VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...
OIs ppt.ppt
1. Prophylaxis and Treatment of
Opportunistic Infections
Unit 11
HIV Care and ART: A Course for
Pharmacists by Salahadin M.Ali
2. 2
Introductory Case: Meseret
Meseret is a 45 year-old Ethiopian female who has
not followed up with her physician on a regular basis
Over the last month she has experienced
progressive shortness of breath, associated with dry
cough. She is now unable to walk across the room
without becoming short of breath. She comes to
clinic to be evaluated
She states that she has had a fever, but she has not
actually taken her temperature
3. 3
Introductory Case: Meseret (cont.)
She has diffuse body aches associated with her
symptoms. She occasionally has a headache. She
states that she has lost approximately 5 kg over the
last 1-2 weeks. Her previous weight was 60kg
She is diagnosed with severe Pneumocystis jerovici
pneumonia (PCP) and is going to begin therapy
Which of the following statements is true about the
treatment of PCP?
4. 4
Introductory Case: Meseret (cont.)
The treatment of choice for severe PCP is:
1. Cotrimoxazole 15 mg/kg/day based on TMP oral or IV
divided q6-8h x 21 days + Prednisone 40 mg bid for 5 days,
40 mg qd for 5 days, 20 mg qd for 11 days
2. Cotrimoxazole (TMP/SMX) 160/800 mg IV divided q6-8h x
21 days + Prednisone 40 mg bid for 5 days, 40 mg qd for 5
days, 20 mg qd for 11 days
3. Cotrimoxazole 1 DS tablet po TID x 21 days + prednisone as
above
4. Cotrimoxazole 2 DS tablets po TID x 21 days
5. 5
Learning Objectives
Identify the signs and symptoms of opportunistic
infections (OI) in HIV infected individuals
Explain the diagnostic results of common OIs
associated with HIV
Describe the prophylaxis and treatment of the most
common OIs associated with HIV in Ethiopia
list commonly used drugs and their adverse effects
for common OIs
6. 6
Background
Opportunistic infections (OIs) occur when a patient’s
immune system is impaired
OIs are the leading cause of morbidity and mortality
in HIV-infected persons
Most of the common OIs are preventable as well as
treatable
However, in resource-limited settings, it may be
difficult to manage OIs
7.
8. 8
CD4 Count as it Correlates with
Selected Diseases & OIs
> 500 Bacterial infections, HIV meningitis, tuberculosis, vaginal
candidiasis
< 500 Herpes zoster, herpes simplex, oral thrush
< 300 Kaposi’s sarcoma, non-Hodgkins lymphoms
< 200 HIV-associated dementia, PCP
< 150 Coccidiodomycosis
< 100 Aspergillosis, cryptococcosis, esophageal candidiasis,
histoplasmosis, PML toxoplasmosis
< 50 Cytomegalovirus (CMV), mycobacterium avium (MAC)
<
Based on information from Multicenter AIDS Cohert Study (MACS), http://www.statepi.jhsph.edu
9. 9
Condition
Percentage Decline in Fatal HIV Related
Diseases in 1997-2001 vs 1990-1995
PCP 69
MAC 89
Bacterial Pneumonia 37
Wasting 75
Candida Esophagitis 68
CMV 89
Non Hodgkins
Lymphoma
75
Kaposi's Sarcoma 80
Source: XIV International AIDS Conference- US Data
11. 11
Major Diagnostic Categories
(TAH 2000) (2)
Diagnosis # of Patients % of Total
Cryptococcal meningitis 14 5.9
Peripheral neuropathy 11 4.6
Myelopathy 11 4.6
Lymphoma 7 3.0
Others 82 34.6
Source: Tikur Ambessa Hospital, 2000
12. 12
Preventing Exposure: Risk Factors to OIs
Sexual
Intravenous drug use (IVDU)
Environmental and occupational
Pet-related
Food and water
Travel-related
Asplenia (spleen removal)
13. 13
Immunization Guidelines
Avoid use of live-attenuated vaccines
Administer single-dose vaccines early in the course
of HIV infection (for optimal response)
Routinely recommended
Pneumovax, influenza, Td
Hepatitis B and A if indicated
Transient increases in HIV RNA levels may be
observed with some immunizations
14. 14
Prophylaxis and Treatment
Primary prophylaxis
Preventing an initial episode of an infection from occurring
Treatment/induction
Managing an active infection
Secondary prophylaxis/suppressive
therapy/maintenance therapy
Preventing recurrence of infection following treatment of
active infection
16. 16
Candidiasis
Of candidiasis infections,
75% are oral (thrush)
20-40% are esophageal
30-40% are vulvo-vaginal
Recurrence is common (~30%)
Incidence of candida infections has decreased by
60-80% with the initiation HAART in the U.S.
