Opportunistic Infections Flashcards
What are immunocompromised states?
- HIV and other disease that destroy immune response CD4 cells <200 cells/mm3
- systemic steroids ≥14 days at a prednisone equivalent dose of ≥ 20mg/day or ≥2mg/kg/day
- immunosuppressants for autoimmune conditions or post-transplant (TNF-alpha inhibitors, Humira)
- cancer chemotherapy that destroys WBCs, especially if severe neutropenia ANC<500 cells/mm3
- asplenia or functional asplenia
What is the criteria for starting prophylaxis against pneumocystis jirovecil pneumonia (PJP or PCP)?
CD4 count <200 cells/mm3 or AIDS defining illness or oropharyngeal candadiasis
What are primary prophylaxis treatments for pneumocystis jirovecil pneumonia (PJP or PCP)?
- SMX/TMP DS or SS QD (DOC)
- SMX/TMP DS 3x/wk
- Dapsone
- Dapsone + pyrimethamine + leucovorin
- Atovaquone
- Atovaquone + pyrimethamine + leucovorin
- inhaled pentamide
What is the criteria to D/C prophylaxis against pneumocystis jirovecil pneumonia (PJP or PCP)?
CD4 count >200 cells/mm3 for > 3 months and remains on ART
What is the criteria for starting prophylaxis against toxoplasma gondii encephalitis?
CD4 count <100 cells/mm3 with positive Toxoplasma IgG
What is the primary prophylaxis treament regimens for toxoplasma gondii encephalitis?
- SMX/TMP DS (DOC)
- SMX/TMP DS 3x/wk or SS QD
- Dapsone + pyrimethamine + leucovorin
- Atovaquone
- Atovaquone + pyrimethamine + leucovorin
What is the criteria to D/C prophylaxis against toxoplasma gondii encephalitis?
CD4 count >200 cells/mm3 for > 3 months and remains on ART
What are the criteria for starting prophylaxis against mycobacterium avium complex (MAC)?
Initiate if not taking ART, not recommended if ART is started immediately; CD4 count less than <50 cells/mm3, and no active MAC infection
What are the primary prophylaxis treatment regimens for mycobacterium avium complex (MAC)?
- Azythromicin 1,200mg weekly (better for compliance)
- Azythromicing 600mg twice weekly
- Clarithromycin 500mg BID (lots of drug interactions)
What is the criteria to D/C prophylaxis against mycobacterium avium complex (MAC)?
taking fully suppressive ART
Which OIs are most common in HIV patients?
- mycobacterium avium complex (MAC)
- toxoplasma gondii encephalitis
- pneumocystis jirovecil pneumoniea (PJP or PCP)
What are preferred regimens for the treatment of candidiasis (thrush/white film in the mouth/throat?
fluconazole (systemic treatment preferred in HIV patients)
What are alternative regimens for candidiasis?
Oropharyngeal candidiasis:
1. itraconazole (DOC)
2. posaconazole topicals (clotrimazole troche, nystatin)
Esophageal candidiasis:
1. voriconazole
2. isavucoazonium
3. echinocandin (caspofungin)
When should patients recieve secondary prophylaxis for candidiasis?
not recommended
What is the preferred regimen for the treatment of cryptococcal meningitis?
Amphotericin B (liposomal) + flucytosine
What are the alternative regimens for the treatment of cryptococcal meningitis?
- fluconazole + flucytosine
- Amphotericin B + fluconazole
What is used for secondary prophylaxis of cryptococcal meningitis?
fluconazole (low dose)
What is the preferred regimen for the treatment of cytomegalovirus (CMV)?
- valganciclovir
- ganciclovir
What are the alternative regimens for the treatment of cytomegalovirus (CMV)?
If toxicities to ganciclovir or resistant strains:
1. foscarnet
2. cidofovir
When is secondary prophylaxis used for cytomegalovirus?
NONE; for HIV continue ART and maintain CD4 count > 100 cells/mm3
What is the preferred regimen for the treatment of mycobacterium avium complex?
Clarithromycin/Azithromycin + ethambutol
What are the alternative regimens for the treatment of mycobacterium avium complex?
Add a 3rd or 4th agent with amikacin, streptomycin, moxifloxacin, orlevofloxacin
What is used as secondary prophylaxis of mycobacterium avium complex?
Clarithromycin/Azithromycin + ethambutol (same as treatment)
What is the preferred regimen for the treatment of pneumocystis jirovecil pneumonia?
SMX/TMP (high dose) +/- prednisone or methyprednosolone for 21 days
What are the alternative regimens for the treatment of pneumocystis jirovecil pneumonia for G6PD deficiency?
- pentamidine IV
- atovaquone
What is secondary prophylaxis of pneumocystis jirovecil pneumonia?
SMX/TMP DS or SS daily
What are the risk factors for toxoplasmosis gondii encephalitis?
exposure to parasite via ingestion f uncooked/raw meat or shellfish or contact with cat feces/litter
What is the preferred regimen for the treatment of toxoplasmosis gondii encephalitis?
pyrimethamine + leucovorin + sulfadiazine
What are the alternative regimens for the treatment of toxoplasmosis gondii encephalitis?
- clindamycin + pyrimethamine + leucovorin
- SMX/TMP
What is used for secondary prophylaxis of toxoplasmosis gondii encephalitis?
pyrimethamine + leucovorin + sulfadiazine (at reduced doses)
Why is leucovorin added to all pyrimthamine containing regimens
rescue therapy to reduce the risk of pyrimethamine induced myelosuppression
Which drugs can be used if a patient has a G6PD deficiency for PJP prophylaxis?
- atovaquone
- pentamidine
