed initial therapy
- asymptomatic of signs and symptoms of TE
- CD4 count > 200 for > 6 months
Cryptococcosis info
90% in pts with CD4 < 100
Cryptococcosis presentation
Fever
Malaise
Headache
Neck stiffness
Photophobia
Cryptococcosis diagnosis
CSF analysis
CSF pressure > 25
Antigen test
Cryptococcosis prophylaxis
not recommended, doesn’t occur often
Cryptococcosis treatment phases
induction > 2 weeks
consolidation > 8 weeks
Maintenance > 1yrs
Induction preferred regimen Cryptococcosis
Luposomal Ampho 3-5mg/kg + flucytosine 25mg/kg
Ampho deoxycholate 0.7-1.0mg/kg + flucytosine 25mg/kg
2 weeks
Induction alternative Cryptococcosis
Ampho B lipid complex 5mg/kg IV + flucytosine or fluc 800
Ampho B alone
Fluc + flucytosine
Fluc 1200 QD IV/PO
2 weeks
Preferred Consolidation Cryptococcosis therapy
Fluc 800mg QD > 8 weeks
can reduce to 400mg QD if 2 week CSF cultures are negative
Alternative consolidation cryptococcosis therapy
Itraconazole 200mg PO BID > 8 weeks
Maintenance Cryptococcosis therapy
Fluc 200mg QD for at least 1 year
When to d/c maintenance cryptococcosis therapy
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
MAC presentation and diagnosis
Fever
diarrhea
night sweats
fatigue, weight loss
Diagnosis: isolation of MAC from sterile fluid/tissue culture
MAC prophylaxis
not recommended for adults/adolescent who immediately initiate ART
Who should get MAC prophylaxis
Viremic pts, not receiving or no option for ART, CD4 < 50
Rule out disseminated MAC disease before starting
Preferred MAC prophylaxis
Azithromycin 1200 QW
Clarithromycin 500 BID
Azithromycin 600 BIW
Alternative: Rifabutin 300 QD
MAC treatment
Clarithromycin 500 BID + ethambutol 15mg/kg
Azithromycin 500-600 QD + ethambutol 15mg/kg
to prevent/delay resistance
When can you add 3rd or 4th drug for MAC treatment?
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)
MAC monitoring
improvement within 2-4 weeks after start therapy
dec mycobacteria
failure = no response 4-8 weeks, then test for resistance
When to D/c MAC maintenance therapy
- successfully completed at least 12 months therapy
- no signs and symptoms of MAC disease
- CD4 > 100 for 6 months in response to ART
