Opportunistic Infections Exam 4 Flashcards
What is primary prophylaxis?
Therapy given to a patient in order to prevent a first episode of an OI
What is secondary prophylaxis?
Therapy given to a patient after having already received treatment for an active OI in order to prevent a second occurrence
What is the CD4 count that puts pts at risk for Candidiasis?
CD4 <200 cells/mm^3
Primary prophylaxis for Candidiasis
- Not recommended
- Very minimal morbidity and mortality is associated with infections
- Acute treatment is often highly effective
- Routine prophylaxis may lead to development of drug resistant species
Secondary prophylaxis for Candidiasis
- Only recommended in patient who have frequent or severe recurrences
- Fluconazole 100-200 mg by mouth once daily
- Can be stopped when CD4 increases above 200 cells/mm^3
Treatment for Candidiasis
Fluconazole 100 mg-200 mg by mouth once daily for 7-14 days
What is the CD4 count that puts pts at risk for Pneumocystis Pneumonia?
CD4 <200 cells/mm^3
Primary prophylaxis for Pneumocystis Pneumonia
- Should be started in all patients with a CD4 count <200 cells/mm^3, CD4% <14%, or history of an AIDS-defining illness.
- Preferred Therapy: Bactrim 160/800 mg PO once daily; Can cause allergic reactions, rash, pancytopenia, nausea and vomiting
- Alternative Therapy: Dapsone 100 mg PO once daily, Atovaquone 1500 mg PO once daily with food (Poor adherence)
Secondary prophylaxis for Pneumocystis Pneumonia
- Same as primary prophylaxis unless patient experienced an episode of PJP with a CD4 >200 cells/mm^3, in which case
prophylaxis should be continued for life. - Start prophylaxis with preferred drug regimen when CD4 <200 cells/mm^3 (14%) and can discontinue once CD4 >200 cells/mm^3 (14%) for greater than 3 months
Treatment for Pneumocystis Pneumonia
- TMP-SMX dosed based off TMP 15–20 mg/kg/day IV or PO divided into 3 to 4 daily doses for 21 days
- Adjunctive steroid treatment in patient with PaO2 <70mmHg on room air:
+ Prednisone 40 mg PO BID days 1 - 5
+ Prednisone 40 mg PO Daily days 6 – 10
+ Prednisone 20 mg PO Daily days 11 – 21
When can Primary and Secondary prophylaxis for Pneumocystis Pneumonia be discontinued?
- Can be discontinued when CD4 count increased to ≥200 cells/mm^3 (14%) for at least 3 months in response to HIV treatment.
What is the CD4 count that puts pts at risk for Toxoplasmic Encephalitis?
CD4 <100 cells/mm^3
Primary prophylaxis for Toxoplasmic Encephalitis
- Should be started in patients with anti-toxoplasma IgG antibodies and CD4 counts <100 cells/mm^3
- Preferred Therapy: Bactrim 160/800 mg PO once daily
- Alternative Therapy: Atovaquone 1500 mg PO once daily with food
Secondary prophylaxis for Toxoplasmic Encephalitis
Pyrimethamine 25–50 mg PO daily + sulfadiazine 2000–4000 mg PO daily (in 2 to 4 divided doses) + leucovorin 10–25 mg PO daily
Treatment for Toxoplasmic Encephalitis
- Pyrimethamine 200 mg PO once, followed by dose based on body weight:
- Body weight ≤60 kg: pyrimethamine 50 mg PO daily + sulfadiazine 1000 mg PO q6h + leucovorin 10–25 mg PO daily (can increase to 50 mg daily or BID)
- Body weight >60 kg: pyrimethamine 75 mg PO daily + sulfadiazine 1500 mg PO q6h + leucovorin 10–25 mg PO daily (can increase to 50 mg daily or BID)
When can Primary prophylaxis for Toxoplasmic Encephalitis be discontinued?
when CD4 count increased to ≥200 cells/mm^3 (14%) for at least 3 months in response to HIV treatment
When can Secondary prophylaxis for Toxoplasmic Encephalitis be discontinued?
when CD4 count increased to ≥200 cells/mm^3 (14%) for at least 6 months in response to HIV treatment and the patient no longer has any signs or symptoms
What is the CD4 count that puts pts at risk for Mycobacterium avium Complex Disease?
