Opportunistic Infections Flashcards
What is the most profound effect of HAART?
- reducing OI related mortality in HIV infected people
What are OIs directly related to?
- related to the overall immune function of CD4 T cells
- HAART reduced OIs and improved survival, independent of antimicrobial prophylaxis (does not replace the need for antimicrobial prophylaxis in severe immune suppression
- although hospitalizations and deaths have decreased dramatically due to ART, OIs remain a leading cause of morbidity and mortality in HIV infected persons
What are some of the AIDs indicator conditions?
- cervical cancer, encephalopathy, lymphoma, wasting syndrome due to HIV
What are some of the bacterial OIs associated with HIV?
- mycobacterium avid complex (MAC) infection- lungs
- recurrent bacterial infections can also occur such as repeated episodes of bacterial pneumonia or salmonella sepsis
What are some of the fungal OIs associated with HIV?
- pneumoncystis carnii pneumonia, lungs
- candidia- in the mouth, esophagus, trachea, bronchi, lungs or gut
- histoplasmosis
- coccidiomycosis
- aspergillosis
- cryptococcosis- outside the lungs particularly cryptococcal meningitis
What are some of the protozoal OIs associated with HIV?
- toxoplasmosis of the brain
- cryptosporidium
What are some of the viral OIs associated with HIV?
- CMV disease outside of the liver, spleen or lymph nodes and CMV retinitis
- HSV systemic- encephalitis
What CD4 found is considered the danger zone?
- under 200 (opportunistic infections can affect the body with a count over 200 though be conscious of this)
What is immune reconstitution inflammatory syndrome (IRIS)?
- characterized by a fever, worsening clinical signs of the OI or symptoms of new OI
- occur in the first few weeks after starting ART
What may IRIS occur with?
- mycobacterial infections
- pneumocystis carnii pneumonia
- toxoplasmosis
- hep B and hep C
- tuberculosis
- CMV infection
- varicella zoster infection
- cryptococcal infection
- progressive multifocal leukoencephalopathy
When do OIs usually occur in respect to initiating an ART?
- shortly after initiation (within 12 weeks) of ART
- subclinical infection unmasked by early immune reconstitution (not failure of ART)
- start treatment for the OI- continue ART - OI occurs over 12 weeks after initiation of ART in patients with CD4 cound >200 cells/mm3 and suppressed HIV RNA
- - may be difficult to determine IRIS or new OI due to incomplete immunity
- - start treatment for OI; continue ART; consider modifying ART if CD4 response to ART is suboptimal - OI in patient with immunologic and virology failure on ART- clinical failure of ART
- - start treatment for OI; modify ART for better virologic control
What is mucocutaneous candidiasis as an OI?
- usually caused by candida albicans- other species are seen in advances immunosuppression
- oropharyngeal and esophageal candidiasis are common here
— most common in those with a CD4 count < 200
(vulvovaginal candidiasis can also be an issue here)
what are the characteristics of oropharyngeal candidiasis?
- pseudomembranous- painless, creamy white plaques on buccal, oropharyngeal mucosa and/or tongue; can be scraped off easily
- erythematous - patches on anterior or posterior palate or tongue
- angular cheilosis
What are the characteristics of esophageal candidiasis?
- retrosternal burning or discomfort, odynophagia, fever
- endoscopy- whitish plaques +/- mucosal ulceration
What are the characteristics of vulvovaginal candidiasis?
- creamy discharge, mucosal burning and itching
What is the treatment for mucocutaneous candidiasis?
treat for 7-14 days
- oral fluconazole is the treatment of choice
- effective and in some studies is superior to topical therapy
- more convenient and generally better tolerated compared to topical
- topical (nystatin suscpension, clotrimazole troches)
Should we be recommending primary prophylaxis for all those with mucocutaneous candidiasis??
NO
- very low attributable mortality
- acute therapy is highly effective
- can lead to disease caused by drug resistant species
- drug interactions
- expensive
What is the cause of PC pneumonia?
- caused by pneumocystitis jiroveci
- ubiquitous in the environment - initial infection usually in early childhood - 2/3 of healthy children have antibodies by age 2-4 years old
- PCP may result from reactivation or new exposure
- in immunocompromised patients, possible airborne spread
What is the most common and life threatening OI?
-PCP pneumonia
Who is at most risk of being affected by PCP penumonia?
- patients that are aware of their HIV infection or are not receiving ongoing HIV care or amoung those with advanced immunosuppression (CD4 counts <200 cells/mm3)
- incidence of PCP has declined substantially with widespread use of prophylaxis and ART
What are the signs that are associated with PCP?
- progressive exertional dyspnea, fever, nonproductive cough, chest discomfort
- hypoxemia: characteristic, may be mild or severe
- subacute onset, worsens over days-weeks (fulminant pneumonia is uncommon)
- chest exam may be normal, or diffuse dry rales, tachypnea, tachycardia (esp with exertion)
- CXR- bilateral infiltrates
- definitive diagnosis- organisms in sputum
What is the duration of treatment for PCP?
- 21 days
What is the treatment of choice for PCP?
