Opportunistic Infections - Eisenhower

Why do OIs occur

13% of people with HIV are unaware of their diagnosis. Of those who are diagnosed 34% are not effectively virally suppressed. These persons are at risk for opportunistic infections, which are preventable sources of morbidity and mortality.

Factors that may contribute to OIs

Misconception that substance use may interact with ARV

Delay in diagnosis and/or start of treatment

Lack of resources for screening and education

Poor healthy literacy

Issues with medication access and coverage

Stigma associated with diagnosis

AIDS Defining Conditions

Cytomegalovirus Retinitis

Pneumocystis Jiroveci Pneumonia

Chronic Intestinal Cryptosporidiosis

HIV Related Encephalopathy

M. TB

Invasive Cervical Cancer

Presentation of Coccidioidomycosis

Focal or diffuse pneumonia

Extra thoracic involvement such as meningitis or osteoarticular infection

Positive serology without evidence of localized infection

Exposure prevention of Coccidioidomycosis

Avoid travel to endemic regions

Residents of endemic regions should avoid extensive exposure to disturbed native soil and stay inside during dust storms. Yearly or biannual serological testing should be considered

Presentation of Histoplasmosis

Cough and Dyspnea

Fever, n/v/d, abdominal pain, weight loss

Advanced HIV: fever, fatigue, weight loss, hepatosplenomegaly

Exposure prevention of histoplasmosis

Avoid travel to endemic regions

Residents of endemic areas with CD4 <200 minimize exposure to activities with increased risk.

Risk activities for Histoplasmosis

Chicken coops, disturbing surface soil

Presentation of candidiasis

Painless, white, plaque like lesions on buccal surface.

Exposure prevention of candidiasis

Commonly found on mucosal surfaces in healthy individuals

Presentation of Pneumocystis Jirovecii pneumonia

Subacute progressive dyspnea, fever, cough, chest discomfort

Exposure prevention of pneumocystis jirovecii pneumonia

Insufficient data to support isolation during outbreaks

Presentation of Cryptococcosis

Subacute meningitis or meningoencephalitis with fever, malaise, and headache developing slowly over median duration of 2 weeks

Exposure prevention of Cryptococcosis

Limited evidence to suggest avoiding exposure to dried bird droppings

Presentation of Toxoplasma gondii encephalitis

Focal encephalitis with headache, confusion, weakness, fever

Exposure prevention of toxoplasma gondii encephalitis

CD4 <200 do not consume raw/undercooked meat or shellfish. Wash hands after contact with raw meat. Wash fruits and vegetables.

Cat owners with CD <200 avoid working with cat little. Keep cats inside.

Treatment plan for Coccidioides (Coccidioides Pneumonia)

Fluconazole 400mg PO QD or Itraconazole 200mg PO TID for 3 days then BID

Counseling of antifungals

Moderate CYP2C9 and 3A4 inhibition

Strong 2C19 inhibitor

AEs: nausea, HA, abdominal pain, diarrhea

Serious: SJS, hepatotoxicity, anaphylaxis, teratogenicity

Monitoring on fluconazole

Serial X-rays and serology q3-6 months during treatment to monitor treatment efficacy

When to DC antifungal treatment

Clinical response demonstrated after 3-6 months

CD4 >250

Virologic suppression on ART

Continued monitoring for recurrence q2-3 years after treatment discontinuation

PLWH

Persons living with HIV should be tested annually or biannually for OIs if they live in endemic areas

Treatment for Candidiasis

Fluconazole 200mg loading dose followed by 100-200mg PO QD

Alternative: 50mg miconazole mucoadhesive buccal tablet QD. Or Nystatin suspension 4-6mL PO QID. Or one 10mg clotrimazole troche PO five times a day

Oral Fluconazole

As effective or superior to topical agents for oropharyngeal thrush. More convenient and usually better tolerated.

Topical antifungals

Reduce systemic drug exposure, reduce risk of DDIs and systemic adverse events, may reduce risk of antifungal resistance.

Miconazole buccal tablets and clotrimazole troches

Shown to be equivalent. Buccal tablets may cause n/v/d, upper abdominal pain, or altered taste

Nystatin and clotrimazole

Unfavorable taste and multiple daily dosing

Patient education for Miconazole buccal tablets

Place 1 time each day to upper gum, usually in morning

Avoid hitting tablet when brushing teeth

May eat and drink

Avoid gum

Do not crush, chew, or swallow tablet

Avoid dentures

Avoid messing with tablet after placement

Always check if tablet is in place

If tablet falls off with first 6 hours of placement, replace it if later don’t

Monkey Pox Prevention

Jynneos - live, attenuated, non-replicating virus vaccine considered safe for PLWH

Recommended for LGBTQ

Role of Pharmacists in Management of OIs

Provide patient education

Evaluate medication access and cost

Check medication assistance eligibility

Promote and assess adherence

Review updates in guidelines

Manage ART in setting of acute OIs

Assist with transitions of care

Check for D/D interactions

Monitor treatment efficacy

Provide interdisciplinary care