Opportunistic Infections in HIV Patients Flashcards
1
Q
What are the opportunistic infections that can occur in HIV patients?
A
- Pneumocystis pneumonia (PJP)
- Toxoplasma encephalitis
- CMV retinitis
- Cryptococcal meningitis
- TB
- Disseminated MAC disease
- Histoplasmosis
- Kaposi sarcoma
- Lymphomas
2
Q
What are the normal CD4 counts in adults?
A
800-1,200 cells/mm3
3
Q
What are the CD4 counts that are associated with development of OIs?
A
- CD4 <500
- Especially <200
4
Q
Which OIs occur at any CD4 count?
A
- MAC TB
- Pneumonias
- Dermatomal varicella zoster
5
Q
Which OIs occur at CD4 <500?
A
- Candidiasis
- Leukoplakia
6
Q
Which OIs occur at CD4 <200?
A
PJP, CMV retinitis, toxoplasmosis, MAC, cryptococcus meningitis or diarrhea, lymphomas, and Kaposi’s sarcoma
7
Q
Which infections can increase HIV viral load?
A
TB, syphilis
8
Q
What is primary prophylaxis of OIs?
A
- Admin. of anti-infective agent to prevent the FIRST episode of a particular OI in HIV patient
- At risk for developing that OI based on CD4 count
9
Q
What is secondary prophylaxis of OIs?
A
- Chronic maintenance or suppressive therapy
- Admin. of anti-infective therapy to prevent FURTHER RECURRENCES of a particular OI in HIV patient
- Have been successfully treated for that OI and remain at risk for developing that OI based on CD4 count
10
Q
In which pts is IRIS more likely to occur?
A
- CD4 <50
- HIV RNA levels >100,000 copies/ml
11
Q
If IRIS happens, when is it most common?
A
Within 4-8 weeks of starting ART
12
Q
What is the treatment for mild IRIS?
A
- NSAIDs for fever and pain
- Inhaled corticosteroids for bronchospasms
13
Q
What is the treatment for severe IRIS?
A
Prednisone 1-2 mg/kg daily for 1-2 weeks, followed by taper
14
Q
In which OIs should steroids be avoided in?
A
Cryptococcal meningitis, Kaposi’s sarcoma
15
Q
What is the preferred treatment for oropharyngeal candidiasis?
A
Fluconazole 200mg loading dose, followed by 100-200mg PO daily for 7-14 days
16
Q
What is the alternative treatment for oropharyngeal candidiasis? (mild to moderate only)
A
- Nystatin suspension 5ml 7-14 days
- Clotrimazole troches 10ml 7-14 days
17
Q
What is the preferred treatment for esophageal candidiasis?
A
Fluconazole 200mg (up to 400mg) IV or PO daily for 14-21 days
18
Q
What is the treatment for uncomplicated vulvovaginal candidiasis?
A
- Fluconazole 150mg PO x1 dose
- Topical -azoles for 3-7 days
- Ibrexafungerp 300mg PO BID x1 day
19
Q
What is the treatment for severe vulvovaginal candidiasis?
A
Fluconazole 100-200mg PO daily or topical antifungals for ≥7 days
20
Q
What is the treatment for azole-refractory C. glabrata vulvovaginal vaginitis?
A
Boric acid 600mg vaginal suppository once daily for 14 days
21
Q
What is the treatment for recurrent vulvovaginal candidiasis?
A
- Oteseconazole 600mg PO day 1, 450mg day 2, then 150mg once weekly starting at day 14 for 11 weeks (no reproductive potential)
- Fluconazole 150mg PO day 1, 4, 7, then oteseconazole 150mg PO daily at days 14-20, then oteseconazole 150mg once weekly starting at day 28 for 11 weeks (no reproductive potential)
- Fluconazole 150mg PO q72hrs x3 doses, followed by ibrexafungerp 300mg PO BID on 1 day/month for 6 months (use contraception during and for 4 days after last dose)
22
Q
Is primary prophylaxis for candidiasis OIs recommended?
