| Prophylaxis |
Immunologic Categories
for Children and Adults
|
Age
|
<12 mo |
1-5 yr |
6-12 yr |
Immunologic
category |
cells/µL
(%) |
cells/µL
(%) |
cells/µL
(%) |
| No evidence of suppression |
>1500 (>25) |
>1000 (>25) |
>500 (>25) |
| Evidence of moderate
suppression |
750-1499 (15-24) |
500-999 (15-24) |
200-499 (15-24) |
| Severe suppression |
<750 (<15) |
<500 (<15) |
<200 (<15) |
* Adapted from 1994 revised classification system
for human immunodeficiency virus infection in children aged <13 years
Source: MMWR 2002;51:RR-12:8
|
Prophylaxis has been investigated for a number of opportunistic infections.22 With the advent of HAART; there has been a
significant decline in the rate of opportunistic infections. Dramatic decreases have been
seen in the rates of CMV disease, Pneumocystis jiroveci pneumonia (PCP), Mycobacterium
avium complex (MAC), and cryptococcal meningitis since 1994. This is due to
suppression of viral loads below 5000 and return to CD4 lymphocyte counts to higher than
200. Medical management is based on the patient's immunologic category (no evidence of
suppression, evidence of moderate suppression, or severe suppression). There is
unequivocal benefit to treatment protecting against Pneumocystis jiroveci pneumonia,
and trimethroprim-sulfamethoxazole is the preferred prophylactic agent, providing
virtually complete protection as long as the patient is not allergic to sulfa, a
development unfortunately seen in more than 50% of HIV positive patients.
Prophylaxis is recommended in those with fewer than 200 CD4 lymphocytes, or who have a
history of oropharyngeal candidiasis. Persons with a CD4 lymphocyte percentage of less
than 14% or history of an AIDS-defining illness should also be considered for prophylaxis.
PCP prophylaxis can be safely discontinued in patients responding to HAART when CD4 cells
remained sustained above 200 for > 3 months. Alternatives to TMP/SMX, which are less effective and
associated with breakthrough infection, include dapsone with or without pyrimethamine +/-
leucovorin, aerosolized pentamidine and atovaquone.
Prophylaxis for reactive PPD skin tests for tuberculosis include isoniazid plus
pyridoxine for 9 months or rifampin and pyrazinamide for two months. Prophylaxis against Mycobacterium
avium complex is less clear but does show a survival benefit in those with previous
MAC bacteremia and in those where it can be prevented. Risk is seen with CD4 counts less
than 50 and prophylactic medications include clarithromycin, weekly azithromycin or
rifabutin. Resistance has been documented, particularly with the former two drugs,
although they are preferred over rifabutin, which is not as well tolerated and has a
number of potential drug interactions. MAC prophylaxis can be discontinued when CD4 counts rise above 100 for >3 months. |
Opportunistic Infections:
Prophylaxis to prevent first episode of opportunistic
disease
in adults and adolescents infected with human immunodeficiency virus |
| Pathogen |
Preventive Regimens
|
Indication |
First Choice |
Alternative |
| I. Strongly
recommended as standard of care |
| Pneumocystis
jiroveci |
CD4+
count <200/µL or oropharyngeal candidiasis |
Trimethoprim-
sulfamethoxazole (TMP-SMZ), 1 DSpo q.d. |
Dapsone,
50 mg po b.i.d. or 100 mg po q.d. ; dapsone, 50 mg po q.d. plus
pyrimethamine, 0 mg po q.w5. plus leucovorin, 52 mg po q.w. ; dapsone, 200 mg po plus
pyrimethamine, 75 mg po plus leucovorin, 25 mg po q.w. ; aerosolized pentamidine, 300 mg
q.m. via Respirgard II(TM) nebulizer ; atovaquone, 1500 mg po q.d ; TMP-SMZ, 1 DS po
t.i.w. |
Mycobacterium
tuberculosis
Isoniazid-sensitive |
TST
reaction >=5mm or prior positive TST result without treatment or contact with
case of active tuberculosis |
Isoniazid,
300 mg po plus pyridoxine, 50 mg po q.d. x 9 mo or isoniazid, 900 mg po plus
pyridoxine, 100 mg po b.i.w. x 9 mo ; rifampin, 600 mg plus pyrazinamide, 20 mg/kg
po q.d. x 2 mo (AI |
Rifampin 600 mg po q.d. x 4 mos.
