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Opportunistic Infection Prophylaxis Update

July 1996

Prevention of opportunistic infections remains a critically important management strategy for patients with HIV disease. Guidelines published last year by the US Public Health Service/Infectious Disease Society of America Working Group categorized prophylaxis options into three groups. Category I are those treatments recognized as the standard of care for all eligible patients; in other words, not to use these treatments constitutes a breach of professional standards. Category II includes treatments that should be strongly considered for all eligible patients, but not to offer these therapies would not constitute substandard care. Category III includes treatments that may be considered for selected patients, but there is no mandate to use or even consider these options as standard therapies. The major considerations that led to the categorizations were incidence of disease, efficacy of prophylaxis, impact on survival and cost.

Since publication of these guidelines there have been two important advances in prophylaxis. First, prophylaxis for Mycobacterium avium complex (MAC) has been shown to prolong survival, and the macrolides clarithromycin and azithromycin have been found to be superior to rifabutin. Most authorities now agree that prophylaxis of MAC for patients with CD4 counts

Below is an updated summary of the USPHS/IDSA guidelines, with alternatives for the first line treatments. It is likely that this document will be amended to make MAC a Category I disease and CMV a Category II disease.

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Tables are reprinted from Chaisson, RE, 6th Annual Clinical Care Options for HIV Symposium, Opportunistic Infections: Impact on the Natural History of HIV Infection. May 2-5, 1996, Section 5. Adapted from MMWR 1995; 44(RR-8):1-10.

Table 1
PROPHYLAXIS OF FIRST EPISODE
OF OPPORTUNISTIC DISEASES IN HIV-INFECTED ADULTS:
STRONGLY RECOMMENDED AS STANDARD OF CARE
PREVENTIVE REGIMENS
PATHOGENINDICATIONFIRST CHOICEALTERNATIVES
Pneumocystis carinii
  • CD4+3 or unexplained fever for >= 2 weeks
  • oropharyngeal candidiasis
  • TMP-SMX 1 DS PO qd
  • TMP-SMX 1 SS PO qd or 1 DS PO tiw
  • dapsone 50 mg PO bid or 100 mg PO qd
  • dapsone 50 mg PO qd, plus pyrimethamine 50 mg PO qw, plus leucovorin 25 mg PO qw,
  • dapsone 200 mg PO qw, plus pyrimethamine 75 mg PO qw, plus leucovorin 25 mg PO qw
  • aerosolized pentamidine 300 mg qm via Respirgard II nebulizer
Mycobacterium tuberculosis
Isoniazid- sensitive
  • TST reaction of >= 5 mm or prior positive TST result with treatment or contact with case of active tuberculosis
  • isoniazid 300 mg PO, plus pyridoxine 50 mg PO qd x 12 months
  • isoniazid 900 mg PO, plus pyridoxine 50 mg PO biw x 12 months
  • rifampin 600 mg PO qd x 12 months
Mycobacterium tuberculosis
Isoniazid- resistant
  • same as above, high probability of exposure to isoniazid-resistant tuberculosis
  • rifampin 600 mg PO qd x 12 months
  • rifabutin 300 mg PO qd x 12 months
Mycobacterium tuberculosis
Multidrug- resistant (isoniazid and rifampin)
  • same as above, high probability of exposure to multidrug-resistant tuberculosis
  • choice of drugs requires consultation with public health authorities
  • none
Toxplasma gondii
  • IgG antibody to toxoplasma and CD4+3
  • TMP-SMX 1 DS PO qd
  • TMP-SMX 1 SS PO qd or 1 DS PO tiw
  • dapsone 50 mg PO qd, plus pyrimethamine 50 mg PO qw, plus leucovorin 25 mg PO qw
Adapted from USPHA/IDSA guidelines for the prevention of opportunistic infections in persons with HIV: A summary. MMWR 1995;44 (RR-8):1-10.

Table 2
PROPHYLAXIS OF FIRST EPISODE
OF OPPORTUNISTIC DISEASES IN HIV-INFECTED ADULTS:
RECOMMENDED FOR CONSIDERATION IN ALL PATIENTS
PREVENTIVE REGIMENS
PATHOGENINDICATIONFIRST CHOICEALTERNATIVES
Streptococcus pneumoniae
  • all patients
  • pneumococcal vaccine
    0.5 ml IM x 1
  • none
Mycobacterium avium complex*
  • CD4+3
  • clarithromycin
    500 mg PO bid
  • azithromycin
    1200 mg PO weekly
  • rifabutin 300 mg PO qd (AI)

Adapted from USPHA/IDSA guidelines for the prevention of opportunistic infections in persons with HIV: A summary. MMWR 1995;44 (RR-8):1-10.

* Note: Although the USPHS/IDSA guidelines do not include MAC prophylaxis as ?Standard of Care? therapy, most experts now agree that the proven survival advantage demonstrated with clarithromycin makes prophylaxis mandatory.


Table 3
PROPHYLAXIS OF FIRST EPISODE
OF OPPORTUNISTIC DISEASES IN HIV-INFECTED ADULTS:
INDICATED FOR CONSIDERATION IN SELECTED PATIENTS
PREVENTIVE REGIMENS
PATHOGENINDICATIONFIRST CHOICEALTERNATIVES
Bacteria
  • neutropenia stimulating factor 5-10 µg/kg sc qd x 2-4 w; or granulocyte macrophage- colony stimulating factor 250 µg/m2 over 2 h qd x 2-4 w
  • granulocyte- colony
  • none
Candida species
  • CD4+3 PO qd
  • fluconazole 100-200 mg
  • ketoconazole 200 mg PO qd
Cryptococcus neoformans
  • CD4+3 PO qd
  • fluconazole 100-200 mg
  • itraconazole 200mg PO qd
Histoplasma capsulatum
  • CD4+3, endemic geographic area
  • itraconaxole 200 mg
  • fluconazole 200 mg PO qd
Coccidiodes immitis
  • CD4+3, endemic geographic region
  • fluconazole 100-200 mg
  • itraconazole 200 mg PO qd
CMV
  • CD4+ 3, CMV antibody positivity
  • ganciclovir 1 g PO tid
  • valaciclovir 2 g qid (prevents CMV but may hasten death)
Unknown (herpesviruses)?
  • CD4+3
  • acyclovir 800 mg PO qid
  • acyclovir 200 mg PO tid
Hepatitis B virus
  • all susceptible (anti-HBc-negative) patients
  • Energix-B, 20 µg IMx3
  • Recombivax HB, 10 µg IMx3
  • none
Influenza virus
  • all patients (annually, before influenza season)
  • whole or split virus, 0.5 mL im/y
  • rimantadine 200 mg PO bid
Herpes simplex virus
  • any CD4+ cell count
  • history of recurrences
  • acyclovir 400 - 800 mg PO bid
  • amantadine 100 mg PO bid
Adapted from USPHA/IDSA guidelines for the prevention of opportunistic infections in persons with HIV: A summary. MMWR 1995;44 (RR-8):1-10.



  
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This article was provided by Johns Hopkins AIDS Service. It is a part of the publication Hopkins HIV Report.
 

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