Prophylaxis of opportunistic infections in HIV disease
























CD4 count level Recommended primary prophylaxis and vaccinations
All patients regardless of CD4 count TB prophylaxis if indicated
Influenza vaccination annually
Pneumococcal vaccinationa
PPSV23 – 1 dose then 2nd booster ≥5 years after previous dose. Can give 3rd booster at ≥65 years and ≥5 years after previous dose.
PCV13 – 1 dose
Td booster every 10 years (substitute 1-time dose of Tdap for Td booster)
Hepatitis A (HAV) vaccination if HAV susceptible
Hepatitis B (HBV) vaccination if HBV susceptible
HPV vaccination if ≤26 years of age (women and men)
PCP prophylaxis if indicated (see Table 102.2 for indications)
CD4 <250 cell/mm3 Coccidioidomycosis prophylaxis if indicated (see Table 102.2)
CD4 <200 cell/mm3 PCP prophylaxis
CD4 <150 cell/mm3 Histoplasma prophylaxis if indicated (see Table 102.2)
CD4 <100 cell/mm3 Toxoplasma prophylaxis if indicated (see Table 102.2)
CD4 <50 cell/mm3 Mycobacterium avium complex prophylaxis Fundoscopic exam for CMV


Abbreviations: TB = tuberculosis; PPSV23 = pneumococcal polysaccharide 23 vaccine; PCV13 = pneumococcal conjugate 13-valent vaccine, Td = tetanus-diphtheria vaccine; Tdap = combined tetanus, diphtheria, pertussis vaccines; HPV, human papillomavirus; PCP = Pneumocystis jirovecii pneumonia; CMV = cytomegalovirus.




a If no prior pneumococcal vaccination, give PCV13 first then give PPSV23 ≥8 weeks later. If previously vaccinated with PPSV23, give PCV13 ≥12 months later.




Table 102.2 Preferred and alternative agents for primary prophylaxis



































Infection Indication Drug/dosage
Pneumocystis jirovecii pneumonia (PCP)

1. CD4 T-cell count <200 cells/mm3

2. History of oral candidiasis

3. CD4 percentage <14%

4. History of an AIDS-defining illness

5. CD4 count between 200 and 250 cells/mm3 when unlikely that the CD4 count will be monitored regularly
 Preferred:a

  • Trimethoprim–sulfamethoxazole (TMP–SMX) 1 DS (160/800 mg) tablet PO daily
  • TMP–SMX 1 SS (80/400 mg) tablet PO daily

Alternative:

  • TMP–SMX 1 DS (160/800 mg) tablet PO 3 times a week
  • Dapsone 100 mg PO daily or 50 mg PO twice daily
  • Dapsone 50 mg PO daily plus pyrimethamine 50 mg and leucovorin 25 mg PO weekly
  • Dapsone 200 mg and pyrimethamine 75 mg and leucovorin 25 mg PO weekly
  • Aerosolized pentamidine 300 mg via Respirgard II nebulizer (Marquest; Englewood, Colorado) monthly
  • Atovaquone 1500 mg PO daily
  • Atovaquone 1500 mg and pyrimethamine 25 mg and leucovorin 10 mg daily
Toxoplasmosis

  • CD4 count <100 cells/mm3 and Toxoplasma IgG seropositive
 Preferred:

  • TMP–SMX 1 DS tablet PO daily

Alternative:

  • TMP–SMX 1 DS table PO 3 times weekly
  • TMP–SMX 1 SS tablet PO daily
  • Dapsone 50 mg PO daily plus pyrimethamine 50 mg PO weekly and leucovorin 25 mg PO weekly
  • Dapsone 200 mg and pyrimethamine 75 mg and leucovorin 25 mg PO weekly
  • Atovaquone 1500 mg PO daily
  • Atovaquone 1500 mg PO and pyrimethamine 25 mg and leucovorin 10 mg PO daily
Histoplasmosis

  • Individuals with a CD4 count <150 cells/mm3 with increased risk of Histoplasma exposure

  • Itraconazole 200 mg PO daily
Coccidioidomycosis

  • Individuals with a CD4 count <250 cells/mm3 and newly positive IgM or IgG Coccidioides serology

  • Fluconazole 400 mg PO daily
Tuberculosis (TB)

1. Positive tuberculin skin test (TST) of ≥5 mm induration at 48–72 hours

2. Positive interferon-gamma release assay (IGRA) result

3. Recent exposure to active TB
 Preferred:

  • Isoniazid 300 mg and pyridoxine 25 mg PO daily × 9 months
  • Isoniazid 900 mg PO twice weekly plus pyridoxine 25 mg PO daily × 9 months

Alternative:

  • Isoniazid 15 mg/kg and rifapentine 900 mg PO weekly given as directly observed therapy × 3 months (if not on ART)
  • Rifampin 600 mg PO daily × 4 months (if not on a protease inhibitor or non-nucleoside reverse transcriptase inhibitor)
  • Rifabutin – dosage based on ART used × 4 months
Disseminated Mycobacterium avium complex disease

  • CD4 count <50 cells/mm3 and no evidence of disseminated disease
 Preferred:

  • Azithromycin 1200 mg PO weekly
  • Azithromycin 600 mg PO twice weekly
  • Clarithromycin 500 mg PO BID

Alternative:

  • Rifabutin 300 mg PO daily (dose adjusted for ART)
Cytomegalovirus (CMV)

  • CD4 ≤50 cells/mm3 and CMV IgG antibody positive

  • Fundoscopic monitoring




a Per Centers for Disease Control “Treatment of Opportunistic Infection Guidelines.” See text for timing of discontinuation of prophylaxis.


