HIV opportunistic infections

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Author:
mmccaf9260
ID:
18449
Filename:
HIV opportunistic infections
Updated:
2010-05-09 12:59:19
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HIV opportunistic infections
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Description:
Therapeutics 3
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  1. Primary prophylaxis needed for candidiasis?
    No!
  2. Tx for oropharyngeal
    • fluconazole 100 mg po qday x 7-14 days
    • or
    • clotrimazole troches 10 mg fid
    • nystatin susp 4-6 ml qid
    • alternative: itrconazole soln 200 mg qday
  3. Tx for esophageal candidiasis
    • fluconazole 100 mg (up to 400mg) po or IV qday
    • itraconazole soln 200 mg qday
  4. Tx for vulvovaginal candidiasis
    • fluconazole 150 mg po for 1 dose
    • topical azole for 3-7 days
    • alternative: itraconazole soln 200 mg bid x 1 day or 200 mg qday x 3 days
    • complicated or recurrent: fluconazole 150 mg po q 72 hrs for 2-3 doses, topical antifungal agents greater than 7 days
  5. What CD4 count is candidiasis more prevelant?
    <200
  6. When is PCP more prevelant?
    • when patients are unaware they have HIV
    • those who are not in care
    • CD4 count <100
  7. Risk factors for PCP
    • CD4 count <200
    • prior PCP
    • CD4% <14%
    • oral thrush
    • recurrent bacterial pneumonia
    • unintentional weight loss
    • high viral load
  8. When and what to prophylaxis for PCP and when to stop?
    • CD4 count <200 or hx of oropharyngeal
    • d/c with CD4 >200 for >3 months, but reinitiate when CD4 <200
    • bactrim (ss or ds) 1 po qday
    • dapsone 100 mg po qday (test for G6PD first)
  9. Tx for PCP
    • TMP-SMX 15-20 mg/kg/day in divided doses q 6-8 hours
    • or
    • Bactrim DS 2 ts po tid
    • alternative (moderate to severe): pentamidine 4 mg/kg IV qday or
    • primaquine 15-30 mg (base) po qd + clinda 600-900 mg IV q6-8h
    • atovaquone 750 mg po bid
    • could add steroids for moderate to severe disease (room air <70 mmHg or A-a gradient >35 mmHg) but need to taper x 21 days
  10. Secondary prophylaxis of PCP
    • bactrim ds or ss 1 po qday
    • patient can d/c if cd4 count >200
    • but if patient gets PCP while cd4 >200 will be on bactrim for life
  11. TB epidemiology
    • injection drug users
    • occurs at any CD4 count
    • patients with TB have higher HIV viral loads and faster progression of HIV
    • all HIV patients should be screened for latent TB at HIV diagnosis
    • annual testing is also recommended
  12. Tx of LTBI
    • INH 300 mg PPO qd or 900 mg BIW for 9 months
    • plus
    • pyridoxine 50 mg po qd to reduce risk of peripheral neuropathy
    • alternative: rifampin 300 mg qd x 4 months
  13. Tx of TB disease
    • Initial phase (2 months)- RIPE
    • Continuation phase (4 months)- INH + RIF or (RFB)
    • if positive cultures after initial 2 months, contine RIPE for 3 more months (total of 9 months)
  14. Rifamycins interact with what classes of ART?
    • PI
    • CCR5
    • Integrase inhibitors
  15. MAC epidemiology and risk factors
    • usually occurs in CD4 count <50
    • risk factors: viral load >100,000 copies, previous opportunistic infection, previous colonization with MAC
  16. CD4 counts for prophylaxis for MAC
    • CD4 <50
    • d/c in patient on ART with increase in CD4 count >100 for greater than 3 months
    • restart prophylxis if CD4 <50 again
  17. Primary prophylaxis for MAC
    • azithromycin 1200 mg po qweek
    • clarithromycin 500 mg po bid
    • azithromycin po TIW
    • alternative: RFB 300 mg po qd
  18. Tx for MAC
    • initial tx at least 12 months
    • clarithromycin 500 mg po bid + ethambutol 15 mg/kg po qd
    • alternative to clarithromycin: azithromycin 500-600 mg po qday
    • consider adding RFB as 3rd drug- especially if CD4 <50
    • consider adding fluoroquinolones, amikacin, streptomycin
  19. Epidemiology of cryptococcus
    • CD4 <50
    • if relapse occurs, almost always fatal
  20. Tx for cryptococcus
    • induction: greater than 2 weeks. amphotericin 0.7 mg/kg IV QD + flucytosine 25 mg/kg po QID
    • Consolidation: 8 weeks. Fluconazole 400 mg po qd
    • chronic maintenance: fluconazole 200 mg po qd
    • consolidation therapy should not be started until at least 2 weeks of significant clinical improvment, and negative CSF culture on lumbar puncture
  21. Epidemiology of histoplasmosis
    • grows in bird and bat droppings
    • seen in CD4 <150
  22. primary prophylaxis for histoplasmosis
    • itraconazole- can reduce frequency of disease but no survival benefit
    • itraconazole 200 mg po qd for patients CD4 <200
    • can d/c when CD4 >150 x 6 months
  23. Tx for histoplasmosis
    • induction: (2 weeks or until clinically improved) amp B
    • maintenance: itraconazole 200 mg po tid x 3 days then bid
    • total duration at least 12 months
    • if meningitis: induction 4-6 weeks
  24. Epidemiology of Toxoplasmosis
    acquired from tissue cysts in undercooked meat or ingestion of sporulated oocysts (from cat feces) in soil, water, or food
  25. Primary prophylaxis of Toxoplasmosis
    • CD4 <100
    • bactrim ds 1 po qd
    • d/c if on ART, CD4>200 for >3 months
    • restart if CD4 <200
  26. Tx for toxoplasmosis
    • pryrimethamine + sulfadiazine + leucovorin
    • duration at least 6 weeks
  27. CMV: preventing disease
    • maintain CD4 >100
    • primary prophylaxis with valganciclovir not recommended
    • regular eye exams
    • vigilance for increase in floaters
  28. CMV treatment for retinitis
    • IV ganciclovir followed by oral valganciclovir
    • IV foscarnet
    • IV cidofovir
    • ganciclovir intraocular implant
    • valganciclovir
    • tx for colitis, esophagitis: IV ganciclovir or foscarnet; oral valganciclovir for 21-28 days, maintenance not necessary

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