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Switching HIV to facilitate use of Antibiotics

May 19, 2006

I started HIV treatment in December of last year. I am currently taking Truvada (one pill once a day) and Kaletra Tablets (4 pills once a day) From December to April my Cd4 has increased from 290 to 620, and my Viral load has dropped from 100,000 to 133. I have had absolutely no noticeable side effects in that time.

However, I have developed a persistant Staphylococcus aureus infection with multiple antibiotic resistance in my nose. A couple months ago my doctor and I treated the infection with Bactrim (Sulfam/trim 800/160 1 tablet twice a day) and the infection appeared to go away; a lab test even showed i was negative for the bacteria.

Nevertheless, just this week the infection seems to have come back. My doctor put me on Bactrim again (now 2 tablets twice a day) but he also wants to use a second antiobiotic, Rifampin, which he says cannot be used with a Protease inhibitor like Kaletra. I really like my current drug regimine, it's easy, it's effective, it causes me no side effects; but we are considering switching me off Kaletra to an NNRTI like Sustiva so that I can use that second antibiotic to increase the chance of really killing this Staph infection.

If i switch to Sustiva, while my virus seems to be supressed and show no immediate signd of resistance, will it encourage resistance to any of my medications? Will I be able to switch BACK to Kaletra when I am done with the course of antiobiotics? If I CAN switch back to Kaletra, will my virus no longer be 'treatment naive' requiring me to take the Kaletra twice a day rather than once? I really don't want to change my regimen because 'if it ain't broke, don't fix it'. But I also REALLY need to kill this painful infection. I had new blood samples and a bacteria swab culture taken yesterday and will discuss my options with my doctor next week, but I wanted a second opinion. Thank you

Response from Dr. Young

Thanks for your post.

Yes, yours is a complicated one from the drug-drug interaction story.

Rifampin is sometimes used to treat refractory Staph infections-- I've used it frequently in patients in your situation.

Your doctor's on the ball in noting the possible drug drug interaction between rifampin and protease inhibitors. Indeed, this is a real problem when patients need rifampin for treating TB with HIV. Switching to efavrienz mid-stream should be ok, and if your vira load is undetectable shouldn't pose any significant risk of resistance. You can switch back to lopinavir/ritonavir (Kaletra) afterwards.

Be aware that since rifampin interacts (a little) with efavirenz, the dose should be increased to 800 mg a day.

Hope this helps, let us know how things turn out. BY

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