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HIV II Update on Opportunistic Infections Prevention and Treatment

HIV II Update on Opportunistic Infections Prevention and Treatment

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Page 1: HIV II Update on Opportunistic Infections Prevention and Treatment

HIV II

Update on Opportunistic InfectionsPrevention and Treatment

Page 2: HIV II Update on Opportunistic Infections Prevention and Treatment
Page 3: HIV II Update on Opportunistic Infections Prevention and Treatment

Pathophysiology

Depletion of CD-4 cells (T-helper)

HIV bindsCell entrycell death

Page 4: HIV II Update on Opportunistic Infections Prevention and Treatment

CD4-deficiency

Direct mechanisms   Accumulation of

unintegrated viral DNA Interference with cellular

RNA processing Intracellular gp 120-CD4

autofusion events Loss of plasma

membrane integrity because of viral budding

Elimination of HIV-infected cells by virus-specific immune responses

Indirect mechanisms   Aberrant intracellular

signaling events Syncytium formation Autoimmunity Superantigenic

stimulation Innocent bystander

killing of viral antigen-coated cells

Apoptosis Inhibition of

lymphopoiesis

Page 5: HIV II Update on Opportunistic Infections Prevention and Treatment

CD4 depletion syndromes

HIV/AIDSidiopathic CD4+ T lymphocytopeniaIatrogenic

Corticosteroids Immunosuppresants

Page 6: HIV II Update on Opportunistic Infections Prevention and Treatment

Opportunistic infections

For patients taking potent combination antiretroviral therapy (ART), beginning in 1996, there has been a dramatic decline in the incidence of AIDS-related opportunistic infections (OIs) such as Pneumocystis carinii pneumonia (PCP), disseminated Mycobacterium avium complex (MAC), and invasive cytomegalovirus (CMV) disease

Page 7: HIV II Update on Opportunistic Infections Prevention and Treatment

Treatment Guidelines

2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV

Treatment of Tuberculosis - June 20, 2003

Page 8: HIV II Update on Opportunistic Infections Prevention and Treatment

Rating Strength of the Recommendation

A Both strong evidence for efficacy and substantial clinical benefit support recommendation for use. Should always be offered.

B Moderate evidence for efficacy -- or strong evidence for efficacy but only limited clinical benefit -- supports recommendation for use. Should generally be offered.

C Evidence for efficacy is insufficient to support a recommendation for or against use. Or evidence for efficacy might not outweigh adverse consequences (e.g., drug toxicity, drug interactions) or cost of the chemoprophylaxis or alternative approaches. Optional.

D Moderate evidence for lack of efficacy or for adverse outcome supports a recommendation against use. Should generally not be offered.

E Good evidence for lack of efficacy or for adverse outcome supports a recommendation against use. Should never be offered.

Gross PA, Barrett TL, Dellinger EP, et al. Purpose of quality standards for infectious diseases. Clin Infect Dis

1994; 18(3):421.

Page 9: HIV II Update on Opportunistic Infections Prevention and Treatment

Quality of evidence supporting the recommendation

I Evidence from at least one properly randomized, controlled trial.

II Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies (preferably from more than one center), or from multiple time-series studies. Or dramatic results from uncontrolled experiments.

III Evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees.

Page 10: HIV II Update on Opportunistic Infections Prevention and Treatment

HIV and fever

Disseminated MAC before HAART, most common cause of

FUO in advanced AIDS.Disseminated histobartonellosisCMVcryptococcosis

Page 11: HIV II Update on Opportunistic Infections Prevention and Treatment

Mycobacterium avium-intracellulare complex (MAC)

