Opportunistic Infections Part 2 Flashcards
What is the presentation of histoplasmosis?
spectrum of disease: asymptomatic and self-limited pulmonary disease up to disseminated disease
fever, fatigue, weight loss, hepatosplenomegaly; cough and dyspnea!!
GI disease: fever, N/V/D, abdominal pain, weight loss
What is the diagnosis of histoplasmosis?
detection of histoplasma antigen in blood or urine; sensitive method and rapid results
What should patients with histoplasmosis be counseled on to avoid exposure to?
if their CD4 counts <200 cells/mm^3, they should avoid: creating dust when working with surface soil, cleaning chicken coops, disturbing areas contaminated with bird or bat droppings, cleaning, remodeling, or demolishing buildings, and exploring caves
What is the treatment for mild-moderate disease of histoplasmosis?
people with HIV diagnosed with histoplasmosis should start ART as soon as possible after initiating antifungal therapy, as IRIS has rarely been reported with histoplasmosis
itraconazole 200 mg PO TID x 3 days, then 200 mg PO BID for >/=12 mo
What are alternative therapies for mild-moderate histoplasmosis?
posaconazole 300 mg PO BID x 1 day, then 300 mg PO daily
voriconazole 400 mg PO BID x 1 day, then 200 mg BID
fluconazole 800 mg PO daily
What is the treatment for severe disease histoplasmosis?
liposomal amphotericin B 3 mg/kg IV daily for at least 2 weeks followed by itraconazole 200 mg PO TID x 3 days, then 200 mg PO BID for at least 12 mo
What are alternative therapies to severe disease histoplasmosis?
if a pt can NOT take itraconazole: amphotericin B lipid complex 5mg/kg IV daily for at least 2 weeks followed by posaconazole, voriconazole, or fluconazole for 12 mo
What is the use of primary prophylaxis in histoplasmosis?
only for people with CD4 count < 150 cells/mm^3 and at high risk
itraconazole 200 mg PO daily
may stop in pts taking ART with CD4 count >/=150 cells/mm^3 for 6 mo and with viral suppression on ART
What is the use of secondary prophylaxis in histoplasmosis?
itraconazole 200 mg PO daily
may stop if: received azole therapy for > 1yr, negative fungal blood cultures, serum/urine histoplasma antigen below the level of quantification, viral suppression on ART, CD4 count >/=150 cells/mm^3 for >/=6mo in response to ART - must have ALL of these met
restart if CD4 count <150 cells/mm^3
What is the mode of transmission for infections due to mycobacterium avium complex?
inhalatin, ingestion, or inoculation through respiratory and GI tracts
What is the presentation of mycobacterium avium complex?
presents as a disseminated multi-organ infection in with with HIV with advanced immunosuppression who are NOT on ART
sx: fever, night sweats!!, weight loss, diarrhea, abdominal pain, and malaise/fatigue
What is the diagnosis of mycobacterium avium complex?
physical exam or radiographic tests may reveal hepatomegaly, splenomegaly, or lymphadenopathy
lab tests - anemia, elevated liver alkaline phosphatase
confirmed diagnosis: s/s + isolation of MAC from acid-fast bacilli cultures of blood, lymph fluid, bone marrow, or other tissue/body fluids
What should be included in the treatment of mycobacterium avium complex?
should include at least 2 drugs as initial therapy to prevent or delay emergence of resistance
pts with disseminated MAC who are not on ART should initiate ART ASAP
What is the preferred treatment for mycobacterium avium complex?
clarithromycin 500 mg PO BID + ethambutol 15 mg/kd PO daily
OR
azithromycin 500-600 mg PO daily + ethambutol 15 mg/kg PO daily
if more severe disease add rifabutin 300 mg PO daily
What is the treatment in more severe disease of mycobacterium avium complex?
