Opportunistic Infections Flashcards
what are opportunistic infections
infections that are more frequent or more severe because of immunosuppresion
examples of opportunistic infections
pneumocystic carnii pneumonia candida aspergillosis toxoplasmosis CMV HSV
management of acute OI no ART
OI presenting symptoms
start treatment for the OI
start HAART during treatment (usually)
what is immune reconstitution inflammatory syndrome
fever, worsening clinical signs of the OI or symptoms of the new OI
occur in the first weeks after starting ART
unmasks new infection the IS was too weak to respond to before
management of OI shortly after initiation (within 12 weeks) of ART
subclinical infection unmasked by early immune reconstitution not failure of ART
start treatment of OI and continue ART
OI occurs >12 weeks after initiation of ART in patients with CD4 count > 200 and suppressed HIV RNA
may be difficult to determine whether IRIS or new OI due to incomplete immunity
start treatment of OI continue ART
consider modifying ART if CD4 response to ART suboptimal
OI in patient with immunologic and virologic failure on ART
start treatment for OI , modify ART for better virlogic control
two fungal OI
mucocutaneous candidiasis
pneumocystis carnii pneumonia
clinical manifestation of mucocutaneous candidiasis
thrush
esophageal - burning, white plaques
vulvovaginal
treatment for mucocutaneous candidiasis
treat 7-14 days oral fluconazole
mucocutanous candidiasis prophylaxis
routine prophylaxis not recommended
acute therapu highly effective, could lead to drug resistance, DI
define primary prophylaxis
prevention before development of disease
define secondary prophylaxis
prevention of reoccurrence - after treatment of OI
how is PCP pneumonia acquired
in the environment exposed during early childood
usually have healthy antibodies but may result from reactivation or new exposure
clinical manifestation of PCP
dyspnea, fever, nonproductive cough, chest discomfort hypoxemia subacute onset CXR bilateral infiltrates diagnosis with organism in the sputum
treatment of PCP
untreated = 100% mortality
TMPSMX iv for 21 days
prednisone for mod-sev to decrease inflammation
when to start ART if not on it and get PCP
initiate within 2 weeks of diagnosis if signs of clinical improvement
PCP prophylaxis
initiate primary in patient with CD4<200(basically if they have AIDS) or history of oropharyngeal candidiasis
primary/secondary proph for life unless immune reconstitution on ART
only discontinue in patients with ART with sustained increase in CD4>200 for >3months
restart if CD$ drops below 400 or PCP occurs
prophylaxis DOC
TMPSMX DS 1 tab daily or 3 times a week
example of parasitic infection
toxoplasma gondii encephalitis
how do you acquire toxoplasma gondii
primary infection from tissue cysts in raw or undercooked meat or ingestion of sporulated oocyts (from cat feces) in sol water or food
no transmission person to persion
who does toxoplasma gondii normally occur in
patients with CD4 <50
clinical presentation of toxoplasma gondii
CNS - fever, headache, seizure
dissemination - other organ involvement
diagnosis of toxoplasma gondii
CT MRI of brain shows contrast enhacning lesions often with edema
detection of organism with brain biopsy - invasive
toxoplasmosis IgG antibody positive
preferred regimen of toxoplasma gondii
pyrimethamine +sulfadiazine + leucovorin
but very expensive
potential and alternative regimens for toxoplasma gondii
alternative: pyrimethamine + clinda + leucovorin - doesnt protect against PCP
potential regimen: TMPSMX can be considered an option if reason not to use preferred
duration of treatment for toxoplasma gondii
> 6 weeks
toxoplasma gondii adjuvant treatment
adjunctive corticosteroids if indicated for treatment of cerebral swelling, discontinue as soon as possible
anticonvulsants should be given if history of seizures
when to start ART when infected with toxoplasma gondii
no set recommendation
many start within 2-3 weeks of toxoplasmosis diagnosis
primary prophylaxis for toxoplasma gondii
TMPSMX DS 1 tab daily or 3x a week
alternative: dapsone-pyrimethamine + leucovorin, atovaquone
when should toxoplasma gondii prophylaxis be given
CD4 count <100 cells and positive IgG
when to discontinue primary prophylaxis for toxoplasma gondii
CD4> 200 for > 3 months on ART
reintroduced if CD4 decreases to <200
secondary prophylaxis for toxoplasma gondii
pyrimethamine + sulfadiazine + leucovorin
alternatives: pyrimethamine +clinda, atovaquone
when should you discontinue secondary prophylaxis for toxoplasma gondii
if completed initial therapy and remained asymptomatic and have a sustained increase in their CD4 counts >200 cells after ART >6months
treatment of mycobacterial infections
concomitant but staggered start of HAART in patients not already on HAART due to AE from medicationa and risk of severe IRIS
start of HAART based on CD4 count
significant _____ between antiretrovirals and TB meds
drug interactions
transmission of mycobacterium avium complex
inhalation, ingestion, or inoculation via resp tract or GI
MAC organisms everywher in the environment
who is at a major risk of disseminated MAC
CD4 count <50
diagnosis of disseminated MAC
culture of organism from blood, bone marrow, lymph node or other normally sterile tissue or fluid
symptoms of disseminated MAC
multiorgan infection
pneumonitis, pericarditis, skin abcess….
fever, nigh sweats, weight loss….
initial treatment of disseminated MAC
> 12 months
at least 2 effective drugs to prevent reisstance
preferred: clarithromycin + ethambutol
alternative*: azithro + ethambutal
when to initiate ART in disseminated MAC
asap after effective treatment
when to use secondary prophylaxis in disseminated MAC
lifelong chronic maintenance therapy after completion of intial therapy unless immune reconstitution on ART
consider discontinuation if treated >12mon, no signs of symptoms of MAC, sustained increase in CD4 count to >100 cells
primary prophylaxis for disseminated MAC
indicated if CD4 <50
azithro 1200mg once weekly
alternative: rifabutin
discontinue when patient of ART with CD4 >100 for >3 months