Disseminated FUO

Fever, night sweats, weight loss, diarrhea

Anemia, elevated alkaline phosphatase

GI Visceral pulmonary

Localized"immune reconstitution" illnesses biopsies show a

granulomatous response lymphadenitis

(mesenteric, cervical, thoracic)

can mimic Pott's disease with disease presenting in the spine

Pulmonary

Page 12: HIV II Update on Opportunistic Infections Prevention and Treatment

MAC

Findings Adenopathy Elevated alk phos anemia

Diagnosis Blood culture Tissue culture Histopathology

Treatment Macrolide +

ethambutol + rifabutin

Amikacin ciprofloxacin

Page 13: HIV II Update on Opportunistic Infections Prevention and Treatment

MAC

Sources Food Water soil

Screening not rec b/c no data for benefit, although predicts disease

No recs for avoidance

Page 14: HIV II Update on Opportunistic Infections Prevention and Treatment

MAC prophylaxis

Primary CD4 < 50 until >100 3 mo. (AI) Clarithromycin Azithromycin Rifabutin (not combo-EI)

Exclude TBDI’s

Secondary for 12 mo and until CD4 no sx and CD4 >100 6 mo (BCx neg) Macrolide + ethambutol, +/- rifabutin High dose clarithromycin asso. W/higher mortality (EI) Clofazimine too many ADR’s (DII)

Restart at CD4 <50-100

Page 15: HIV II Update on Opportunistic Infections Prevention and Treatment

Drug Interactions

Azithromycin not affected by c P450

Protease inhibitors Increase

clarithromycin levels

Some contraindicated w/rifabutin

NNRTIs (efavirenz) Induce

clarithromycin metabolism

Some contraindicated w/rifabutin

Page 16: HIV II Update on Opportunistic Infections Prevention and Treatment

Bartonella

Manifestations Bacillary angiomatosis

(BQ) Lymphadenitis (BH) Hepatosplenic disease

(BH) peliosis hepatis

GI Brain

neuropsych bone

B. henselae and B. quintana

Treatment Erythromycin Tetracycline deriv.

Page 17: HIV II Update on Opportunistic Infections Prevention and Treatment

Bartonellosis

HIV-higher incidenceOlder cats less likely to transmitControl fleasNo rec for primary prophylaxisConsider long-term suppression (C-

III)

Page 18: HIV II Update on Opportunistic Infections Prevention and Treatment

CMV

Risk groups MSM IDU Childcare exposure

Test IgG if lower risk group

Not IDU/MSM

% IgG positive Varies by country

Page 19: HIV II Update on Opportunistic Infections Prevention and Treatment

CMV

Manifestations FUO pancytopenia CNS

Retinitis• Blurred vision • scotomata • field cuts

EncephalitisTransverse myelitisRadiculitis

pneumonitis GI

Gastritis/GUDUcolitis

Page 20: HIV II Update on Opportunistic Infections Prevention and Treatment

CMV

Diagnosis Serology-not helpful Tissue

histopathology Molecular

diagnosticsAntigenPCR

Treatment Valganciclovir Ganciclovir 5 mg/kg

IV bid × 14-21 days Foscarnet 60 mg/kg

IV q8h or 90 mg/kg IV q12h × 14-21 days

Cidofovir 5 mg/kg IV weekly × 2 then every other week

Implants

Page 21: HIV II Update on Opportunistic Infections Prevention and Treatment

CMVprophylaxis

Primary Can consider if IgG

(+) and CD4 <50 Oral ganciclovir or

valganciclovir Regular optho exams Discuss symptoms NOT

acyclovir/valacyclovir

Secondary Intraocular alone not

sufficient Valganciclovir Consider stopping

when CD4>100-150 6mo

Continue regular f/uCMV-neg or

leukopoor irradiated blood if CMV (-)

Page 22: HIV II Update on Opportunistic Infections Prevention and Treatment

HIV and diarrhea

CryptosporidiumMicrosporidiosisIsosporaGiardia

bacterial enteric infections Salmonella Shigella campylobacter Listeria

CMVCdiff

Page 23: HIV II Update on Opportunistic Infections Prevention and Treatment

HIV and diarrhea

•Crampy abdominal pain, bloating, and nausea suggest small bowel •Cryptosporidia•Microsporidia•Isospora•Giardia•cyclospora)•MAC.

