Opportunistic Infections

Question 1

What are immunocompromised states?

Answer 1

1. HIV and other disease that destroy immune response CD4 cells <200 cells/mm3
2. systemic steroids ≥14 days at a prednisone equivalent dose of ≥ 20mg/day or ≥2mg/kg/day
3. immunosuppressants for autoimmune conditions or post-transplant (TNF-alpha inhibitors, Humira)
4. cancer chemotherapy that destroys WBCs, especially if severe neutropenia ANC<500 cells/mm3
5. asplenia or functional asplenia

Question 2

What is the criteria for starting prophylaxis against pneumocystis jirovecil pneumonia (PJP or PCP)?

Answer 2

CD4 count <200 cells/mm3 or AIDS defining illness or oropharyngeal candadiasis

Question 3

What are primary prophylaxis treatments for pneumocystis jirovecil pneumonia (PJP or PCP)?

Answer 3

1. SMX/TMP DS or SS QD (DOC)
2. SMX/TMP DS 3x/wk
3. Dapsone
4. Dapsone + pyrimethamine + leucovorin
5. Atovaquone
6. Atovaquone + pyrimethamine + leucovorin
7. inhaled pentamide

Question 4

What is the criteria to D/C prophylaxis against pneumocystis jirovecil pneumonia (PJP or PCP)?

Answer 4

CD4 count >200 cells/mm3 for > 3 months and remains on ART

Question 5

What is the criteria for starting prophylaxis against toxoplasma gondii encephalitis?

Answer 5

CD4 count <100 cells/mm3 with positive Toxoplasma IgG

Question 6

What is the primary prophylaxis treament regimens for toxoplasma gondii encephalitis?

Answer 6

1. SMX/TMP DS (DOC)
2. SMX/TMP DS 3x/wk or SS QD
3. Dapsone + pyrimethamine + leucovorin
4. Atovaquone
5. Atovaquone + pyrimethamine + leucovorin

Question 7

What is the criteria to D/C prophylaxis against toxoplasma gondii encephalitis?

Answer 7

CD4 count >200 cells/mm3 for > 3 months and remains on ART

Question 8

What are the criteria for starting prophylaxis against mycobacterium avium complex (MAC)?

Answer 8

Initiate if not taking ART, not recommended if ART is started immediately; CD4 count less than <50 cells/mm3, and no active MAC infection

Question 9

What are the primary prophylaxis treatment regimens for mycobacterium avium complex (MAC)?

Answer 9

1. Azythromicin 1,200mg weekly (better for compliance)
2. Azythromicing 600mg twice weekly
3. Clarithromycin 500mg BID (lots of drug interactions)

Question 10

What is the criteria to D/C prophylaxis against mycobacterium avium complex (MAC)?

Answer 10

taking fully suppressive ART

Question 11

Which OIs are most common in HIV patients?

Answer 11

1. mycobacterium avium complex (MAC)
2. toxoplasma gondii encephalitis
3. pneumocystis jirovecil pneumoniea (PJP or PCP)

Question 12

What are preferred regimens for the treatment of candidiasis (thrush/white film in the mouth/throat?

Answer 12

fluconazole (systemic treatment preferred in HIV patients)

Question 13

What are alternative regimens for candidiasis?

Answer 13

Oropharyngeal candidiasis:
1. itraconazole (DOC)
2. posaconazole topicals (clotrimazole troche, nystatin)
Esophageal candidiasis:
1. voriconazole
2. isavucoazonium
3. echinocandin (caspofungin)

Question 14

When should patients recieve secondary prophylaxis for candidiasis?

Answer 14

not recommended

Question 15

What is the preferred regimen for the treatment of cryptococcal meningitis?

Answer 15

Amphotericin B (liposomal) + flucytosine

Question 16

What are the alternative regimens for the treatment of cryptococcal meningitis?

Answer 16

1. fluconazole + flucytosine
2. Amphotericin B + fluconazole

Question 17

What is used for secondary prophylaxis of cryptococcal meningitis?

Answer 17

fluconazole (low dose)

Question 18

What is the preferred regimen for the treatment of cytomegalovirus (CMV)?

Answer 18

1. valganciclovir
2. ganciclovir

Question 19

What are the alternative regimens for the treatment of cytomegalovirus (CMV)?

Answer 19

If toxicities to ganciclovir or resistant strains:
1. foscarnet
2. cidofovir

Question 20

When is secondary prophylaxis used for cytomegalovirus?

Answer 20

NONE; for HIV continue ART and maintain CD4 count > 100 cells/mm3

Question 21

What is the preferred regimen for the treatment of mycobacterium avium complex?

Answer 21

Clarithromycin/Azithromycin + ethambutol

Question 22

What are the alternative regimens for the treatment of mycobacterium avium complex?

Answer 22

Add a 3rd or 4th agent with amikacin, streptomycin, moxifloxacin, orlevofloxacin

Question 23

What is used as secondary prophylaxis of mycobacterium avium complex?

Answer 23

Clarithromycin/Azithromycin + ethambutol (same as treatment)

Question 24

What is the preferred regimen for the treatment of pneumocystis jirovecil pneumonia?

Answer 24

SMX/TMP (high dose) +/- prednisone or methyprednosolone for 21 days

Question 25

What are the alternative regimens for the treatment of pneumocystis jirovecil pneumonia for G6PD deficiency?

Answer 25

1. pentamidine IV
2. atovaquone

Question 26

What is secondary prophylaxis of pneumocystis jirovecil pneumonia?

Answer 26

SMX/TMP DS or SS daily

Question 27

What are the risk factors for toxoplasmosis gondii encephalitis?

Answer 27

exposure to parasite via ingestion f uncooked/raw meat or shellfish or contact with cat feces/litter

Question 28

What is the preferred regimen for the treatment of toxoplasmosis gondii encephalitis?

Answer 28

pyrimethamine + leucovorin + sulfadiazine

Question 29

What are the alternative regimens for the treatment of toxoplasmosis gondii encephalitis?

Answer 29

1. clindamycin + pyrimethamine + leucovorin
2. SMX/TMP

Question 30

What is used for secondary prophylaxis of toxoplasmosis gondii encephalitis?

Answer 30

pyrimethamine + leucovorin + sulfadiazine (at reduced doses)

Question 31

Why is leucovorin added to all pyrimthamine containing regimens

Answer 31

rescue therapy to reduce the risk of pyrimethamine induced myelosuppression

Question 32

Which drugs can be used if a patient has a G6PD deficiency for PJP prophylaxis?

Answer 32

1. atovaquone
2. pentamidine