severe if: risk of mortality is high, drug resistance is likely, CD4 count <50 cells/mm^3, high mycobacterial loads in blood, or ineffective ART - add a 4th drug
levofloxacin 500 mg or moxifloxacin 400 mg QD
amikacin 10-15 mg/kg IV daily or streptomycin 1 gm IV or IM daily
linezolid, tedizolid, or omadacycline (if refractory)
Whe is the treatment for disseminated mycobacterium avium complex initiated?
should be administered for >/=12 mo
CD4 count should be >100 cells/mm^3 for >/=6mo before discontinuing therapy
When should you not initiate prophylaxis in mycobacterium avium complex?
those who immediately initiate ART after HIV diagnosis
What is the primary prophylaxis in mycobacterium avium complex?
CD4 count <50 cells/mm^3 AND not receiving ART or remains viremic on ART or has no options for a fully suppressive ART regimen
azithromycin 1,200 mg PO once weekly
d/c if pt continuing on fully suppressive ART regimen
restart if CD4 count falls <50 cells/mm^3 and pt not on fully suppressive ART
What is the secondary prophylaxis in mycobacterium avium complex?
treatment duration should be at least 12 mo; shorter duration may be considered, but CD4 count should be >100 cells/mm^3 for >/=6mo in response to ART
clarithromycin 500 mg PO BID with ethambutol 15 mg/kg PO daily +/- rifabutin 300 mg PO daily
When can you stop secondary prophylaxis in mycobacterium avium complex?
completed >/=12 mo of therapy, no s/sx of MAC disease, have sustained (>6 mo) CD4 count >100 cells/m^3 in response to ART
must meet all criteria
restart if CD4 count <100 cells/mm^3 and a fully suppressive ART regimen is not possible
What is pneumocystis jirovecii pneumonia?
classified as a fungus, shares biologic characteristics with protozoa
spread by airborne route
What is the presentation of pneumocystis jirovecii pneumonia?
subacute onset of progressive dyspnea, fever, non-productive cough, and chest discomfort; fever; with exertion, tachypnea, tachycardia, and diffuse rales may be observed
hypoxemia most characteristic lab abnormality!!
What is the diagnosis of pneumocystis jirovecii pneumonia?
pO2 might be hypoxemic (<70 mmHg)
elevated lactate dehydrogenase (LDH) > 500 mg/dL is common, but not specific
CXR: diffuse, bilateral, symmetrical interstitial infiltrates; histopathologic demonstration of the organism in tissue, sputum, or bronchoalveolar lavage fluid = definitive diagnosis
PCR - highly sensitive and specific!
What is recommended in the treatment for pneumocystis jirovecii pneumonia?
ART should be initiated in patients within 2 weeks of diagnosis of PCP
What is the moderate-severe disease preferred treatment of pneumocystis jirovecii pneumonia?
trimethoprim-sulfamethoxazole 15-20 mg/kg/day for 21 days
What is the alternative treatment for moderate-severe disease pneumocystis jirovecii pneumonia?
primaquine 30 mg PO once daily plus clindamycin
pentamidine 4 mg/kg IV once daily infused over >60 min (less effective and more SE compared to other)
use this in pts with true SULFA allergy
What adjunctive corticosteroids are used in the treatment of pneumocystis jirovecii pneumonia?
moderate-severe PJP (pO2 < 70mmHg on room air) - start ideally within 72hrs of initiating PJP therapy
prednisone 40 mg PO BID x 5 days, then 40 mg PO daily x 5 days, then 20 mg daily x 11 days
What do we need to monitor for bactrim?
potassium levels for hyperkalemia and serum creatinine levels
What is the preferred treatment for mild-moderate disease pneumocystis jirovecii pneumonia?
trimethoprim-sulfamethoxazole 15-20 mg/kg/day PO given in 3 divided doses
OR
TMP-SMZ, two DS tabs PO TID
both for 21 days
What are alternative therapies for mild-moderate pneumocystis jirovecii pneumonia?
dapsone 100 mg PO daily + TMP 15 mg/kg/day PO given in 3 divided doses
OR
primaquine 30 mg PO once daily plus clindamycin
OR
atovaquone 750 mg PO BID
What has to be checked before administering dapsone or primaquine?