A
- Not routinely recommended
- ART is most effective
23
Q
What is the secondary prophylaxis regimens for candidiasis OIs?
A
For frequent or severe recurrences
- DoC: Fluconazole 100-200mg PO daily
- Alt.: Posaconazole suspension 400mg PO BID
24
Q
When to d/c candidiasis prophylaxis?
A
Consider d/c when CD4 >200
25
What are the SEs of azoles.
NVD, abdominal pain, increased LFTs, QTc prolongation
26
When to initiate ART in cryptococcal meningitis?
Delayed until after induction (2 wks) or induction/consolidation (10-12 weeks) to avoid IRIS
27
What are the 3 phases of cryptococcal meningitis treatment?
Induction, consolidation, maintenance
28
What is the preferred induction treatment for cryptococcal meningitis?
Amphotericin B 3-4mg/kg IV once daily + flucytosine 25mg/kg PO QID for 2 weeks
29
What is the preferred consolidation treatment for cryptococcal meningitis?
Fluconazole 800mg PO daily (400mg in clinically stable pts w/ sterile CSF and on ART) for ≥8 weeks
30
Preferred maintenance treatment for cryptococcal meningitis.
Fluconazole 200mg PO daily for 1 year or longer
31
Is primary prophylaxis of cryptococcal meningitis recommended?
NOT recommended
32
When is secondary prophylaxis for cryptococcal meningitis required and what is it?
- Required after induction/consolidation phase
- Secondary prophylaxis is the maintenance phase
33
When can prophylaxis be d/c for cryptococcal meningitis?
- 1 year of treatment completed,
- Asymptomatic,
- CD4 count ≥100 for 3 months on ART w/ suppressed viral load
34
When must prophylaxis for cryptococcal meningitis be restarted?
CD4 count <100
35
AEs of amphotericin B.
Nephrotoxicity, hypokalemia, hypomagnesemia
36
Monitoring for amphotericin B.
SCr, BUN, K, Mg several times weekly
37
When to initiate ART in pts w/ histoplasmosis?
ASAP after initiating antifungal therapy, as IRIS is rare
38
What is the preferred treatment for mild-moderate histoplasmosis?
Itraconazole 200mg PO TID x3 days, then 200mg PO BID for ≥12 months
39
Alternative treatments for mild-moderate histoplasmosis.
- Posaconazole 300mg PO BID x1 day, then 300mg PO daily
- Voriconazole 400mg PO BID x1 day, then 200mg BID
- Fluconazole 800mg PO daily
40
What is the preferred treatment for severe histoplasmosis?
Liposomal amphotericin B 3mg/kg IV daily for at least 2 weeks, followed by itraconazole 200mg PO TID x3 days, then 200mg PO BID for at least 12 months
41
What is the alternative treatment regimen for severe histoplasmosis in patients who can't take itraconazole?
Amphotericin B lipid complex 5mg/kg IV daily for at least 2 weeks, followed by posaconazole, voriconazole, or fluconazole for at least 12 months
42
When to initiate primary prophylaxis for histoplasmosis.
- CD4 <150
- At high risk due to job or environment
43
What is the primary prophylaxis regimen for histoplasmosis?
Itraconazole 200mg PO daily
44
When can primary prophylaxis for histoplasmosis be d/c?
In patients taking ART w/:
- CD4 ≥150 for 6 months
- Viral suppression on ART
45
When is secondary prophylaxis for histoplasmosis initiated?
For severe disseminated or CNS infection after completing maintenance therapy for ≥12 months or relapse despite appropriate initial therapy
46
What is the secondary prophylaxis regimen for histoplasmosis?
Itraconazole 200mg PO daily
47
When can secondary prophylaxis for histoplasmosis be d/c?
All criteria met:
- Azole therapy for >1 year, and
- Negative fungal cultures, and
- Serum or urine histoplasma antigen below quantification level, and
- Viral suppression on ART, and
- CD4 ≥150 for ≥6 months in response to ART
48
When to restart prophylaxis for histoplasmosis?