•High-volume, watery diarrhea with weight loss and electrolyte disturbance is most characteristic of cryptosporidiosis•bloody stools with abdominal cramping and fever ( invasive bacterial pathogen)

•Clostridium difficile•CMV colitis

Page 24: HIV II Update on Opportunistic Infections Prevention and Treatment

HIV and diarrhea

Stool studies O&P Trichrome AFB Immunohisto Cdiff

Thorough history Medication review Low threshold for flex

sig

Given the availability of effective treatment; more aggressive evaluation that often includes endoscopy has replaced the less invasive approach.

Treatment Antimotility agents

Imodium, Lomotil Opium

Calcium octreotide

Page 25: HIV II Update on Opportunistic Infections Prevention and Treatment

Bacterial Enteric InfectionsPrevention

Seek vet care for animals with diarrhea

WASH HANDS Travel precautions

Bottled beverages Avoid fresh produce Avoid ice Consider prophylaxis or

early empiric therapy Cipro 500 qd Bactrim

Avoid Reptiles, chicks and

ducklings Raw eggs Raw poultry, meat and

seafood Unpasteurized dairy

products/juices Raw seed sprouts Soft cheeses Deli counters unless can

reheat Refrigerated meat

spreads

Page 26: HIV II Update on Opportunistic Infections Prevention and Treatment

Cryptosporidium

coccidian protozoan (I. belli, C. cayetanensis, and Toxoplasma gondii)

5%-10% of diarrhea in immunocompetent

Asymptomatic carriers mammalian hosts-

cattle, horses, rabbits, guinea pigs, mice.

transmission fecal-oral.

Waterborne outbreaks due to contamination of drinking water

thick-walled, highly resistant oocyst

excysts in stomach sporozoites infect

enterocytes and persist at the apical pole of intestinal epithelial cells-microscopic appearance of extracellular, adherent parasite

Page 27: HIV II Update on Opportunistic Infections Prevention and Treatment

Cryptosporidiosisprevention

biopsy fecal examination

Modifed AFB Immunohisto stains

Treatment Azithromycin Paromomycin Octreotide nitazoxanide HAART

Clarithromycin/rifabutin work, but no data.

Counsel regarding exposure-avoid feces diapers young animals (screen

BIII) water

boil water when suggested (AI)

filters (CIII) oysters bottled (CIII)

Page 28: HIV II Update on Opportunistic Infections Prevention and Treatment

Microsporidiosis

observed initially in intestinal biopsy specimens in 1982

No disease in normal hosts

2 types Enterocytozoon bieneusi,

reproduces within enterocytes

Encephalitozoon (Septata) intestinalis infects epithelial cells and stromal cells of the lamina propria and causes systemic infection

Diagnosis Difficult to see by light

microscopy-order trichrome stain

Treatment Albendazole (for

intestinalis) Atovaquone metronidazole.

No recs for prevention

Page 29: HIV II Update on Opportunistic Infections Prevention and Treatment

Isospora

no other known hostendemic in Brazil, Colombia, Chile,

and parts of equatorial Africa and southwest Asia.

seen rarely in normals fecal-oral route

Page 30: HIV II Update on Opportunistic Infections Prevention and Treatment

Isospora

Immunocompetent watery diarrhea usually clear the infection

within about 2 weeks; may persist

HIV-chronic high-volume watery diarrhea

Detection in stool samples difficult, and concentration or flotation methods. AFB +

histologic sections Villus atrophy,

eosinophil infiltrates, and disorganization of the epithelium

shown better with Giemsa on histo

Cipro better than Bactrim

Page 31: HIV II Update on Opportunistic Infections Prevention and Treatment

Cyclospora

first reported in the 1980sendemic in tropical countries and

other areas w/poor standards of hygiene and water purification

severity related to the degree of immunosuppression

Rx Bactrim

Page 32: HIV II Update on Opportunistic Infections Prevention and Treatment

Cyclospora

Epidemics attributed to contamination of water supplies, fruits, and vegetables

similar to Cryptosporidium but larger (8 to 10 mum versus 4 to 5 mum) and AFB +

fecal-oral routeintermittent watery diarrhea for 3 > mo. infect enterocytes and proliferate within a

supranuclear parasitophorous vacuole.

