Opportunistic infections - 8 questions Flashcards
Normal CD4 count in adults
800-1200 cells/mm2
What CD4 count is at risk for OIs
CD4 counts less than 500
Especially <200
Infection risk and CD4 count
CD4 count <500 : candidiasis and leukoplakia
CD4 count <200: PJP, CMV retinitis, Toxoplasmosis, MAC
Primary prophylaxis
Administration of an anti-infective agent to prevent
usually given to HIV patients when at risk for possible OI due to CD4 count
Secondary prophylaxis
administration of anti-infective therapy to prevent further recurrences of particular OI in patients living with HIV after they have been successfully treated for that OI and remain at risk for developing that OI based on their CD4 count
IRIS Immune reconstitution inflammatory syndrome
what is it and what is the treatment
characterized by fever, inflammation, and worsening clinical manafestation of OIs
More likely to occur in patients with low CD4 count <50 and high HIV RNA >100,000
Treatment
Mild: NSAIDS and inhaled corticosteroids
Severe: Prednisone 1-2 weeks, followed by taper
Infections due to Candida Species:
presentation and treatment
Oropharyngeal Candidiasis - thrush
Cottage cheese like lesions on the buccal mucosa, leads to dry mouth and taste alterations
Treatment:
Preferred use of topical agents to prevent resistance to fluconazole
DOC: Nystatin suspension 5ml swish AND swallow QID x 7-14 days
Alternative: Clotrimazole troches 10mg oral lozenge 5 times daily for 7-14 days
Alternative:
Fluconazole 200mg loading dose followed by 100-200mg PO daily FOR 7-14 days
Infections due to Candida Species:
presentation and treatment
Esophageal candidiasis
fever, retrosternal burning pain or discomfort, dysphagia, odynophagia
Treatment:
Fluconazole 200mg (up to 400mg) IV or PO daily FOR 14-21 days
Infections due to Candida Species:
presentation and treatment
Vulvovaginal candidiasis
White thick vaginal discharge, vaginal itching, vaginal burning, and vulvar erythema
Treatment:
Based on uncomplicated, severe, Azole- refractory
uncomplicated:
- Fluconazole 150mg PO x 1 dose
severe:
- Fluconazole 100-200mg PO daily or topical antifungals for > or equal to 7 days
Azole- refractory:
- Boric acid 600mg vaginal suppository once daily for 14 days
Infections due to Cryptococcus neoformans:
presentation, Diagnosis, treatment, and use of prophylaxis
Cryptococcal meningitis
Presentation: usually subacute meningitis with symptoms present for weeks or months, fever, malaise, headahce, nausea, dizziness, lethargy, irritability, neck stiffness and photophobia
Diagnosis: CSF analysis
- increased ICP, mildly elevated protein, increased cryptococcal antigen titer in CSF and serum, PCR test positive for C. neoformans
Treatment: 3 phases
Induction:
- Amphotericin B 3-4mg/kg IV once daily + Flucytosine 25mg/kg PO QID for 2 weeks
Consolidation:
- Fluconazole 800mg PO daily for > or equal to 8 weeks
- can use fluconazole 400mg PO daily x 8 weeks in stable patients with sterile CSF culture and on ART
Maintenance (secondary Prophylaxis):
- Fluconazole 200mg PO daily for 1 year or longer
- can D/C prophylaxis after 1 year IF patient asymptomatic, has CD4 count > or equal to 100 for 3 months on ART
- Restart ART if patients CD4 count is <100
Infection due to mycobacterium avium complex
presentation, Diagnosis, treatment
Presentation: Gradual onset of systemic symptoms that have been present for several months, NIGHT SWEATS, fever, weightloss, diarrhea, abdominal pain, and malaise/fatigue