CD4 <50 cells/mm^3
Primary prophylaxis for Mycobacterium avium Complex Disease
- Should be started in all patients with a CD4 count <50 cells/mm^3
- Azithromycin 1200 mg by mouth once weekly or 600 mg by mouth twice weekly
- Main side effects are nausea and diarrhea
Secondary prophylaxis for Mycobacterium avium Complex Disease
Secondary prophylaxis consists of the same medications as the treatment regimens
Treatment for Mycobacterium avium Complex Disease
- Azithromycin 500–600 mg by mouth daily with ethambutol 15 mg/kg by mouth daily (generally preferred based on ease of administration and drug interactions)
- Azithromycin 500–600 mg by mouth daily with ethambutol 15 mg/kg by mouth daily with rifabutin 300 mg by mouth daily
When can Primary prophylaxis for Mycobacterium avium Complex Disease be discontinued?
when CD4 count increased to ≥100 cells/mm^3 for at least 3 months in response to HIV treatment
When can Secondary prophylaxis and treatment for Mycobacterium avium Complex Disease be discontinued?
once they have completed at least 12 months of therapy, have no signs and symptoms of MAC, and have a CD4 count >100 cells/mm^3 for 6 months in response to ART
What is the CD4 count that puts pts at risk for Cytomegalovirus?
CD4 <50 cells/mm^3
Primary prophylaxis for Cytomegalovirus
- Main recommendation for preventing disease is initiation of ART
- Routine primary prophylaxis in not recommended
Treatment for Cytomegalovirus
- Most treatment is individualized based on site of infection
- CMV retinitis:
+ Intravitreal injections of ganciclovir (2 mg/injection) followed by
+ Valganiciclovir 900 mg PO BID for 14-21 days followed by maintenance therapy / secondary prophylaxis
Secondary prophylaxis for Cytomegalovirus
- Valganciclovir 900 mg PO daily
- Can cause pancytopenia, insomnia, nausea
When can Secondary prophylaxis for Cytomegalovirus be discontinued?
- Pt received treatment for 3-6 months
- CD4 count >100 cells/mm^3 for 3-6 months in response to ART
- Clearance by an ophthalmologist
Which medications are CI in pts who have a CD4 < 200 cells/mm^3?
- varicella-zoster
- herpes-zoster
- measles, mumps, rubella vaccines
Influenza in HIV patients
- All HIV positive patients should receive an annual flu vaccine
- Patients should receive the inactivated injection
Hepatitis A and B
- Recommended in all HIV patients
- Test for immunity at initial visit
- May need to repeat vaccination in CD4 < 500 cells/µL
Human Papilloma Virus
- Some debate over vaccination as many HIV patients are likely already exposed
- Must weigh cost vs. benefit
Tetanus, diphtheria, pertussis
- regardless of CD4 count
- Td booster every 10 years (one time dose of Tdap for pertussis booster)
Varicella
- only in those whose CD4 count is >200 cells/mm^3
- 2 doses
Herpes Zoster (zoster vaccine live)
- CI in those whose CD4 count is < 200 cells/mm^3
- No recommendation
Herpes Zoster (recombinant zoster vaccine)
No recommendation
HPV
- regardless of CD4 count
- 3 doses through age 26
Measles, mumps, rubella
- CI in those whose CD4 count is < 200 cells/mm^3
- in those whose CD4 count is >200 cells/mm^3 -> 1 or 2 doses
Pneumococcal polysaccharide (PPSV23)
- regardless of CD4 count
- 1 dose followed by booster at 5 years
Pneumococcal 13-valent conjugate (PCV-13)
- regardless of CD4 count
- 1 dose
Meningococcal
- regardless of CD4 count
- 1 dose or more
Hepatitis A
- regardless of CD4 count
- 2 doses
Hepatitis B
- regardless of CD4 count
- 3 doses
