Brown Medical School
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 Treatment | Alternative Treatment |
| Pneumocystis carinii | Trimethoprim (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 gondii | Pyrimethamine 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 weeks | Pyrimethamine + 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 PO | Azithromycin 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 zoster | Dermatomal:
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 daysDisseminated, 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 | Dermatomal:
Acyclovir 30 mg/kg/day IVFoscarnet 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 Simplex | Mild:
Acyclovir 400 mg PO tid or famciclovir 250 mg PO tid or valacyclovir 1.0 g PO bid; all given for 7 to 10 daysSevere 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 weeksTopical 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.
References
- Bartlett J.G. and Gallant J.E. 2001-2002 Medical Management of HIV Infection, Chapter 5. Johns Hopkins University, Baltimore, MD. 2001.
- 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus.
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