- TMP IV
- adjust the dose for the renal insufficiency - AE: rash, SJS, fever, leukopenia, thrombocytopenia, azotemia, hepatitis, hyperkalemia
- corticosteroids: for moderate to severe disease (hypoxia) (within 72 hours- improved mortality)
- prednisone 40 mg BID days 1-5 days then taper
What are the alternative therapeutic regimens for moderate-to-severe PCP disease?
- clindamycin-primaquine
- IV pentamidine
Should prophylaxis be initiated in PCP pneumonia?
- initiate: primary prophylaxis in patients with CD4 count <200 cells/mm3 or history of oropharyngeal candidiasis - consider for those with CD4 count <14% or AIDs defining illness
- primary/secondary prophylaxis for life, unless immune reconstitution on ART
What is the preferred treatment for primary/secondary prophylaxis
TMP/SMX 1 DS tab daily or 1 SS tab daily
- alternatives: TMP/SMX 1 DS tab three times a week
When should prophylaxis for PCP be d/c?
- when there is an increase in CD4 count >200 cells/mm3 for over 3 months
- restart maintence therapy if CD4 count decreases to <200 cells/mm3 or if PCP recurs at CD4 count >200 cells/mm3
What is the epidemiology of toxoplasma gondii?
- disease usuaully caused by reactivation of latent tissue cysts in raw or undercooked meat or ingestion of sporulated oocysts (from cat feces) in soil, water or food
- primary infection may be associated with acute cerebral or disseminated disease
- no transmission by person to person contact
- primarily occurs in patients with CD4 count <50 cells/mm3
What is the clinical presentation of toxoplasma gondii (CNS)?
- fever, headache, seizures, focal neurological abnormalities, mental status changes. coma
- dissemination to eye, lung or other organs can occur
Disseminaiton may occur to where in the body after toxoplasma gondii?
- eye, lung and other organ involvement
What is the preferred regimen of toxoplasma gondii encephalitis?
- pyrimethamine and sulfadiazine and leucovorin
What is the alternative regimen of toxoplasma gondii?
- pyrimethamine and clindamycin and leucovorin
What is the DOT of toxoplasma gondii?
over 6 weeks, longer is extensive disease or incomplete response
What is the adjunctive treatment of toxoplasma gondii? (TG)
- adjunctive corticosteroids should only be administered if clinically indicated for treatment of cerebral swelling; monitor closely and d/c as soon as possible. Monitor for development of other OIs
- anticonvulsants should be administered to those patients with TE who have a history of seizures, but should not be administered as prophylactics to all patents
When is prophylaxis important for those with TG?
- use in primary prophylaxis if the CD4 count < 100 cells/mm3 and positive IgG T. Gondii serology
- TMPSMX- 1 ds tab daily (also covers PCP)
- d/c primary prophylaxis in those with a CD4 count >200 cells/mm3 for over 3 months on ART
- reintroduced if the CD4 count decreases to <100-200 cells/mm3
What is used as secondary prophylaxis for TG?
- pyrimethamine and sulfadiazine and leucovorin
- alternatives: pyrimethamine and clindamycin
- atovaquone (+/- pyramethamine and sulfadiazine)
What is the treatment of mycobacterial infections in those with HIV?
- concomitant but staggered start of HAART in patient not already on HAART due to AE from medication and risk of severe IRIS - start of HAART based on CD4 count
What is MAC?
mycobacterium avid complex
- in nontuberculosis mycobacteria
Where are MAC organisms found?
- everywhere in the environment - water and soil
What is the transmission of MAC?
- inhalation, ingestion, or inoculation via the respiratory or GI tract
- generally occurs in those with CD4 counts, <50 cells/mm3
What is the clinical manifestation of MAC?
- dissemination multi-organ infection
- localized manifestations: pneumonisitis, pericarditis, osteomyelisitis, skin or soft tissue abscesses, genital ulcers, CNS infection
- fever, night sweats, weight loss, fatigue, diarrhea, abdominal pain, anemia, neutropenia
What is the major risk factor associated with MAC?
- CD4 count <50 cells/mm3
What constitutes a diagnosis of MAC?
- culture of organism from blood, bone marrow, lymph node or other normally sterile tissue or fluid
What is the initial treatment associated with dissmeninated MAC?
- > 12 months
- at least 2 effective drugs, to prevent resistance
- clarithromycin and ethambutol po daily (+/- rifampin)
What is the alternative treatment to treating disseminated MAC?
- azithromycin po daily and ethambutol po (+/- rifampin)
- if not on ART then initiate ASAP after effective tx
What is needed for prevention of disseminated MAC?
- lifelong chronic maintenance therapy after completion of initial therapy unless immune reconstitution on ART
- consider d/c of secondary prophylaxis if treated >12 months, no signs or symptoms of MAC, and sustained (>6 months) increase in CD4 count to >100 count/mm3 on ART
- restart secondary prophylaxis if CD4 count decreases to <100 cells/mm3
When is primary prophylaxis warranted for disseminated MAC?
- CD4 count under 50 cells/mm3
What is used for primary prophylaxis of disseminated MAC?
- azithromycin 1200-1250 mg po once weekly
- clarithromycin 500 mg po BID
- d/c primary prophylaxis when CD4 count is over 100 cells/mm3
