EXAM 2- SING - OIs in AIDs

What is an opportunistic infection?

Infections that are more frequent or more severe because of HIV-mediated immunosuppression

Pneumocystis Pneumonia (PCP)

• CD4 count threshold?

• Presentation?

• Organ(s) involved/location?

• CD4 <200 cells/mm3

• presentation

  • dyspnea, fever, nonproductive cough, chest discomfort,

  • increased LDG >500

  • pulmonary inflitrates

  • hypoxemia

• lungs

What is an opportunistic infection?

Infections that are more frequent or more severe because of HIV-mediated immunosuppression

Pneumocystis Pneumonia (PCP)

• CD4 count threshold?

• Presentation?

• Organ(s) involved/location?

• CD4 <200 cells/mm3

• presentation

  • dyspnea, fever, nonproductive cough, chest discomfort,

  • increased LDG >500

  • pulmonary inflitrates

  • hypoxemia

• lungs

Mycobacterium avium complex (MAC)

• CD4 count threshold?

• Presentation?

• Organ(s) involved/location?

• CD4 <50 cells/mm3

• presentation

  • non-specific: fever, night sweats, weight loss, fatigue, diarrhea, abdominal pain

  • physical: hepato or splenomegaly, or lymphadenopathy

• typically multi-organ infection

Cytomegalovirus (CMV)

• CD4 count threshold?

• Presentation?

• Organ(s) involved/location?

• CD4 <50 cells/mm3

• presentation

  • retinitis

  • colitis

  • neurological

• organs: brain, eye, stomach, intestines, lungs

Candidiasis (mucocutaneous)

• CD4 count threshold?

• Presentation?

• Organ(s) involved/location?

• CD4 <200 cells/mm3

• presentation

  • oro- painless, creamy white, plaque like lesions

  • eso- retrosternal burning pain or discomfort

• mouth, esophagus

Toxoplasma Encephalitis

• CD4 count threshold?

• usually CD4 <100 cells/mm3

• greatest risk when counts CD4 <50 cells/mm3

No live vaccines below what CD4 count?

<200

Can HIV/AIDs pts. receive the Live influenza vaccine?

NO—> NOT AT ALL

What other vaccines are recommended for people with HIV??

• Hep A and B

• Men ACWY

• pneumococcal

• Tdap or Td booster every 10 years

• zoster

• COVID-19

• Mpox is potential exposure

Pneumocystis Pneumonia (PCP)

• preferred prophylaxis regimen

• SMX-TMP, 1 DS tablet PO daily

• SMX-TMP, 1 SS tablet PO daily

Mycobacterium avium complex (MAC)

• preferred prophylaxis regimen

• Azithromycin 1200 PO qw or 600mg PO biweekly

• Clarithromycin 500mg PO BID

Cytomegalovirus (CMV)

• is primary prophylaxis recommended?

• how to prevent?

  • CD4 count?

• PROPHYLAXIS NOT REC

• to prevent use ART therapy to maintain CD4 counts >100 cells/mm3

Candidiasis (mucocutaneous)

• is primary prophylaxis recommended?

• how to prevent?

• PROPHYLAXIS NOT RECOMMENDED

• admin of ART and immune restoration

Toxoplasma Encephalitis

• preferred prophylaxis regimen

• SMX-TMP 1 DS PO daily

When do you start/stop prophylaxis for Pneumocystis Pneumonia (PCP)

• start: what CD4 count?

• when to d/c?

• start:

  • CD4 count 100-200 cells/mm3, if plasma HIV RNA level is above detection limits

  • or

  • CD4 <100 cells/mm3, regardless of plasma HIV RNA level

• d/c

  • CD4 count increased to ≥200 cells/mm3 for at least 3m in response to ART

  • may consider if CD4 100-200 cells/mm3 if viral load undetectable for at least 3-6m

When do you start/stop prophylaxis for Mycobacterium avium Complex (MAC)?

• start: what CD4 count? specifically when?

• when to d/c?

• start:

  • not receiving ART or remains viremic on ART or no options for fully suppressive ART regimen

  • AND

  • CD4 count <50 cells/mm3

  • NOT recommended when immediately initiating ART

• d/c:

  • initiation of fully suppressive ART

When do you start/stop prophylaxis for Toxoplasma Encephalitis?

• start: what CD4 count? with positive what?

• when to d/c?

• start:

  • Toxoplasma IgG + and CD4 count <100 cells/mm3

• d/c:

  • CD4 count >200 cells/mm3 for >3 months and sustained HIV RNA below limits of detection in

    response to ART OR

  • Can consider if CD4 count is 100-200 cells/mm3 and HIV RNA levels remain below limits of

    detection for at least 3-6 months

TX FOR PNEUMOCYSTITIS PNEUMONIA (PCP):

• preferred regimen?

  • mild-moderate

  • moderate-severe

  • when are steroids recommended?

• duration

• chronic maintenance therapy?

• preferred:

  • mild-mod: PO SMX-TMP

  • mod-severe: IV SMX-TMP

  • steroids?

    • used in pts. with mod-severe PCP, decreases mortality

    • use if PaO2 <70 on room air or A-a gradient ≥35mmHg

    • start within 72hrs of initiating PCP therapy

• duration

  • mild-mod: 21 days

  • mod-severe: 21 days

TX FOR MYCOBACTERIUM AVIUM COMPLEX (MAC):

• preferred tx regimen?

  • at least how many drugs? why?

• duration?

• chronic maintenance therapy?

• preferred tx:

  • at least 2 drugs to prevent/delay resistance

  • clarithromycin + ethambutol

  • azithromycin + ethambutol

• duration: 12 months

• chronic maintenance: same as tx regimens

TX FOR CYTOMEGALOVIRUS (CMV):

• preferred tx regimen for retinitis

• duration?

• chronic maintenance therapy?

• preferred tx:

  • valganciclovir PO

  • ganciclovir IV, followed by valganciclovir PO

• duration: 14-21 days

• chronic maintenance therapy? same as preferred

  • stop until ART has CD4 >100 cells/mm3 for ≥3m

  • routine follow up q3m

TX FOR CANDIDIASIS (mucocutaneous):

• preferred tx regimen?

• duration?

  • oropharyngeal

  • esophageal

• preferred tx:

  • FLUCONAZOLE 200mg on day 1, followed by 100-200mg PO once daily

• duration:

  • oro: 7-14 days

  • eso: 14-21 days

TX FOR TOXOPLASMA ENCEPHALITIS

• preferred tx regimen?

  • why leucovorin?

• duration

• chronic maintenance therapy?

• preferred tx:

  • PYRIMETHAMINE + SULFADIAZINE + LEUCOVORIN

    • leucovorin reduces risk of developing hematologic toxicities with pyrimethamine therapy

  • OR

  • SMX-TMP

• duration: 6w minimum

• chronic maintenance therapy

  • preferred: pyrimethamine + sulfadiazine + leucovorin

  • or SMX/TMP