Abbreviations: CD4 = CD4 T-cell count; DS = double-strength; PO = by mouth; SS = single-strength; AIDS = acquired immunodeficiency syndrome; IgG, immunoglobulin G; BID, twice daily; ART = antiretroviral therapy.



Table 102.3 Preferred and alternative agents for secondary prophylaxis















































Infection Drug/dosage
Pneumocystis jirovecii pneumonia (PCP) Same as primary prophylaxis
Toxoplasmosis Preferred:a

  • Pyrimethamine 25–50 mg PO daily plus sulfadiazine 2000–4000 mg PO daily (in 2–4 divided doses) plus leucovorin 10–25 mg PO daily

Alternative:

  • Clindamycin 600 mg PO q8h plus pyrimethamine 25–50 mg PO daily plus leucovorin 10–25 mg PO daily (requires additional agent to prevent PCP)
  • TMP–SMX 1 DS PO BID
  • Atovaquone 750–1500 mg PO BID
  • Atovaquone 750–1500 mg PO BID plus pyrimethamine 25 mg and leucovorin 10 mg PO daily
  • Atovaquone 750–1500 mg PO BID plus sulfadiazine 2000–4000 mg PO daily (in 2–4 divided doses)
Oropharyngeal, esophageal or vulvovaginal candidiasis Only if frequent or severe recurrences Oropharyngeal:

  • Fluconazole 100 mg PO daily
  • Fluconazole 100 mg PO 3 times weekly

Esophageal:

  • Fluconazole 100–200 mg PO daily
  • Posaconazole 400 mg PO BID

Vulvovaginal:

  • Fluconazole 150 mg PO weekly
Cryptococcosis

  • Fluconazole 200 mg PO daily
Histoplasmosis

  • Itraconazole 200 mg TID × 3 days, then 200 mg BID
Coccidioidomycosis Preferred:

  • Fluconazole 400 mg PO daily
  • Itraconazole 200 mg PO BID

Alternative:

  • Posaconazole 200 mg PO BID
  • Voriconazole 200 mg PO BID
Disseminated Mycobacterium avium complex disease Preferred:

  • Clarithromycin 500 mg PO BID plus ethambutol 15 mg/kg PO daily
  • Azithromycin 500–600 mg PO daily plus ethambutol 15 mg/kg PO daily (if drug interactions or intolerance preclude clarithromycin use)

Alternative:
Third or fourth drug should be considered for patients with CD4 <50 cells/mm3, high mycobacterial loads (>2 log CFU/mL of blood), or in the absence of effective ART
Third or fourth drug options:

  • Rifabutin 300 mg PO daily (dose adjusted for ART)
  • An aminoglycoside: amikacin 10–15 mg/kg IV daily or streptomycin 1 g IV or IM daily
  • A fluoroquinolone: levofloxacin 500 mg PO daily or moxifloxacin 400 mg PO daily
Cytomegalovirus (CMV) Preferred:

  • Valganciclovir 900 mg PO daily plus ganciclovir intraocular implant (if sight-threatening retinitis present)
  • Valganciclovir 900 mg PO daily (if retinal lesions are small and peripheral)

Alternative:

  • Ganciclovir 5 mg/kg IV 5–7 times weekly
  • Foscarnet 90–120 mg/kg IV daily
  • Cidofovir 5 mg/kg IV every other week with saline hydration before and after treatment plus probenecid 2 g PO 3 hours prior to cidofovir, then 1 g PO 2 hours after cidofovir and 1 g PO 8 hours after cidofovir (4 g total of probenecid)
Herpes simplex Only for frequent or severe recurrences

  • Valacyclovir 500 mg PO BID
  • Famciclovir 500 mg PO BID
  • Acyclovir 400 mg PO BID
Salmonella bacteremia Long-term role of secondary prophylaxis unclear Preferred:

  • Ciprofloxacin, 500 mg PO BID

Alternative:

  • TMP–SMX 1 DS PO BID




a Per Centers for Disease Control “Treatment of Opportunistic Infection Guidelines.” See text for timing of discontinuation of prophylaxis.


Abbreviations: PO = by mouth; TMP–SMX = trimethoprim–sulfamethoxazole; DS = double-strength; BID = twice daily; TID = three times daily; CD4 = CD4 T-cell count; CFU = colony-forming unit; ART = antiretroviral therapy; IV = intravenous; IM = intramuscular.


Pneumocystis pneumonia


Primary and secondary prophylaxis

Use of TMP–SMX has decreased the frequency of PCP infection from 70% to 80% of patients with acquired immunodeficiency syndrome (AIDS) to less than one case per 100 person-years in the United States and Western Europe. All patients with a CD4 T-cell count below 200 cells/mm3

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Jun 18, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Prophylaxis of opportunistic infections in HIV disease

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