21. 21
Oral Candidiasis vs. Leukoplakia
Thrush can be scraped away, unlike Leukoplakia
Courtesy of www.HIVdent.org
Courtesy of www.HIVdent.org
Courtesy of HIV Web Study, www.hivwebstudy.org
Courtesy of www.HIVdent.org
22. 22
Oropharyngeal Candidiasis:
Treatment Principles
Mild to moderate disease: topical therapy
Nystatin 500,000 units (4-6 mL) gargled 4-5x day
• Clinical response occurs in 90-100% of patients within 7 days
Miconazole oral gel
Moderate to severe disease: systemic therapies
Fluconazole 100 mg/day, Itraconazole 200 mg/day,
Ketoconazole 200 mg/day
Continue antifungal therapy for two weeks until
symptoms resolve
Reduce colony forming units
Reduce risk factors/increase time to recurrence
23. 23
Candidiasis: Episodic vs. Chronic
Suppressive Therapy
Episodic therapy is generally preferred to avoid
resistance
Recurrent symptomatic oropharyngeal candidiasis
(OPC) may require chronic suppressive therapy
Chronic suppressive therapy increases the risk of
developing azole-resistant disease
May consider discontinuing maintenance therapy
with immune reconstitution from potent ART
24. 24
Fluconazole-Resistant (Refractory)
Oral Candidiasis
Failure to respond to antifungal therapy
Occurs in about 5-7% patients with advanced AIDS (CD4
cell count <50/mm3)
Occurs with extensive prior treatment with fluconazole
Prevalence has decreased with HAART
27. 27
Oropharyngeal Candidiasis Treatment
Topical Therapy
(preferred):
Miconazole oral gel**
Nystatin oral suspension
500,000 units 5x day **
Nystatin pastilles 100,000
units:1 to 2 pastilles
(200,000 to 400,000 units)
4 to 5x daily
Clotrimazole 1% cream
Systemic Therapies:
Fluconazole 100 mg daily
**
Itraconazole capsule
200mg daily with food
Itraconazole suspension 10
mg/ml 100-200 mg daily
without food
Ketoconazole tablet 200
mg daily, PO
HAART
**Preferred
Duration: 14 days for all regimens
28. 28
Candidiasis Treatment - Esophageal
Duration: 2-3 weeks for all regimens
Systemic therapy:
Fluconazole 200-400 mg daily
Itraconazole capsule 200mg daily with food
Itraconazole suspension 100-200 mg daily without food
Amphotericin B - IV 0.3-0.6 mg/kg/day
29. 29
Candidiasis: Refractory candida
(fluconazole resistant)
Duration: 2-3 weeks for all regimens
Higher doses of fluconazole
400-800 mg daily
Itraconazole suspension
IV Amphotericin 0.3-0.5 mg/kg/day
30. Adverse effect of Azole antifungals
Relatively non-toxic
Most common adverse reactions
Gastro intestinal upset like Nausea, vomiting
Abnormalities of liver enzyme
Other side effects are drug specific
30
31. 31
Clinically Significant Interactions
with Fluconazole
Rifampin
Gastrointestinal effects,
hepatitis
Coumarin
Increased coumarin effect
Statins
Increased risk of myopathy,
rhabdomyolysis and acute
renal failure
Phenytoin
Monitor for toxicity
Protease Inhibitors
(Monitor for PI toxicity)
Nevirapine
Increased risk of
hepatotoxicity and rash
32. 32
HIV Associated Cryptococcal Meningitis
Clinical presentation:
Occurs in advanced immune damage CD4 <100
Characterized by subtle clinical manifestations; headache,
fever, malaise. Meningeal signs are not always present.