CD4 <150
49
Initiation of ART in patients w/ disseminated MAC.
ASAP
50
Preferred treatment for MAC.
- Clarithromycin 500mg PO BID + ethambutol 15mg/kg PO daily, or
- Azithromycin 500-600mg PO daily + ethambutol 15/mg/kg PO daily
51
Addition of what drug for severe MAC?
Add rifabutin 300mg PO daily
52
Addition of what for severe MAC, high drug resistance, CD4 <50, high mycobacterial load in blood, or ineffective ART?
Add 4th drug:
- Levo 500mg or moxi 400mg QD
- Amikacin 10-15mg/kg IV daily or strepto 1g IV or IM daily,
- Linezolid, tedizolid, or omadacycline (for refractory)
53
Treatment duration for disseminated MAC.
≥12 months
54
When can shorter duration for disseminated MAC be considered?
CD4 >100 for ≥6 months
55
Is prophylaxis in MAC recommended?
Not recommended in patients who have initiated ART after HIV diagnosis
56
When is primary prophylaxis in MAC initiated?
- CD4 <50, AND not receiving ART, remains viremic on ART, or no options for fully suppressive ART regimen
- Disseminated MAC ruled out
57
Preferred primary prophylaxis for MAC.
Azithromycin 1,200mg PO once weekly
58
When to d/c primary prophylaxis for MAC?
Patient is continuing on fully suppressive ART therapy
59
When to restart primary prophylaxis for MAC?
- CD4 <50
- Not on fully suppressive ART
60
What is the secondary prophylaxis regimen for MAC?
Clarithromycin 500mg PO BID with ethambutol 15mg/kg PO daily ± rifabutin 300mg PO daily
61
Secondary prophylaxis duration for MAC.
At least 12 months
62
When can shorter duration of secondary prophylaxis for MAC be considered?
CD4 >100 for ≥6 months in response to ART
63
When can secondary prophylaxis for MAC be d/c?
All criteria fulfilled:
- Completed ≥12 months of therapy, and
- No s/sxs of MAC, and
- CD4 >100 for >6 months in response to ART
64
When to restart secondary prophylaxis for MAC?
CD4 <100 and fully suppressive ART regimen not possible
65
SEs of azithromycin/clarithromycin.
NV, abdominal pain, abnormal taste, hepatotoxicity
66
SEs of ethambutol.
Optic neuritis, hepatotoxicity
67
SEs of rifabutin.
Hepatotoxicity, uveitis, red-orange discoloration of body fluids
68
SEs of amikacin, streptomycin.
Nephrotoxicity, ototoxicity
69
When do you initiate ART in PJP patients?
Within 2 weeks
70
What is the preferred treatment of mild-moderate PJP?
- Bactrim 15-20mg/kg/day PO given in 3 divided doses, or
- Bactrim 2 DS tabs PO TID
71
Alternative treatments for mild-moderate PJP.
- Dapsone 100mg PO daily + TMP 15mg/kg/day PO given in 3 divided doses, or
- Primaquine 30mg PO once daily + clindamycin, or
- Atovaquone 750mg PO BID
72
Preferred treatment for moderate-severe PJP.
Bactrim 15-20mg/kg/day of TMP component IV divided q6-8 hrs for 21 days
73
Alternative treatments for moderate-severe PJP.
- Primaquine + clinda, or
- Pentamidine
74
When to initiate adjunctive corticosteroids in PJP patients?
- Use for moderate-severe PJP (pO2 <70 on RA)
- Start within 72 hrs of initiating PJP therapy
75
What is the adjunctive corticosteroids regimen for moderate-severe PJP?
Add prednisone 40mg PO BID x5 days, then 40mg PO daily x5 days, then 20mg daily x11 days
76
When to initiate primary prophylaxis for PJP?