Diagnosis: A confirmed diagnosis of disseminated MAC is based on compatible clinical signs and symptoms WITH isolation of MAC from acid-fast bacilli cultures of blood, lymph fluid, bone marrow, or other tissues
Treatment: ( FOR > OR EQUAL TO 12 MONTHS)
- If patients are not on ART should initiate ART immediately with MAC therapy
Preferred:
- Clarithromycin 500mg PO BID + Ethambutol 15mg/kg PO daily
OR
Azithromycin 500-600mg PO daily + Ethambutol 15mg/kg PO daily
* IF MORE SEVERE ADD rifabutin 300mg PO daily
*More severe disease present (CD4 <50) a fourth drug should be considered ADDED
- Levofloxacin 500mg or moxifloxacin 400mg QD
Infection due to mycobacterium avium complex
PRIMARY AND SECONDARY PROPHYLAXIS
PRIMARY:
- CD4<50 AND not receiving ART
- TX: Azithromycin 1,200mg PO once weekly
SECONDARY:
- Treatment duration should be at least 12 months
- Clarithromycin 500mg PO BID with Ethambutol 15mg/kg PO daily (can add Rifabutin 300mg PO daily)
Infection due to Pneumocystis Jirovecii Pneumonia
presentation, Diagnosis, treatment
Presentation: Subacute onset of progressive dyspnea, fever, non-productive cough, and chest discomfort that worsens over period of days or week, Mild cases will show normal pulmonary exam when at rest but with exerction, tachypnea, tachycardia, and diffuse dry rales
Diagnosis:
pO2 <70
LDH >500
Treatment:
If patient has not started ART it should be initiated in patients within 2 weeks of diagnosis of PCP if possible
Moderate-severe disease:
- Bactrim 15-20mg/kg/day IV q6-8h for 21 days
Alternative options include: primaquine, pentamidine
*IF PATINETS pO2 <70 ADD prednisone 40mg PO BID x 5 days, then 40mg PO daily x 5 days, then 20mg daily x 11 days
Mild-moderate disease:
- Bactrim two DS tablets PO TID for 21 days (can also use same IV therapy for moderate to severe in this case)
Alternative options include: Dapsone, Primaquine, atovaquone (must get G6PD testing done first)
Infection due to Pneumocystis Jirovecii Pneumonia
PRIMARY AND SECONDARY PROPHYLAXIS
PRIMARY:
- should be given if CD4 count <100-200 and HIV RNA level above detection limits AND if CD4<100 regardless of HIV RNA level
SECONDARY:
- MUST BE GIVEN TO ALL PATIENTS AFTER ACUTE PJP EPISODE
Treatment:
Bactrim DS or SS tablet QD
Bactrim DS MWF
Infection due to toxoplasma gondii
presentation, Diagnosis, treatment
Presentation: headache, focal neuological deficits, and fever
Diagnosis: Positive IgG anti-toxoplasma immunoglobulin antibodies, CT scan reveals ring enhancing lesions in grey matter
Treatment: (duration at least 6 weeks)
- if ART not already started should initiate in patients withing 2-3 weeks of diagnosis/ treatment of toxoplasmosis
Acute infection:
- Body weight < or equal to 60kg: Pyrimethamine 50mg PO + sulfadiazine 1,000mg PO q6h + leucovorin 10-25mg PO daily
- Body weight > 60kg: Pyrimethamine 75mg PO + sulfadiazine 1,500mg PO q6h + leucovorin 10-25mg PO daily
OR
Bactrim 5mg/kg IV or PO BID
Chronic maintenance:
- Pyrimethamine 25-50mg PO + sulfadiazine 2,000-4,000mg PO daily (in 2-4 divided doses) + leucovorin 10-25mg PO daily
OR
Bactrim DS one tablet PO BID
Infection due to toxoplasma gondii
PRIMARY AND SECONDARY PROPHYLAXIS
PRIMARY:
- given to patients who are toxoplasma IgG positive with CD4 cell count <100
- Bactrim DS one table PO daily
SECONDARY:
ALL PATIENTS
-Pyrimethamine 25-50mg PO + sulfadiazine 2,000-4,000mg PO daily (in 2-4 divided doses) + leucovorin 10-25mg PO daily
OR
-Bactrim DS one tablet PO BID