or rifabutin 300 mg po daily x 4 mos.;pyrazinamide, 15-20 mg/kg po q.d. x 2 mo plus either rifampin 600 mg daily x
2 mos or rifabutin 300 mg po q.d. x 2 mo |
| Isoniazid-resistant |
Same;
high probability of exposure to isoniazid-resistant TB |
Rifampin 600 mg po
q dayor rifabutin 300 mg po q.d. x 4 mo |
pyrazinamide
15-20 mg/kg po q.d. x 2 mo plus either rifampin, 600 mg po q.d. or rifabutin, 300 mg po q.d. x 2 mo |
| Multidrug-(isoniazid
and rifampin) resistant |
Same;
high probability of exposure to multidrug-resistant tuberculosis |
Choice
of drugs requires consultation with public health authorities |
None |
| Toxoplasma
gondii |
IgG
antibody to Toxoplasma and CD4+ count <100/µL |
TMP-SMZ,
1 DS po q.d. |
TMP-SMZ,
1 SS po q.d. : dapsone, 50 mg po q.d. plus pyrimethamine, 50 mg po q.w. plus
leucovorin, 25 mg po q.w. ; atovaquone, 1500 mg po q.d. with or without pyrimethamine, 25
mg po q.d. plus leucovorin, 10 mg po q.d. |
| Mycobacterium
avium complex |
CD4+
count <50/µL |
Azithromycin,
1,200 mg po q.w., or clarithromycin, 500 mg po b.i.d. |
Rifabutin,
300 mg po q.d. ; azithromycin, 1,200 mg po q.w. plus rifabutin, 300 mg po q.d. |
Varicella
zoster virus
(VZV) |
Significant
exposure to chickenpox or shingles for patients who have no history of either condition
or, if available, negative antibody to VZV |
Varicella
zoster immune globulin (VZIG), 5 vials (1.25 mL each) im, administered <=96 h after
exposure, ideally within 48 h |
|
| Source: MMWR
1999;48 RR-10:40-1 |
| |
| II. Generally
recommended |
| Streptococcus
pneumoniae |
All
patients |
Pneumococcal
vaccine, 0.5 mL im |
None
|
| Hepatitis
B virus |
All
susceptible (anti-HBc-negative) patients |
Hepatitis
B vaccine:3 doses |
None |
| Influenza
virus |
All
patients (annually, before influenza season) |
Whole or
split virus, 0.5 mL im/yr |
Oseltamivir,
75 mg by mouth daily; Rimantadine, 100 mg po b.i.d. , or amantadine, 100 mg po b.i.d. |
| Hepatitis
A virus++ |
All
susceptible (anti-HAV-negative) patients with chronic hepatitis C |
Hepatitis
A vaccine: two doses |
None |
| Source: MMWR
1999;48 RR-10:40-2 |
| |
| III.
Not routinely indicated |
| Bacteria |
Neutropenia |
Granulocyte-colony-stimulating
factor (G-CSF), 5-10 µg/kg sc q.d. x 2-4 w or granulocyte- macrophage colony-stimulating
factor (GM-CSF), 250 µg/m² iv over 2 h q.d. x 2-4 w |
None |
| Cryptococcus
neoformans |
CD4+
count <50/µL |
Fluconazole,
100-200 mg po q.d. |
Itraconazole,
200 mg po q.d. |
| Histoplasma capsulatum |
CD4+ count <100/µL,
endemic geographic area |
Itraconazole capsule, 200
mg po q.d. |
None |
| Cytomegalovirus (CMV) |
CD4+ count <50/µL and
CMV antibody positivity |
Oral ganciclovir, 1g po
t.i.d. |
None |
| Source: MMWR
1999;48:RR-10:42 |
Opportunistic Infections
Prophylaxis to prevent recurrence of
opportunistic disease
(after chemotherapy for acute disease) |
| Pathogen |
Preventive Regimens
|
Indication |
First Choice |
Alternative |
| Recommended for life as
standard of care |
| Pneumocystis
jiroveci |
Prior P.
