Treatment and Prevention of Opportunistic Infections Options for by tracy12


									 Treatment and Prevention
of Opportunistic Infections:
 Options for the Caribbean
  Excerpted from presentation by
     Jonathan E. Kaplan, M.D.
What is the most frequent serious
opportunistic infection in HIV-infected
adults in the Caribbean region?
A.   .Toxoplasma gondii encephalitis
B.   .Tuberculosis
C.   .Pneumocystis jiroveci pneumonia (PCP)
D.   .Cryptosporidium spp. infection
E.   .Hookworm infection
Can you confirm the diagnosis of
Pneumocystis jiroveci pneumonia
(PCP) in your practice setting?

A. Yes
B. No
C. Don’t know
What clinical specimens are
collected to diagnose
Pneumocysis infection?
•   Expectorated sputum
•   Induced sputum
•   Bronchial washings
•   Lung biopsy
•   Blood cultures
How you confirm cryptococcal
infection in your practice setting?

A. India Ink stain
B. Culture
C. Cryptococcal antigen test
Chemoprophylaxis against Pneumocystis
jiroveci pneumonia (PCP) with
trimethoprim-sulfamethoxazole (TMP-
SMZ) can also reduce the incidence of:
 A.   Non-typhoidal Salmonella disease
 B.   Toxoplasmic encephalitis
 C.   Bacterial pneumonia
 D.   Isosporiasis
 E.   All of the above
                  Natural Course of HIV Infection and
                  Common Complications
                  900                 Asymptomatic
                                                                         Relative level of
                  800                                                    Plasma HIV-RNA
CD4+ cell Count

                  700                 CD4+ T cells                       TB
                         Acute HIV
                  600    infection
                  300                                                      OHL

                  200                                                           OC
                  100                                              TB
                                                                           CMV, MAC
                        0 1 2 3 4 5      1   2   3   4    5    6     7      8    9   10   11
                          Months         Years After HIV Infection
Caribbean Guidelines for the
Treatment of Opportunistic
Infections in Adults and Adolescents
Infected with the Human
Immunodeficiency Virus
Mucocutaneous Candidiasis: Treatment

 • Oral          Clotrimazole troches,
   candidiasis     10 mg 5 times/day for 7
   (thrush)        days
 • Esophageal    Fluconazole, 3-6 mg/kg/day
                   for 1-2 weeks. Chronic
   candidiasis     maintenance therapy
                   suggested for several
                   months (fluconazole, 200
Pneumocystis jiroveci (formerly
carinii) Pneumonia (PCP)
• History: subacute onset (days to weeks) of
  shortness of breath, dry cough, fever
• Physical exam: tachypnea and hypoxemia
• CXR typically shows bilateral, diffuse,
  interstitial pulmonary infiltrates
• Diagnosis difficult: requires bronchoscopy or
  sputum induction and special stains
• Treatment: TMP-SMZ (cotrimoxazole, CTX),
  15-20 mg/kg/day for 3-4 weeks
• For severe cases, add prednisone, 40 mg/day
  tapering over 3 weeks
• Chronic maintenance therapy required (CTX
  160/800 mg/day)
AFB Smear

