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Opportunistic HIV Illness Flashcards

1
Q

Stage 3 HIV

A
  • CD4 < 200

- Development of Stage-3-defining OI (will always be stage 3 after this development)

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2
Q

Stage-3-Defining OI

A
  • Opportunistic infection or neoplasm that are common with HIV
  • May indicated that person is immunosuppressed and infected with HIV
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3
Q

Stage-3-Defining OI Examples

A
  • Oral candidiasis
  • Pneumocystic pneumonia
  • Disseminated MAC infection
  • Toxoplasmosis
  • Cytomegalovirus
  • Cryptococcal meningitis
  • Cryptosporidiosis
  • Coccidioidomyocosis
  • Kaposi sarcoma
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4
Q

Prevention Considerations

A

Prevention based on:

  • Prophylaxis
  • SE of prophylaxis
  • Severity of disease
  • Effectiveness of treatment
  • Potential for resistance
  • Cost
  • Primary prevention: based on CD4 count
  • Secondary prevention: patients with relapse risks
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5
Q

Primary Prevention OI

A
  • Pneumocystis pneumonia
  • Toxoplasma encephalitis
  • Disseminated MAC disease

Vaccinations!!!

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6
Q

Secondary Prevention OI

A
  • Pneumocystis pneumonia
  • Toxoplasma encephalitis
  • Disseminated MAC disease
  • Cytomegalovirus
  • Cryptococcal Meningitis
  • Histoplasmosis
  • Coccidioidomycosis
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7
Q

Mucocutaneous Candidiasis

A
  • Oropharyngeal and esophageal candidiasis are common
  • Increased risk when CD4 <200 cells
  • HAART reduces likelihood of infection
  • No measures available to reduce exposure
  • Primary prophylaxis not recommended
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8
Q

Oropharyngeal Candidiasis Treatment

A

Preferred: Fluconazole 100 mg PO daily

Alternatives

  • Clotrimazole troches
  • Miconazole buccal tables
  • Itraconazole solution
  • Posaconazole suspension
  • Nystatin suspension

Duration: 7-14 days

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9
Q

Esophageal Candidiasis

A

Preferred

  • Fluconazole 100 mg IV/PO daily
  • Itraconazole solution 200 mg PO daily

Alternative:

  • Voriconazole
  • Isavuconazole
  • Micafungin
  • Liposomal amphotericin B

Duration: 14-21 days

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10
Q

Triazole AE

A
  • Class: GI disturbances, hepatotoxicity, Rash
  • Itraconazole: negative inotropic effect
  • Voriconazole: visual disturbances and visual/auditory hallucinations

-Many CYP interactions including PIs (fluconazole preferred)

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11
Q

PCP

A
  • Pneumocystis Pneumonia
  • Occurs in ~80% of of AIDS patients prior to ART and primary prophylaxis
  • Now mainly occurs in those who are unaware of these serostatus or don’t receive HIV care
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12
Q

PCP Risks

A

-CD4 < 200

OR if CD4 > 200:

  • H/O PCP
  • Symptomatic HIV infection
  • Recurrent bacterial pneumonia
  • Rapidly declining CD4 counts
  • High plasma HIV RNA
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13
Q

PCP Presentation

A
  • Fever
  • Dyspnea
  • Nonproductive cough
  • Hypoxemia (mild-severe)
  • Elevated lactate dehydrogenase (>500)
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14
Q

PCP Diagnosis

A
  • CT: patched ground-glass opacities

- Fluorescent stain: induced sputum, BAL (preferred)

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15
Q

Primary Prevention PCP Criteria

A
  • Recommended: CD4 < 200

- Consider if CD4 < 14% or count is between 200-250 and ART is delayed

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16
Q

PCP Primary Prevention

A
  • Bactrim DS PO Daily*
  • Bactrim SS PO Daily*

Alternatives:

  • Bactrim DS PO M-W-F*
  • Dapsone QD or BID (dose) (+pyrimethamine + leucovorin*)
  • Atovaquone 1500 PO with food*
  • Aerosolized pentamidine 300 mg q4w
  • = toxoplasmosis coverage
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17
Q

Bactrim

A
  • MoA: Folic acid synthesis inhibitors
  • AE: N/V, rash, photosensitivity, bone marrow suppression, renal dysfunction, hyperkalemia
  • Renal adjustment: not needed with prophylactic doses
  • Normally 1/2 dose at CrCl < 30 and D/C if CrCl < 15
  • Monitoring: CBC and K+
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18
Q