Page 33: HIV II Update on Opportunistic Infections Prevention and Treatment

TABLE 3 -- Diagnostic Workup of HIV-Related Chronic Diarrhea

Stool tests

Bacterial culture (to detect Salmonella species and so on)

Ova and parasite examination (Giardia lamblia and so on)

C. difficile toxin assay

Modified acid-fast stain or immunofluorescence kit (cryptosporidia)

Modified trichrome stain (microsporidia)

Add blood cultures if febrile (bacteria, mycobacteria)

Flexible sigmoidoscopy with mucosal biopsies

Light microscopy (mycobacteria, CMV, cryptosporidia)

Mycobacterial culture (mycobacteria)

Upper endoscopy with duodenal biopsies

Light microscopy (CMV, mycobacteria, cryptosporidia, microsporidia)

Mycobacterial culture (mycobacteria)

± electron microscopy (microsporidia)

Page 34: HIV II Update on Opportunistic Infections Prevention and Treatment

HIV and pneumonia

PCPhistoplasmosiscryptococcosisrhodococcusCMV

Pneumococcus 100-fold risk

Nontypable H. fluPseudomonas

40-fold risk Lowest CD4

HHV-8Coccidiodomycosi

s

Page 35: HIV II Update on Opportunistic Infections Prevention and Treatment

TABLE 1 -- CAUSES OF RESPIRATORY DISEASE IN PERSONS WITH HIV

Very Common Somewhat Common Rare

Pneumocystis carinii Pseudomonas aeruginosa Nocardia asteroides

S. pneumoniae Staphylococcus aureus Legionella spp.

H. influenzae Enteric GNR M. avium complex

MTB * Histoplasma capsulatum Toxoplasma gondii

C. neoformans Cryptosporidium

Cytomeglovirus R. equii

Kaposi's sarcoma Primary pulmonary HTN

Aspergillusspp. Lymphocytic interstitial pneumonia (LIP)

Pulmonary lymphoma

Congestive heart failure

Page 36: HIV II Update on Opportunistic Infections Prevention and Treatment

PCP

Page 37: HIV II Update on Opportunistic Infections Prevention and Treatment

PCP

Symptoms Incidious onset SOB>cough pneumothorax

Findings diffuse infiltrates in a

perihilar or bibasilar distribution and a reticular or reticulonodular pattern

No effusion Elevated LDH SX>>>CXR

Normal in 26%

Diagnosis Sputum for DFA Sputum cytology BAL for same Histopathology/

stains

Page 38: HIV II Update on Opportunistic Infections Prevention and Treatment

PCP

TMP 15 mg/kg/d + SMX 75 mg/kg/d po or IV × 21 days in 3-4 divided doses; for outpatient, 2 DS tablets po tid

rash, fever, gastrointestinal symptoms, hepatitis, hyperkalemia, leukopenia, and hemolytic anemia

Steroid (pO2 < 70 or A-a gradient > 35) TMP-dapsone Clinda/primaquine Atovaquone Trimetrexate/folinic acid Iv Pentam

nausea, infusion-related hypotension, hypoglycemia, hypocalcemia, renal failure, and pancreatitis

Page 39: HIV II Update on Opportunistic Infections Prevention and Treatment

PCPprophylaxis

CD4<200 or history of oral thrush (AII)

CD4%<14 or other OI (BII)

Bactrim (AI) DS daily (toxo,

bacterial pathogens)

SS daily DS TIW (BII) rechallenge if rash

(desens) - 70% tolerate

Page 40: HIV II Update on Opportunistic Infections Prevention and Treatment

PCPprophylaxis

DapsoneDapsone +

pyrimethamine/leucovorin

aerosolized pentam (Respirgard II)-pregnancy 1st term

atovaquone

Other aerosolized Pentam

parenteral pentamoral

pyrimethamine/ sulfadoxine

oral clinda/primaquine

trimetrexateAll BI All CIII

Page 41: HIV II Update on Opportunistic Infections Prevention and Treatment

PCPprophylaxis

Stop when CD4>200 for 3 mo.

