Management of Opportunistic Infections

DOC for PJP prophylaxis + alternatives

• 1st line: bactrim DS 1 t po qd

• Alternatives:

  • Dapsone 100 mg po qd OR

  • Atovaquone 1500 mg po qd with food

What type of primary PPX is indicated for pts with CD4 < 200 ?

PJP

What type of primary PPX is indicated for pts with CD4 < 100?

PJP and toxoplasmosis

What type of primary PPX is indicated for pts with CD4 < 50 ?

PJP, toxoplasmosis, and (if pt is NOT on a suppressive ART regimen) MAC

Criteria to D/C PJP PPX

if CD4 > 200 for 3 months (both primary and secondary)

Criteria to D/C Toxoplasmosis PPX

CD4 < 200

• primary : for 3 months

• secondary : 1) sustained 2) completed initial tx 3) asymptomatic

Criteria to D/C MAC PPX

CD4 > 100

• primary : for 3 months

• secondary : 1) sustained 2) completed 12 months of MAC therapy 3) asymptomatic

primary prophylaxis

prevention for person who has never had the infection before

secondary prophylaxis

prevention for perseon who has had the infection before, but needs to prevent recurrence of infection

What lab parameter would indicate need for PJP prophylaxis

< 200 cells/ mm³ (or CD4 < 14 %)

Pt has a CD4 count = 150 but has a sulfa allergy. What ABX would you recommend for PJP PPX?

Dapsone or atovaquone

which opportunistic pathogen is spread d/t latent infection that is reactivated?

PJP

which opportunistic pathogen is spread through airborne transmission ?

PJP

which opportunistic pathogen is spread d/t eating undercooked meat ?

toxoplasmosis

which opportunistic pathogen is spread d/t exposure to contaminated cat feces?

toxoplasmosis

Which opportunistic pathogen presents with encephalitis ?

toxoplasmosis

Indication for toxoplasmosis indication

pt has IgG for T.gondii & CD4 < 100

DOC for toxoplasmosis + alternatives

• 1st line: bactrim DS 1 t po qd

• Alternatives:

  • bactrim SS 1 t po qd

  • dapsome or atovaquote ( + pyrimethamine and leucovorin)

which opportunistic pathogen is spread in certain geographical regions?

MAC

which opportunistic pathogen is spread d/t infection from inhalation, ingestion or inoculation through respiratory or GI tract ?

MAC

Indication for MAC PPX

• Pt not on fully suppressive ART AND

• CD4 < 50 cells/ mm³

DOC for MAC PPX + dose + alternative

• 1st line : Azithromycin 1200 mg po q week

• Alternative: rifabutin 300 mg po qd (test for active TB)

When to d/c MAC PPX

When CD4 count > 100 cells/mm³ for > 3 months

leading cause of death among people with HIV

LTBI

which opportunistic pathogen is spread from person-to-person transmission ?

LTBI

DOC for LTBI PPX + alternatives

• 1st line: INH 300 mg po q+ pyridoxine (B6) 25-50 mg po qd x 6 months

• Alternatives: rifampin x4 months or rifapentin + INH + pyridoxine x 12 weeks

Monitoring for LTBI PPX

LFTs at baseline, 1 month and 3 months

Which LTBI PPX agents are CI with genvoya and stribild ?

rifampin and rifabutin

which LTBI PPX agents are CI with protease inhibitors ?

rifampin

which LTBI PPX agents are CI with etravirine?

rifampin

which LTBI PPX agents are CI with rilpivirine ?

rifampin

DOC for OROPHARYNGEAL candidiasis + duration

Fluconazole 100 mg po qd x 7-14 days

DOC for ESOPHAGEAL candidiasis + duration

Fluconazole 100 mg (up to 400 mg) PO/IV qd x 14-31 days

DOC for early syphilis tx

Benzathine PCN G 2.4 million units IM x 1 dose

candidiaisis is treated based on what ?

symptoms

PJP treatment + duration

bactrim x 21 days

Dosing for PJP treatment is based off what?

TMP (active ingredient)

toxoplasmosis treatment an dduration

pyrimethamine + sulfadiazine + leucovorin (based on body wt of 60 kg) > 6 weeks

what to use for pt with toxoplasmosis that presents with edema + why

dexamethasone to avoid brain damage

What to use for pt with toxoplasmosis for individuals with hx of seizures?

anticonvulsants

treatment and duration for MAC disease

azithromycin/clarithromycin + ethambutol for at least 12 months (or if pt is asymptomatic, has CD4 < 100 for > 6 months from ART)

Duration of treatment for uncomplicated pulmonary TB

6 months

Duration of treatment for disseminated extrapulmonary TB or (+) cultures after 2 months

9 months

active TB treatment

• intial phase (2 months): RIPE (rifampin, INH, pyrazinamide, ethambutol)

• continutation phase (4 months): INH (+ pyridoxine) + rifamycin

Which opportunistic infection is spread through sexual contact ?

syphilis

DOC for tx of syphilis

• early: benzathine PCN G 2.4 million units IM x 1 dose

• late (> 1 year, unknown duration, no signs of neurosyphilis): benzathine PCN G 2.4 million units IM q wk x 3 doses

PT has early syphilis but has a PCN allergy. What would you recommend?

Doxycycline 100 mg po bid x 14 days OR

Ceftriaxone 1 gm IM or IV daily x10-14 days (preferred in pregnancy)

DOC for late-latent syphillis (> 1 year or of unknown duration)

Benzathine PCN G 2.4 million units IM q week x 3 doses

Which agents require pt be screened for G6PD prior to initiation ?

dapsone and primaquine