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HIV 101: Treatment of Opportunistic Infections

By Rebecca Nerenberg*, Managing Editor, HEPP News

December 2001

The following are recommended as standard of care.1, 2

 Preferred TreatmentAlternative Treatment
Pneumocystis cariniiTrimethoprim (TMP) 15 mg/kg/day + sulfamethoxazole (SMX)75 mg/kg/day PO or IV x 21 days in 3-4 divided doses (typical oral dosage is 2 DS tid)TMP15 mg/kg/day PO + dapsone 100 mg/day PO x 21 days

Pentamidine 4 mg/kg/day IV x 21 days (often reserved for severe cases)

Clindamycin 600 mg IV q8h or 300-450 mg PO q6h + primaquine 30 mg/day base PO x 21 days

Atovaquone 750 mg suspension PO with meal bid x 21 days

Trimetrexate 45 mg/m² /day + folinic acid 20 mg/m² or IV q6h

Toxoplasma gondiiPyrimethamine 100-200 mg loading dose; then 50-100 mg/day PO + folinic acid 10 mg/day PO + sulfadiazine or trisulfapyrimidime 4-8 g/day PO for at least 6 weeksPyrimethamine + folinic acid (see preferred regimen) + clindamycin 900-1,200** mg IV q6h or 300-450 mg PO q6h for at least 6 weeks

Pyrimethamine and folinic acid (see preferred regimen) plus one of the following: azithromycin 1,200-1,500 mg/day, clarithromycin 1 g bid, or atovaquone 750 mg qid with food

Azithromycin + 900 mg PO x 2 first day, then 1,200 mg/day x 6 weeks, then 600 mg/day (patients <50 kg receive half dose) (salvage therapy)

Mycobacterium avium complex (MAC)Clarithromycin 500 mg PO bid plus Ethambutol (EMB) 15 mg/kg/day POAzithromycin 600 mg/day PO in place of clarithrmycin + Ethambutol (EMB) + Rifabutin (RFB) (same doses)

Combination treatment with amikacin 10-15 mg/kg/day IV or ciprofloxacin 500-700 mg bid

Varicella zosterDermatomal:
Acyclovir 800 mg PO 5x/day at least 7 days (until lesions crust) or famciclovir 500 mg PO tid or valacyclovir 1 g PO tid x >7 days

Disseminated, opthalmic nerve involvement or visceral:
Acyclovir 30-36 mg/kg/day IV at least 7 days

Acyclovir-resistant strains:
Foscarnet 40 mg/kg IV q8h or 60 mg/kg q12h

Acyclovir 30 mg/kg/day IV

Foscarnet 40 mg/kg IV q8h or 60 mg/kg IV q12h

Disseminated, opthalmic nerve involvement or visceral:
Foscarnet 40 mg/kg IV q8h or 60 mg/kg IV q12h

Acyclovir-resistant strains:
Cidofovir IV

Topical trifluridine

Cytomegalovirus retinitis (CMV)**Intraocular ganciclovir implant (Vitrasert) q6 months + oral valganciclovir 900 mg/day

Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h x 14 to 21 days

Ganciclovir 5 mg/kg IV bid x 14 to 21 days

Valganciclovir 900 mg PO bid x 21 days, then 900 mg/day

Cidofovir 5 mg/kg IV q week x2, then 5 mg/kg q 2 weeks + probenecid, 2 g PO 3 hours before each dose, 1 g PO at 2 and 8 hours post dose (total of 4 g)

Alternating or combining foscarnet and ganciclovir

Intraocular injections of foscarnet 1.2-2.4 mg in 0.1 mL (N Engl J Med 1994;330:868) or ganciclovir 2,000 µg in 0.05-0.1 mL (Br J Ophthal 1996;80:214)

Fomivirsen, 330 mg by intravitreal injection day 1 and 15, then monthly

Herpes SimplexMild:
Acyclovir 400 mg PO tid or famciclovir 250 mg PO tid or valacyclovir 1.0 g PO bid; all given for 7 to 10 days

Severe or Refractory:
1. Acyclovir up to 800 mg PO 5x/day or 15-30 mg/kg/day IV at least 7 days

2. Valacyclovir 1 g PO bid-tid

Severe or Refractory:
Foscarnet 40 mg/kg IV q8h or 60 mg/kg q12h x 3 weeks

Topical trifluridine as 1% ophthalmic solution q8h

Alternative topical agents:
Cidofovir 3% and foscarnet 1% cream

Cidofovir 5 mg/kg q 2 weeks (limited experience)

** Initital Treatment Recommendations of the IAS-USA (Arch Intern Med 1998;158:957). For information on maintenance and other forms of therapy, consult reference below.

* Nothing to disclose.


  1. Bartlett J.G. and Gallant J.E. 2001-2002 Medical Management of HIV Infection, Chapter 5. Johns Hopkins University, Baltimore, MD. 2001.

  2. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus.

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