Restart if CD4<200Stop secondary

prophylaxis if CD4>200 unless PCP occurred at higher CD4

Children of HIV mothers need prophylaxis

Children with PCP can not stop secondary prophylaxis.

Page 42: HIV II Update on Opportunistic Infections Prevention and Treatment

Histoplasmosis

Mississippi valley and Ohio valley + worldwide

Normal hosts usually asympto or mild URI-no rx

THE MOST common endemic mycosis

Pulmonary, mucosal, disseminated or CNS

Respiratory culture Blood culture Bone marrow biopsy Urine Ag

Some cross reaction More sensitive in dissem

disease, esp HIV Rx ampho, itra

Page 43: HIV II Update on Opportunistic Infections Prevention and Treatment

Clin Chest Med - 01-DEC-1996; 17(4): 725-44

Page 44: HIV II Update on Opportunistic Infections Prevention and Treatment

HistoplasmosisPrevention

Routine skin testing not predictive

Avoid Creating soil/old

building dust Cleaning chicken

coops Disturbing bird roosts Exploring caves

Secondary prophylaxis Itraconazole No data-no rec for

stoppingPrimary

Prophylaxis No proven survival

benefit Consider in high

risk and CD4<100

Page 45: HIV II Update on Opportunistic Infections Prevention and Treatment

Typical CAP

Increased mortality with Pneumococcal

Increased incidence of Pseudomonas

Bactrim and macrolide prophylaxis prevent resp infections, but not rec solely for this reason

Maintain normal granulocyte count & IgG

Prevention Pneumovax

BII rec if CD4>200No data for CD4<200Repeat in 5 yearsRepeat when CD4

>200

Page 46: HIV II Update on Opportunistic Infections Prevention and Treatment

Tuberculosis

Low threshold of suspicion

Lower CD4=atypical presentation

Higher mortalityTuberculin skin

testing (TST) negative in 40% of patients with disease

4-drug therapy initially

Drug interactions major issue

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Page 49: HIV II Update on Opportunistic Infections Prevention and Treatment

Tuberculosis

New guidelines Emphasize DOT and

provider responsibility

Louis Pasteur once said, "The microbe is nothing...the terrain everything"

Reculture at 2 mo of trx

Extend if still + and cavitary disease

INH--rifapentine once weekly continuation phase (Regimens 1c and 2b) is contraindicated

CD4+ cell counts <100/µl should receive daily or three times weekly treatment

“paradoxical” flares occur Associated w/HAART Effusions, infiltrates,

enlargement of CNS lesions, nodes, fever

Steroids used

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Tuberculosisprevention

PPD on diagnosis of HIV (5mm)

if positive treat INH/B6 9 months (AII) rifampin 4 months

(BIII) rif/PZA for 2 months

hepatic toxicity

rifabutin can be sub’d (less data)

Close contacts should be treated if HIV+

if exposed to MDR TB needs expert advice and PH

BCG contraindicatedVague guidelines for

repeating PPD yearly if “high risk” repeat when CD4>200

Page 55: HIV II Update on Opportunistic Infections Prevention and Treatment

Coccidiocomycosis

Growth is enhanced by bat and rodent droppings.