In ALL HIV patients w/:
- CD4 100-200, if HIV RNA level above detection limits, or
- CD4 <100, regardless of HIV RNA
77
Who do you initiate secondary prophylaxis for PJP in?
In ALL HIV patients
78
When to d/c secondary prophylaxis for PJP?
- When CD4 increases from <200 to ≥200 for >3 months in response to ART, or
- When CD4 100-200 if HIV RNA below detection limits for ≥3-6 months
79
When to restart secondary prophylaxis for PJP?
CD4 <100 regardless of HIV RNA level
80
SEs of Bactrim.
Rash, fever, leukopenia, thrombocypotenia, hepatitis, hyperkalemia
81
What are the primary and secondary prophylaxis treatment regimens for PJP?
- Bactrim DS PO daily, or
- Bactrim SS PO daily, or
- Bactrim DS PO MWF
82
Toxoplasma gondii infections occur almost exclusively due to?
Reactivation of latent tissue cysts
83
How does toxoplasma gondii infection look on CT scan or MRI of brain?
One or more ring-enhancing lesions in grey matter of cortex or basal ganglia
84
When are adjunctive corticosteroids in toxoplasma gondii infection used?
For patients w/ mass effect associated w/ focal lesions or associated edema
85
Use of anticonvulsants in toxoplasma gondii infection.
- Admin. to patients w/ a hx of seizures at least through acute treatment
- NOT prophylactically in all patients
86
Initiation of ART in toxoplasma gondii infection.
Initiate ART within 2-3 weeks of diagnosis/treatment
87
Preferred treatment for acute toxoplasma infection.
Pyrimethamine 200mg PO x1 followed by:
- ≤60 kg: pyrimethamine 50mg PO daily + sulfadiazine 1,000mg PO q6h + leucovorin 10-25mg PO daily
- >60 kg: pyrimethamine 75mg PO daily + sulfadiazine 1,500mg PO q6h + leucovorin 10-25mg PO daily
for at least 6 weeks
OR
Bactrim 5mg/kg IV or PO BID for at least 6 weeks
88
Preferred treatment for chronic maintenance of toxoplasma infection.
Pyrimethamine 25-50mg/kg PO daily + sulfadiazine 2,000-4,000mg PO daily (in 2-4 divided doses) + leucovorin 10-25mg PO daily
OR
Bactrim DS tab PO BID
89
When to initiate primary prophylaxis for toxoplasma infection?
Given to ALL patients who:
- are positive w/ toxoplasma IgG
- w/ CD4 <100
90
Preferred primary prophylaxis for toxoplasma infection.
Bactrim DS tab PO daily
91
When can primary prophylaxis for toxoplasma infection be d/c?
- CD4 >200 for >3 months in response to ART, or
- CD4 100-200 and HIV RNA below detection limits for 3-6 months
92
When to restart primary prophylaxis for toxoplasma infection?
- If CD4 <100, or
- CD4 100-200 and HIV RNA is above detection limits
93
When to initiate secondary prophylaxis for toxoplasma infection?
To ALL patients after completion of tx for acute episode
94
What is the secondary prophylaxis regimen for toxoplasma infection?
Same as maintenance therapy:
- Pyrimethamine 25-50mg/kg PO daily + sulfadiazine 2,000-4,000mg PO daily (in 2-4 divided doses) + leucovorin 10-25mg PO daily
OR
- Bactrim DS tab PO BID
95
When to d/c secondary prophylaxis for toxoplasma infection?
- CD4 >200 for >6 months in response to ART, and
- Successful completion w/ initial therapy, and
- Asymptomatic
96
When to restart secondary prophylaxis for toxoplasma infection?
CD4 <200 regardless of HIV RNA level
97
What are the SEs of pyrimethamine?
Rash, nausea, BMS that can be reversed by increasing leucovorin dose
98
SEs of sulfadiazine.
Rash, fever, leukopenia, hepatitis, NVD, renal insufficiency, crystalluria