G6PD levels
if G6PD deficiency present, use something else
What is primary prophylaxis for pneumocystis jirovecii pneumonia?
should be given to prevent the 1st episode of PJP in all HIV-infected pts with: CD4 cell count 100-200 cells/mm^3, if HIV RNA level about detection limits or CD4 cell count <100 cells/mm^3 regardless of HIV RNA level
What is secondary prophylaxis for pneumocystis jirovecii pneumonia?
must be given after completion of treatment for an acute episode of PJP in ALL pts
can d/c when CD4 count increases from <200 to >/=200 cells/mm^3 for >3mo in response to ART
restart if CD4 count <100 cells/mm^3 regardless of HIV RNA level
bactrim - double or single strength QD or double strength MWF
What are infections due to toxoplasma gondii?
presents most often as toxoplasma encephalitis in people with HIV who are severely immunocompromised
TE caused by protozoa found in raw/undercooked meat, shellfish, soil, and cat feces
clinical disease almost exclusively occurs because of reactivation of latent tissue cysts
greatest risk of developing clinical disease is among pts with CD4 cell count <50 cells/mm^3
What is the presentation of toxoplasma gondii?
focal encephalitis: HA, focal neurologic deficits and fever; progression may result in development of seizures, stupor, and coma
What is the diagnosis of toxoplasma gondii?
seropositive for anti-toxoplasma immunoglobulin (IgG) antibodies
CT scan or MRI or brain reveals ring-enhancing lesions in grey matter of cortex/basal ganglia
How long should therapy for acute infection of toxoplasma gondii be continued for?
continued for at least 6 weeks
ART should be initiated in pts with 2-3 weeks of diagnosis/treatment of toxoplasmosis
When should adjunctive corticosteroids and anticonvulsants be administered in patients with toxoplasma gondii?
adjunctive corticostreroids should be given to pts with mass effect associated with focal lesions or associated edema
anticonvulsants should be administered to pts with a h/o seizures at least through the period of acute treatment but NOT administered prophylactically in all
What is the preferred regimen for acute infection of toxoplasma gondii?
pryimethamine 200 mg PO x 1 followed by weight-based dosing:
Body weight </= 60 kg: pyrimethamine 50 mg PO daily + sulfadiazine 1,000 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 1,500 mg PO q6h + leucovorin 10-25 mg PO daily (can increase to 50 mg daily or BID)
OR
trimethoprim-sulfamethoxazole 5mg/kg BID
total duration: at least 6 weeks
What is the preferred regimen for chronic maintenance of toxoplasma gondii?
pyrimethamine 25-50 mg PO daily + sulfadiazine 2,000-4,000 mg PO daily + leucovorin 10-25 mg PO daily
OR
TMP-SMX DS one tab PO BID
What is primary prophylaxis in toxoplasma gondii?
primary prophylaxis should be given to pts who are toxoplasma IgG positive with CD4 cell count <100 cells/mm^3 (have to have BOTH)
TMP-SMX DS one tab PO daily
can d/c when CD4 cell count is >200 cells/mm^3 for >3mo in response to ART or if CD4 cell count is 100-200 cells/mm^3 and HIV RNA below limits of detection for at least 3-6mo
restart if CD4 falls <100 cells/mm^3 OR if CD4 is 100-200 cells/mm^3 and HIV RNA is above detection limits
What is secondary prophylaxis for toxoplasma gondii?
should be given to ALL pts after completion of tx for an acute episode
can d/c prophylaxis when CD4 count >200 cells/mm^3 for >6mo in response to ART AND pt has had successful completion with initial therapy AND pt is asymptomatic
restart if CD4 <200 cells/mm^3 regardless of HIV RNA level