Exposure is heaviest in the late summer and fall

Acute pulm, chronic pulm, dissem, CNS

more severe in immunosuppressed individuals, African Americans, and Filipinos

2/3 of immunosuppressed have disseminated disease

Avoid disturbing native soil

Diagnose by serology or biopsy

Blood cultures not usually positive

Skin test not predictive Often refractory to

treatement Secondary prophylaxis

lifelong, too little data for stopping (>100)

Page 56: HIV II Update on Opportunistic Infections Prevention and Treatment

Med Clin North Am - 01-Nov-2001; 85(6): 1461-91,

Page 57: HIV II Update on Opportunistic Infections Prevention and Treatment

HIV and rash

MolluscumHHV-8 (KS)HPVVZVHSVcryptococcusBartonellaSyphilis

CandidaSeborrheic dermatitisFolliculitis

Eosinophilic bacterial

PsoriasisOnchomycosisPrurigo nodularis scabies

Page 58: HIV II Update on Opportunistic Infections Prevention and Treatment

Molluscum contagiosum

Papular eruption Pearly umbilicated

PoxvirusUsually CD4 < 200Rx liquid nitrogen

Page 59: HIV II Update on Opportunistic Infections Prevention and Treatment

HHV-8

Agent of Kaposi’s sarcoma

Vertical transmission occurs

No screening available Antivirals may have

some effect May be accelerated if

infected after HIV Advise about prevention

Manifestations Cutaneous Mucosal Visceral

GI Pulmonary other

Page 60: HIV II Update on Opportunistic Infections Prevention and Treatment

Human papillomavirus

Manifestations: Condyloma

acuminata Plantar warts Facial Periungual

Genital epithelial cancer

Twice yearly screening, then annual in women

Follow NCI guidelines

Screening for men being developed

Page 61: HIV II Update on Opportunistic Infections Prevention and Treatment

Herpes

HSV Very common (>90%

of MSM sero+) Severe, erosive

disease, proctitis Some need chronic

suppression (acyclovir/famcyclovir)

Resistance occurs and cross-res w/ganciclovir.

VZV Prior frequent

ADI, occurs at CD4 200-500

Dermatomal, ocular, disseminated

No effective secondary prevention recs

Avoid exposure Vaccinate

relatives VZIG if exposed

and negative

Page 62: HIV II Update on Opportunistic Infections Prevention and Treatment

Candida Infections

Manifestations Oral thrush Esophageal candidiasis Candidal dermatitis vulvovaginal

Treatment fluconazole Clotrimazole Nystatin Itraconazole Amphotericin (po or iv)

Responds quickly to therapy

Primary prophylaxis not rec

Secondary is optional, prefer early empiric rx

Azole resistance is an issue

Page 63: HIV II Update on Opportunistic Infections Prevention and Treatment

HIV and headache

Cryptococcus-meningitisToxoplasmosis-enhancingPMLlymphomaHIVCMV (perivent)EBV

nonenhancing

Page 64: HIV II Update on Opportunistic Infections Prevention and Treatment

Cryptococcus

Meningitis Headache subtle cognitive effects. Occaasional meningeal

signs and focal neurologic findings

nonspecific presentation is the norm

Pulmonary disease Disseminated disease

FUO Adenopathy Skin nodules Organ involvement

Diagnosis CSF Ag sens=100% Need opening

pressure

Treatment Ampho + 5FC (GI,

hem toxicity) fluconazole

Page 65: HIV II Update on Opportunistic Infections Prevention and Treatment

Cryptococcal meningitis

ICP management >250 mm H2 O was seen in 119 out of

221 patientshigher titers of cryptococcal antigen more severe clinical manifestations

• headache, meningismus, papilledema, hearing loss, and pathologic reflexes

• shortened long-term survival Desired OP < 200 mm H2 O or 50% of the initial pressure Daily lumbar punctures until the pressure is stable Lumbar drain Ventriculoperitoneal shunting Corticosteroids are not recommended

Page 66: HIV II Update on Opportunistic Infections Prevention and Treatment

CryptococcusPrevention

Primary prophylaxis effective but generally not rec

Secondary until CD4>100-200 6 mo. and no sx (only CIII rec) Fluconazole (AI) Restart at <100-200

Page 67: HIV II Update on Opportunistic Infections Prevention and Treatment

1. Toxoplasmosis seronegative or toxoplasmosis prophylaxis or lesions atypical radiographically for toxoplasmosis (single, crosses midline, periventricular): CSF exam +/- biopsy• + EBV PCR highly correlates with lymphoma• + JCV PCR c/w PML• + toxo PCR diagnostic

2. Toxo IgG + & no prophylaxis: Empiric Rx• Clinical response is usually seen within 7 days (and

often sooner), and • radiographic response in 14 days.

