Opportunisitic Infections

____ is a normal CD4 count

800-1200

list OIs that commonly occur at CD4 <500

candidiasis and leukoplasia

list OIs that commonly occur at CD4 <200

PJP, CMV, toxoplasmosis, MAC, cryptococcus, lymphomas

explain the impact TB and syphilis can have on HIV viral load

increase

IRIS is likely to occur with CD4 _____ and viral load ______

CD4< 50 and viral load > 100,000

list infections where IRIS is more likely to occur. when is ART typically started in these infections?

MAC, TB, and CMV. Wait for clinical response to OI for 2 weeks and then start ART

with TB, when should ART be initiated?

If CD4<50, start within 2 weeks. If CD4>50, start within 8 weeks

explain the treatment of IRIS

for mild IRIS, use NSAIDs and ICS. for severe, use prednisone but avoid if the infection is cryptococcal or kaposi’s sarcoma

list OIs that can occur at any CD4 count

MAC TB, pneumonias, VZV

Treatment for initial mild-mod OC/thrush:

topical nystatin 5ml QID for 7-14 days or clotrimazole 10mg 5 times a day for 7-14 days

Duration of treatment for oropharyngeal candidiasis (OC/thrush)

7-14 days

If the OC or thrush is more severe or doesn’t respond to topicals, what can be used?

Fluconazole 200mg loading dose followed by 100-200mg po qd for 7-14 days

list treatment options for esophageal candidiasis in HIV pts

fluconazole 200mg (up to 400mg) IV or PO qd for 14-21days

Treatment duration for esophageal candidiasis

14-21 days

list treatment options for uncomplicated vulvovaginal candidiasis in HIV pts

fluconazole 150mg po once, topical azoles for 3-7 days, or ibrexafungerp 300mg po bid once

list treatment options for severe vulvovaginal candidiasis in HIV pts

fluconazole 100-200mg po qd or topicals antifungals for at least 7 days

list treatment options for azole refractory C. glabrata vulvovaginal candidiasis in HIV pts

boric acid suppository for 14 days

Explain prophylaxis for vulvovaginal candidiasis

not routine for either prophylaxis nor secondary

when should ART be initiated in ART naive patients getting treated for cryptococcal meningitis

delay until induction which is usually after 2 weeks due to IRIS risk

explain the treatment for the induction phase of cryptococcal meningitis treatment in HIV pts

ampho B 3-4mg/kg IV qd plus flucytosine 25mg/kg po qd for 2 weeks

the induction phase of cryptococcal meningitis treatment has a duration of _____in HIV pts

2 weeks

explain the treatment for the consolidation phase of cryptococcal meningitis treatment in HIV pts

fluconazole 800mg po qd or 400mg if sterile CSF, stable, and on ART for at least 8 weeks

the consolidation phase of cryptococcal meningitis treatment has a duration of _____in HIV pts

at least 8 weeks

explain the treatment for the maintenance phase of cryptococcal meningitis treatment in HIV pts

fluconazole 200mg po qd for at least a year

the maintenance phase of cryptococcal meningitis treatment has a duration of _____ in HIV pts

at least 1 year

explain the use of primary prophylaxis for cryptococcal meningitis in HIV pts

not recommended

explain the use of secondary prophylaxis for cryptococcal meningitis in HIV pts

fluconazole 200mg po qd which may be discontinued if completed for at least 1 year, cd4 is at least 100, and has undetectable viral load. Need to restart if CD4 drops below 100

When do you start ART with histoplasmosis?

immediately

explain the treatment of mild-moderate histoplasmosis in HIV pts

itraconzole 200mg po TID for 3 days and thne 200mg po bid for at least 12 months

the duration of histoplasmosis treatment in HIV patients is ____

at least 12 months

explain the treatment of severe histoplasmosis in HIV pts

liposomal ampho b 3mg/kg IV qd then itraconazole 200mg po tid for 3 days then 200mg po bid for at least 12 months

Prophylaxis treatment for histoplasmosis

itraconazole 200mg po qd

when should ART be initiated in ART naive patients getting treated for MAC?

asap with mac treatment

explain the treatment of non-severe MAC in HIV patients

clarithro bid or azithro qd with ethambutol 15mg/kg po qd

explain the treatment of severe MAC in HIV patients

add rifabutin 300mg po qd to claritho/azithro + ethambutol

explain when a fourth drug should be added to MAC treatment in HIV pts. what drugs could be added?

high mortality, CD4<50, high MAC load, or ineffective ART. Can add levo, moxi, amikacin, or streptomycin

What drug to add to treatment plan for refractory MAC treatment in HIV pts

linezolid or omadacycline

explain when PJP is classified as moderate-severe

O2<70

explain the use of primary prophylaxis for MAC in HIV pts. What do you use?

when cd4<50 and not on ART. Use azithro weekly

explain the use of secondary prophylaxis for MAC in HIV pts

Same as treatment (claritho/azithro + ethambutol ± rifabutin)

list the first line treatment of moderate-severe PJP in HIV patients

smz-tmp 15-20mg/kg/day tmp divided q6-8hrs for 21 days

list alternative treatments for mod-severe PJP in HIV patients

primaquine plus clinda or pentamidine

explain the use of corticosteroids in PJP treatment

used in mod-severe PJP if O2<70. Use prednisone or dexamethasone at 80% dose

list the first line treatments of mild-moderate PJP in HIV patients

smz-tmp 15-20mg/kg/day po divided in 3 doses or bactrim ds 2 tabs po tid

list the alternative treatments of mild-moderate PJP in HIV patients

dapsone plus tmp or primaquine plus clinda or atovaquone

the treatment duration of PJP treatment in HIV patients is _____

21 days

list drugs that need G6PD testing done before initiation

dapsone and primaquine

the duration of treatment of toxoplasmosis in HIV patients is ____

at least 6 weeks

explain what adjunctive therapies may be used in the treatment of toxoplasmosis in HIV patients

corticosteroids if focal lesions or associated edema. Anticonvulsants if history of seizures

list the treatments of toxoplasmosis in HIV patients

pyrimethamine 200mg po once then weight based dosing but both uses pyrimethamine, sulfadiazine, and leucovorin. Or just use bactrim 5mg/kg IV/po bid

list the chronic maintenance options of toxoplasmosis in HIV patients

pyrimethamine 25-50 mg BID PLUS sulfadiazine 2000-4000 mg q6h leucovorin 10-25 mg QD or Bactrim DS 1 tab po bid

explain the use of primary prophylaxis for toxoplasmosis in HIV pts

if toxoplamsa IgG and CD4<100, use bactrim DS 1 tab po qd and restart if CD4<100 or 100-200 and detectable

explain the use of secondary prophylaxis for toxoplasmosis in HIV pts

same as chronic maintenance and only restart if CD4<200