jiroveci pneumonia |
Trimethoprim-sulfamethoxazole(TMP-SMZ),
1 DS po q.d. TMP-SMZ 1 SS po q.d. |
Dapsone,
50 mg po b.i.d. or 100 mg po q.d. dapsone, 50 mg po q.d. plus pyrimethamine,
50 mg po q.w. plus leucovorin, 25 mg po q.w.; dapsone, 200 mg po plus
pyrimethamine, 75 mg po plus leucovorin, 25 mg po q.w.; aerosolized pentamidine,
300 mg q.m. via Respirgard II(TM) nebulizer; atovaquone, 1500 mg po q.d.;TMP-SMZ, 1 DS po
t.i.w. |
| Toxoplasma
gondii |
Prior
toxoplasmic encephalitis |
Sulfadiazine,
500-1,000 mg po q.i.d. pyrimethamine, 25-75mg po q.d. plusleucovorin, 10-25 mg po q.d. |
Clindamycin,
300-450 mg po q 6-8 h pluspyrimethamine,25-75 mg po q.d. plusleucovorin, 10-25 mg poq.d. ;
atovaquone, 750 mg po q. 6-12 h with or without pyrimethamine, 25 mg poq.d. plus
leucovorin, 10 mg po q.d. |
| Mycobacterium
avium complex |
Documented
disseminated disease |
Clarithromycin,
500 mg po b.i.d. plus ethambutol, 15 mg/kg po q.d; with or without rifabutin, 300 mg po
q.d. |
Azithromycin,
500 mg po q.d. plus ethambutol, 15 mg/kg po q.d.; with or without rifabutin, 300 mg po
q.d. |
| Cytomegalovirus |
Prior end-organ disease |
Ganciclovir, 5-6 mg/kg iv
5-7 days/wk or 1,000 mg po t.i.d. ; or foscarnet, 90-120 mg/kg iv q.d. or (for retinitis)
ganciclovir sustained-release implant q 6-9 months plus ganciclovir, 1.0-1.5 g po t.i.d. |
Cidofovir, 5 mg/kg iv
q.o.w. with probenecid 2 grams po 3 hours before the dose followed by 1 gram po given 2
hours after the dose, and 1 gram po 8 hours after the dose (total of 4 grams). Fomivirsen
1 vial (330 µg) injected into the vitreous, then repeated every 2-4 wks; with ganciclovir 1-1.5
g po tid or valganciclovir 900 mg po q d |
| Cryptococcus
neoformans |
Documented
disease |
Fluconazole,
200 mg po q.d. |
Amphotericin
B, 0.6-1.0 mg/kg iv q.w.-t.i.w; itraconazole, 200 mg po q.d. |
| Histoplasma capsulatum |
Documented disease |
Itraconazole capsule, 200
mg po b.i.d. |
Amphotericin B, 1.0 mg/kg
iv q.w. |
| Coccidioides
immitis |
Documented
disease |
Fluconazole,
400 mg po q.d. |
Amphotericin
B, 1.0 mg/kg iv q.w. itraconazole, 200 mg po b.i.d. |
| Salmonella species,
(non-typhi) |
Bacteremia |
Ciprofloxacin, 500 mg po
b.i.d. for several months |
Antibiotic
chemoprophylaxis with another active agent |
| Source: MMWR
1999;48:RR-10:44 |
| |
Opportunistic Infections
Recommended only if subsequent episodes are frequent or severe |
| Pathogen |
Preventive Regimens
|
Indication |
First Choice |
Alternative |
| Recommended
only if subsequent episodes are frequent or severe |
| Herpes
simplex virus |
Frequent/severe
occurences |
Acyclovir,
200 mg po t.i.d or 400 mg po b.i.d; famciclovir 250 mg by mouth bid |
Valacyclovir, 500
mg po b.i.d |
| Candida
(oropharyngeal or vaginal) |
Frequent/severe
occurences |
Fluconazole
100-200 mg po q.d. |
Itraconazole
solution 200mg po g.d.
|
| Candida
(esophageal) |
Frequent/severe
occurences |
Fluconazole
100-200 mg po q.d. |
Itraconazole
solution 200mg po g.d.
|
| Source: MMWR
1999;48:RR-10:45 |
| |
| A variety of preventative regimens are available for first-episode treatment of
hepatitis B and influenza virus and as secondary prophylaxis for various opportunistic
infections. Certain regimens are available for treating herpes simplex virus and Candida
infections (if subsequent episodes are frequent and severe). Prophylactic efficacy against
CMV is highly debatable and adds the prospect of 6 additional pills to take in the form of
ganciclovir three times a day. This practice has not been embraced by a majority of
experts in the field. |
Summary
- Identify patients who may be at high risk for HIV
infection based on epidemiology or exposure potential.
- Consider HIV testing for all persons in high-risk
groups or those who manifest signs of immune suppression.
- Encourage HIV testing of ALL pregnant women.
- Ensure confidentiality, education, pre- and post-test
counseling, and appropriate medical and psychological follow-up.
- Never miss an opportunity to stress risk reduction.
- Confirm all positive HIV antibody tests and evaluate
all patients for level of immune suppression based on T-cell counts, viral-load assays,
and clinical status.
- Provide close follow-up and ensure adherence to all
anti-viral drug-therapy regimens.
- Provide apropriate immunizations, medical prophylaxis
regimens, and periodic viral-load assays for all patients.
- Be sure to stress risk reduction to intimate and
household contacts of all patients
As the knowledge we acquire for the diagnosis and treatment of HIV infection
accumulates, the complexity of issues surrounding the optimal approach to this disease
increases as well. A coherent, well-grounded plan is crucial in order to provide our
patients the best therapeutic modalities presently available to keep them alive and
healthy enough to benefit from the ongoing advances being made in this field. While it
will not be easy, it can be intensely rewarding. |
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