Sulfonamide Hypersensitivity

A
  • Higher incidence in AIDS patients
  • Fever, maculopapular rash, develops 7-14 days after starting
  • Skin testing isn’t helpful
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19
Q

Dapsone

A
  • 100 mg QD or 50 mg BID
  • MoA: Inhibits folate synthesis
  • AE: rash, photosensitivity, anemias, hepatitis
  • Monitoring: G6PD before starting, CBC, LFTs
  • Needs additional agents for toxoplasmosis coverage
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20
Q

Atovaquone

A
  • 1500 mg PO daily
  • Take with food
  • MoA: Inhibits nucleic acid synthesis
  • Monitoring: LFTs
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21
Q

Aerosolized Pentamidine

A
  • 300 mg q4weeks
  • Via respigard II
  • MoA: inhibits nucleic acid synthesis
  • AE: Nausea, HA, bronchospasm, dyspnea, dizziness, syncope
22
Q

D/C Prophylaxis Conditions

A
  • CD4 > 200 for > 3 mo

- Can consider when CD4 100-200 if patients on ART and viral load is undetectable for >= 3 mo

23
Q

D/C Prophylaxis Reasoning

A
  • Prophylaxis has limited disease prevention data
  • Reduced pill burden
  • Reduces potential drug toxicity
  • Reduces cost
24
Q

PCP Treatment

A

-Initiated with definite diagnosis
-Bactrim 15-20 mg/kg/day IV or PO q8H x 21 days (based on trimethoprim)
-Switch to PO once stable
-Prednisone is added in severe disease where PaO2 < 70
Prednisone taper: 40 mg BID days 1-5, 40 mg QD days 6-10, 20 mg QD days 11-21
-Start HAART within 2 weeks of diagnosis when possible

25
Q

Adjunctive Steroids for PCP Treatment

A
  • For moderate to severe disease (PaO2 < 70)
  • Give as early as possible, within 72 hours
  • Decreases inflammatory response
  • Reduces risk of respiratory failure and death
  • Methylprednisolone can be used if IV is necessary at 75% of prednisone dose
26
Q

PCP Alternative Treatments

A

Moderate - Severe:

  • IV Pentamidine
  • PO Primaquine + IV/PO Clindamycin

Mild-Moderate:

  • PO Atovaquone
  • PO Dapsone + TMP
  • PO Primaquine + IV/PO Clindamycin

Treatment: 21 days

27
Q

Pentamidine

A
  • Not received outpatient
  • Life threatening AEs: hypoglycemia, hypotension
  • Other AEs: cumulative nephrotoxicity, arrhythmias, pancreatitis, bone marrow suppression, tissue necrolysis at injection site
  • Monitor: blood pressure, glucose, renal function, electrolytes, CBC
28
Q

Primaquine

A
  • 300mg PO daily
  • AE: N/V, rash, anemia
  • Monitor: CBC, G6PD before starting
29
Q

Clindamycin

A
  • 600 mg PO q8H
  • AE: rash, N/V diarrhea, hepatitis
  • Monitoring: bowel frequency, LFTs
30
Q

PCP Preventing Recurrence

A
  • Secondary prophylaxis is same regimen as primary
  • Continue prophylaxis after treatment is completed
  • D/C prophylaxis once HAART patients CD4 > 200 for 3 months
  • Continue for life if PCP occurred when CD4 > 200 while on ART
31
Q

Toxoplasmosis

A
  • Protozoa found in undercooked meat and spread in cat feces

- Reactivation disease: CD4 < 100 which results in cerebral or disseminated disease

32
Q

Toxoplasmosis Encephalitis Presentation

A
  • HA
  • Confusion
  • Motor weakness
  • Seizures
  • Coma
33
Q

Toxoplasmosis Diagnosis

A
  • Toxo IgG+ (absence means diagnosis unlikely)
  • CT/MRI: multiple lesions with cerebral edema
  • Biopsy and stain uncommon
  • PSR of CSF has low sensitivity
34
Q

Preventing Toxo Exposure

A
  • Test for Toxo IgG at baseline
  • Avoid raw/undercooked meat
  • Wash hands after handling meat, fruit, vegetables, soil
  • Cat owners: avoid changing litter box and only feed dried, commercial food
  • Retest IgG if CD4 declines < 100
35
Q