Toxoplasmosis

Page 68: HIV II Update on Opportunistic Infections Prevention and Treatment

Toxoplasmosis

Encephalitis sensorimotor deficits, seizure,

confusion, ataxia. Fever, headache common. Multiple ring-enhancing lesions Almost always due to reactivation

Page 69: HIV II Update on Opportunistic Infections Prevention and Treatment

ToxoplasmaTreatment

Pyrimethamine 100-200 mg then 50-100 mg/d + folinic acid 10 mg/d + sulfadiazine 4-8 g/d for at least 6 weeks

Or sub clinda, azithro, clarithro or atovaquone

Steroids if mass effect

Page 70: HIV II Update on Opportunistic Infections Prevention and Treatment

Toxoplasmaprophylaxis

Screen for IgG (BIII) if negative, aggressively counsel regarding

avoidance of cat litter, raw meat (165 deg) wash, wear gloves when gardening wash vegetables keep cats indoors, avoid raw meat foods getting rid of or testing the cat is an EIII

offense!CD4 <100 if seropositive only

Page 71: HIV II Update on Opportunistic Infections Prevention and Treatment

Toxoplasmaprimary prophylaxis

Trim/sulfa DS qd (AII)dapsone/pyrimethamine (BI)atovaquone (CIII)dapsone, macrolides, pyrimethamine

don’t work (DII)Aerosolized pentam definitely

doesn’t work (EII)

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Toxoplasmaprimary prophylaxis

Stop primary px when CD4 > 200 for 3 months

stop secondaryrestart when CD4

drops <100 again

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Toxoplasmasecondary prophylaxis

After initial therapy completedPyrimethamine plus sulfadiazinepyrimethamine plus clinda (not for

PCP)stop when CD4>200 for 6 months, no

symptoms and initial therapy completed

restart if drop below 200

Page 74: HIV II Update on Opportunistic Infections Prevention and Treatment

What’s new?

Disease Type ofprophylaxis

CD4 limit Length Strength ofrec

PCP Primary 200 >3 months AIMAC 100 AIToxo 200 AI

PCP Secondary 200 >3months BIIMAC 100 > 6mo plus 12 months

HAART and no sxCIII

toxo 200 >6 months, completed rx and no sx

CIII

Crypto 100-200 >6 months, completed rx and no sx

CIII

Page 75: HIV II Update on Opportunistic Infections Prevention and Treatment

What’s new?

Drug interactionsImmunization guidelinesHHV-8 transmissionemphasized HCV screening

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References

Opportunistic infections in HIV disease: down but not out. Sax PE - Infect Dis Clin North Am - 01-JUN-2001; 15(2): 433-55

Graybill JR, Sobel J, Saag M, et al: Diagnosis and management of increased intracranial pressure in patients with AIDS and cryptococcal meningitis. The NIAID Mycoses Study Group and AIDS Cooperative Treatment Groups. Clin Infect Dis 30:47, 2000

Infectious diarrhea in human immunodeficiency virus. Cohen J - Gastroenterol Clin North Am - 01-SEP-2001; 30(3): 637-64

AMERICAN GASTROENTEROLOGICAL ASSOCIATION PRACTICE GUIDELINES. AGA Technical Review: Malnutrition and Cachexia, Chronic Diarrhea, and Hepatobiliary Disease in Patients With Human Immunodeficiency Virus InfectionVolume Gastroenterology 111 • Number 6 • December 1, 1996

State-of-the-art review of pulmonary fungal infections. Seminars in Respiratory Infections.Volume 17 • Number 2 • June 2002