   AFB (shown in red) are tubercle bacilli
Tuberculosis in HIV-Infected Persons
• Causes 11% of HIV-related deaths worldwide
• Can occur at any CD4 count
• Clinical presentation increasingly atypical as
  CD4 count declines
• In resource-poor areas, a significant percentage
  of newly-diagnosed HIV-infected persons will
  be found to have active TB
• Should always consider TB in an HIV-infected
  persons with a pulmonary infiltrate
Bacterial Pneumonia in HIV-
Infected Persons
• About 8 times more common in HIV-
  infected vs non-HIV-infected persons
• Pneumococcal bacteremia about 100 times
  more common
• Can occur at any CD4 count
• Common etiologies: S. pneumoniae, H.
  influenzae, P. aeruginosa, S. aureus
• Treatment: penicillin/ampicillin +/-
  aminoglycoside; or cephalosporin
Cryptococcal Meningitis
• History: severe headache, fever, mental
• Physical exam: no focal neurological signs
• Differential: bacterial, TB
• LP: high opening pressure, elevated protein,
  low glucose, organisms
• Treatment: amphotericin x 2 wks, then
  fluconazole x 8-10 weeks
• Chronic maintenance therapy: fluconazole,
Cerebral toxoplasmosis
• History: headache, fever, confusion, motor
• Physical exam: focal neurological signs
• Diagnosis: demonstration of multiple mass
  lesions on CT or MRI
• Treatment: pyrimethamine plus sulfadiazine
  plus folinic acid for 8 weeks
• Chronic maintenance therapy: same
WHO Integrated Management of
Adolescent and Adult Illness
• Consists of 4 modules: Acute Care, Chronic HIV
  Care with ARV Treatment, General Principles of
  Good Chronic Care, Palliative Care
• Posted on WHO website in Dec 2003 (available at
• Acute Care: syndromic treatment of illness
  - appropriate for all patients, but with attention to
  - oriented to Health Center level
Immune Reconstitution Syndromes

• Tuberculosis            • Hepatitis C
                          • Cytomegalovirus
• Mycobacterium avium
                          • Varicella Zoster Virus
  complex (MAC)
• Pneumocystis jiroveci
                          • Cryptococcosis
  pneumonia (PCP)
                          • Progressive multifocal
• Toxoplasmosis
• Hepatitis B               (PML)
Caribbean Guidelines for the
Prevention of Opportunistic
Infections in Adults and Children
Infected with Human
Immunodeficiency Virus
What diseases may be prevented?

• Pneumocystis jiroveci pneumonia (PCP)
• Cerebral toxoplasmosis
• Tuberculosis
• Mycobacterium avium complex (MAC)
• Disease caused by S. pneumoniae
Prophylaxis against PCP
• Survival benefit demonstrated; first
  recommended in 1989
• Eligibility criteria: CD4 count <200 cells/uL
  or <14% or history of oral candidiasis
• Drug of choice: TMP-SMZ (CTX) 160/800
  (1 double-strength tab) qd
Cotrimoxazole Prophylaxis
Can prevent:
•   Pneumocystis jiroveci pneumonia
•   Cerebral toxoplasmosis
•   Disease caused by S. pneumoniae
•   Disease caused by non-typhoid Salmonella
•   Nocardiosis
•   Isosporiasis
•   Malaria
 CTX Prophylaxis: Other
• Cheap ($1 US/month)
• Easy to administer: only contraindication is
  history of sulfa allergy
• Main adverse reaction is skin rash, but
  uncommon in dark-skinned persons
• Clinical monitoring is adequate
• Adherence is not critical
• Experience taking daily medication; good
  preparation for ART
Isoniazid Preventive Therapy (IPT)
• International “best practice”
• If skin testing available, may reserve for persons
  with positive tuberculin skin test (> 5 mm
• Otherwise, IPT suggested for all HIV-positive
  patients living in countries with high prevalence of
• IPT also suggested for HIV-positive persons
  exposed to case of active TB
• Give isoniazid (INH), 300 mg per day for 9 mo
Preventing Disease Recurrence: OIs that
Require Preventive Therapy for Life

• Cerebral toxoplasmosis
• Systemic (deep) fungal infections:
  cryptococcosis, histoplasmosis
• Disseminated MAC infection
• CMV disease
 Prophylaxis against First Episode of
 Opportunistic Disease in HIV-
 exposed/infected Infants and Children

Pathogen             Indication             Drug
Pneumocystis    HIV-exposed/infected    Cotrimoxazole
jiroveci        children 1-12 months;
                older HIV-infected
                children with CD4
                < 15%
Mycobacterium   Contact with person       Isoniazid
tuberculosis    with TB

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