Toxoplasmosis Primary Prevention

A
  • Initiate is CD4 < 100
  • Preferred: Bactrim DS PO Daily

Alternatives:

  • Bactrim SS PO QD
  • Bactrim DS PO M-W-F
  • Dapsone + Pyrimethamine + Leucovorin
  • Atovaquone

-D/C when CD4 > 200 for 3 months or CD4 between 100-200 and patient’s on ART and viral load undetectable for 3-6 months

36
Q

Pyrimethamine

A
  • MoA: folate inhibitor
  • Penetrates CSF
  • AE: Rash, anemia, neutropenia, thrombocytopenia
  • Administer leucovorin with all regimens
  • Monitor CBC
37
Q

Toxo Encephalitis Treatment

A 
Preferred for >60 kg:
-Pyramethamine 200 mg PO once then 75 mg PO QD
PLUS
-Sulfadiazine 1.5 g PO q6h
PLUS
-Leucovorin 25 mg PO QD
  • Duration: >= 6 weeks
  • Continue maintenance after completion
  • Use AEDs if history of seizures
38
Q

Sulfadiazine

A
  • MoA: folate inhibitor
  • AE: rash, N/V, diarrhea, photosensitivity, bone marrow suppression, crystalluria
  • Monitor: CBC, UA
  • Advise patient to maintain adequate hydration
39
Q

Toxo Encephalitis Alternative Treatment

A
  • Sub sulfadiazine with Clindamycin or Atovaquone if allergic
  • Bactrim 5mg/kg PO/IV BID
  • Atovaquone on its own
40
Q

Toxoplasmosis Secondary Prophylaxis

A

-50-80% relapse within months

Maintenance Therapy:
-Pyrimethamine + Sulfadiazine + Leucovorin

Alternatives:

  • Pyramethine + Clinda
  • Bactrim DS
  • Atovaquone

-D/C if CD4 > 200 for >= 6mo

41
Q

MAC Characteristics

A
  • Cell wall as mycolic acid
  • Slow-growing
  • Transmitted in air or ingestion
  • Risk: CD4 < 50
  • 3x risk of death
42
Q

MAC Presentation

A
  • Persistent fever
  • Weight loss
  • Night sweats
  • Diarrhea/abdominal pain
  • Anemia
  • Lymphadenopathy/hepatosplenomegaly
43
Q

MAC Primary Prophylaxis Criteria

A

-Not recommended in patients who immediately start ART

Criteria
-Not on fully suppressive ART
AND
-CD4 < 50

44
Q

MAC Primary Prophylaxis Regimens

A
  • Azithromycin
  • Clarithromycin

D/C with initiation of effective ART

45
Q

MAC Treatment

A

-Minimally 2 effective drugs to prevent ressitance

Preferred:
-Clarithromycin
PLUS
-Ethambutol
\+/-
-Rifabutin

Alternative: Azithromycin for Clarithromycin

46
Q

3rd/4th Agent in Disseminated MAC

A

Consider when:

  • High mycobacterial load (>2 log CFU)
  • Absence of effective ART
  • High risk of mortality (CD4 < 50)

-Options: Rifabutin, Fluoroquinolone, injectable aminoglycoside

47
Q

Clarithromycin/Azithromycin

A
  • GI symptoms: diarrhea, nausea, abdominal pain
  • Metallic taste
  • LFT elevations
  • QTc prolongation

-Monitor: LFTs, DDI

48
Q

Ethambutol

A
  • MoA: Inhibits cell wall synthesis
  • AE: visual disturbances
  • Adjust if CrCl < 50
  • Monitor: renal function, eye exams at baseline then monthly
49
Q

Rifabutin

A
  • MoA: inhibits RNA synthesis
  • AE: hepatotoxicity, red/orange secretions, rash, GI disturbances, anemia
  • Monitor: LFTs, CBC
  • Adjust dose with CYP inducers/inhibitors
50
Q

MAC Treatment

A
  • Optimized ART necessary
  • Start ART at same time if possible
  • Consider pill burdens, toxicity, IRIS
51
Q

IRIS

A
  • Immune reconstitution inflammatory syndrome
  • Paradoxical reaction with initiation of HAART
  • Occurs in low CD4 count patients with rapid increases
52
Q

MAC Treatment Duration/Secondary Prophylaxis

A
  • Duration >= 12 months
  • No signs/symptoms of MAC
  • CD4 > 100 for >= 6 mo

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