Opportunistic Infections Flashcards
Which infections do we use primary prevention for?
- Pneumocystis pneumonia
- Toxoplasma encephalitis
- Disseminated MAC
Oropharyngeal and esophageal candidiasis are common in …. What can help reduce this risk?
- Patients with CD4 < 200
- HAART reduces likelihood of infection
Most common pathogen n Oropharyngeal and esophageal candidiasis
-C. albicans
Adverse effects associated with triazoles as a class
- Drug/drug int with Protease Inhibitors
- GI upset
- Hepatotoxicity
- Rash
Itraconazole adverse reactions
-Negative inotropic effects
Voriconazole adverse reactions
- Visual disturbances
- Auditory or visual hallucinations
Why is Fluconazole the best?
- Great oral bioavailability
- Absorption not affected by food or gastric pH
- Less drug/drug int than other azoles
Preferred Treatment of Oropharyngeal Candidiasis
- Fluconazole 100mg PO daily
- Duration 7 to 14 days
Alternative therapies for mild to moderate Oropharyngeal Candidiasis
- Itraconazole
- Clotrimazole
- Posaconazole
- Nystatin
- Miconazole
Preferred Treatment of Esophageal Candidiasis
-Fluconazole 100 to 400mg PO/IV daily
or
-Itraconazole 200mg PO daily
-Duration 14 to 21 days
Alternative/Refractory treatment of Esophageal Candidiasis
- Voriconazole
- Isavuconazole
- Capsofungin
- Amp B
Risk factor for Pneumocystis Pneumonia (PCP)
- CD4< 200 cells/mm3
- CD4 < 14%
Pneumocystis Pneumonia (PCP) signs and symptoms
- Nonproductive cough
- Hypoxemia (PaO2 < 70)
- Dyspnea
- Fever
When to consider prophylaxis for PCP
- Pts with CD4<200cells/uL
- CD4<14%
- CD4 between 200 and 250 with delayed ART therapy
PCP Prophylaxis treatment regimen
- Bactrim DS PO daily
- Bactrim SS PO daily
- Also covers toxoplasmosis
Alternatives to PCP prophylaxis treatment
- Bactrim DS PO m/w/f
- Dapsone plus pyrimethamine plus leucovorin
- Atovaquone
- Aerosolized pentamidine
If taking Bactrim and CrCl < 30 mL/min
- Use half of the usual dose
- If only using for prophylaxis you do NOT need to dose adjust
- Monitor CBC and K+
What do you need to monitor if using Dapsone for PCP therapy
- G6PD levels BEFORE beginning treatment
- Can lead to anemia
- Monitor CBC and LFTs too
Which drug regimens cover PCP and Toxo prophylaxis?
- Bactrim DS/SS
- Atovaquone (take with food)
- Dapsone + Pyrimethamine + Leucovorin
When to Discontinue prophylaxis of PCP
- CD4 count > 200 for >3mo
- CD4 100 to 200 with undetectable HIV viral load for >3mo
PCP treatment
- Bactrim 15 to 20mg/kg/day for 21 days
- If PaO2 < 70 add on Prednisone (40BID to 40QD to 20QD)
- Start HAART within 2 wks of PCP diagnosis
Alternative PCP treatment(s)
- IV Pentamidine (Inpatient ONLY)
- PO Atovaquone
- PO Dapsone + PO TMP
- PO Primaquine + PO/IV Clindamycin
- Treatment duration = 21days
Possible adverse rxns with Pentamidine
- Hypotension
- Hypoglycemia
- Monitor: Blood pressure, glucose, renal function, electrolytes, CBC
Preventing Recurrence of PCP
- Secondary prophylaxis regimen = primary prophylaxis
- Keep therapy going until CD4 > 200 and HAART has been initiated
Toxoplasma gondii risk factors
- CD4 < 100
- Raw meats
- Cat droppings
Signs and symptoms of Toxoplasma gondii
- Headache
- Confusion
- Motor weakness
- Seizure
- Coma
- IgG +
Toxoplasma Primary Prevention
- Bactrim DS PO daily
- Dapsone + pyrimethamine + leucovorin
- Atovaquone
When to discontinue Toxoplasma prophylaxis
- CD4 count > 200cells for >3mo
- Pt on ART with CD4 between 100 and 200 with undetectable HIV viral load for 3 to 6mo
Things to know about Pyrimethamine
- Penetrates CSF
- Coadminister with leucovorin
- Monitor CBC
Toxoplasma Encephalitis treatment
-Pyramethamine 200mg PO x1 then 75mg PO daily PLUS -Sufladiazine 1.5g PO Q6H PLUS -Leucovorin 25mg PO daily -Duration >/= 6weeks
Adverse effects of Sulfadiazine
- Cyrstalluria
- Bone marrow suppression
- N/V
- Advise patient to maintain adequate hydration!
Alternative treatments for Toxoplasma Encephalitis
- Bactrim 5mg/kg IV/PO BID
- For sulfa allergy sub out sulfadiazine for EITHER
a) Clindamycin 600mg IV/PO q6h
b) Atovaquone 1500 PO BID
Toxoplasma secondary prophylaxis
-Pyrimethamine 50mg PO daily PLUS -Sulfadiazine 2g PO BID PLUS -Leucovorin 10mg PO daily -Discontinue if CD4 > 200 for 6mo or greater
Risk factors for MAC
-CD4 <50
Signs and symptoms of MAC
- Weight loss
- Fever
- Night sweats
- Diarrhea/ abdominal pain
MAC prophylaxis regimen
- Azithromycin 1200mg PO qweek
- Clarithromycin 500mg PO BID
When to discontinue MAC prophylaxis
-CD4 count > 100cells for > 3mo
MAC treatment
-Clarithromycin 500mg PO BID PLUS -Ethambutol 15mg/kg/day (400mg tabs) PLUS -Rifabutin 300mg PO daily -ALTERNATIVE = sub azithromycin 600mg daily instead of clarithro -Duration > 12mo
Ethambutol side effects
- Visual disturbances
- Adjust dose if CrCl<50mL/min
- Monitor: Baseline eye exam (then q1mo after that), and Renal function
Rifabutin
- Dose adjustments
a) CYP inducers (Efavirenz) = 450mg PO daily
b) CYP inhibitors (Ritonavir-boosted PIs) = 150mg daily
IRIS
- Happens with initiation of HAART
- Rapid increase in CD4/immune response leads to pt getting worse before he/she gets better!
When to give flu vaccine
-Annually
When to give HPV vaccince
-Ages 9 to 26 that meet criteria
When to give VZV vaccine
- CD4 count > 200
- VZV seronegative
When to give Zostavax vaccine
- Pt > 50yrs
- CD4 count >200
When to give Tdap/Td
- To all adults
- Booster q 10 years
When to give Men-ACWY vaccine
- If not previously vaccinated give 2 dose primary series
- Then Booster q5yr