Symptoms such as stiff neck, photophobia, and vomiting
are only seen in a minority of patients
Altered sensorium in 25% cases; and focal signs in 5%
33. 33
HIV Associated Cryptococcal Meningitis (2)
Treatment:
Standard therapy
• Induction: amphotericin B IV 0.6-0.8 mg/kg/day (with or
without flucytosine 100 mg/kg/day) for 2 weeks
• Consolidation: fluconazole 400 mg daily for 8 weeks or until
CSF is sterile
• Maintenance: fluconazole 200 mg daily, life long
• Management of intracranial pressure: CSF drainage
Ethiopian OI ART guidelines
• Fluconazole 400- 800 mg daily for 8 wks followed by 200mg /
day
• Management of intracranial pressure: CSF drainage
34. 34
Pneumocystis Pneumonia (PCP)
Classified as a fungus
Caused by Pneumocystis jerovici.
Most people exposed to PCP early in life
Disease is likely reactivation of latent infection
Can be transferred from person to person
Risk greatly increased at CD4 count <200
Symptoms: gradual onset of dyspnea,
fever, non-productive cough
36. 36
PCP Treatment
Duration: At least 21 days for all regimens
Cotrimoxazole (IV or PO) **
Trimethoprim (PO/IV) + Dapsone (PO)
Pentamidine (IV)
Primaquine (PO) + Clindamycin (IV or PO)
Atovaquone suspension (PO)
**Preferred
37. 37
PCP Treatment: Adjunctive Corticosteroids
Indicated in patients with O2 saturation <80 or PaO2
<70
Prednisone 40 mg bid x5 days, then 40 mg qd x5
days then 20 mg qd x11 days (total prednisone
course is 21 days)
Prednisone 40mg po = 32 mg methylprednisone IV
Since Prednisone is not available in Ethiopia,
Prednisolone is administered as 60 mg qd x7 days,
40 mg qd x7 days then 20 mg ad x7 days (total for
21 days)
38. 38
PCP Treatment:
Adjunctive Corticosteroids (2)
Several studies have established that the addition of
corticosteroids within 72 hrs of beginning PCP
therapy improves outcome and reduces mortality
Concerns with administering corticosteroids to
immunocompromised patients
39. 39
Drug Dose Adverse Effects/Special
Considerations
Cotrimoxazole 15mg/kg/day (based on TMP
component) +
(sulfamethoxazole 75
mg/kg/day) PO or IV divided
q6h to q8h for 21 days
(Typical oral dose is 2 DS
tablets TID).
Rash, neutropenia, anemia,
increased transaminases,
hepatitis, pancreatitis, GI
disturbances;
Monitor renal function
Dapsone +
Trimethoprim
TMP 15mg/kg/day PO/IV
divided q6h to q8h +
Dapsone 100 mg po qd for 21
days
Dapsone can cause rash &
hemolytic anemia;
Screen for G-6PD deficiency
Treatment Regimens for Acute PCP
Source: Johns Hopkins AIDS Service - Medical Management of HIV Infection. www.hopkins-aids.edu.
40. 40
Treatment Regimens for Acute PCP (2)
Drug Dose Adverse Effects/Special
Considerations
Pentamidine 3-4 mg/kg/day IV
once daily for 21
days
Nephrotoxicity, hypotension, hypoglycemia,
leukopenia, thrombocytopenia, GI
intolerance, pancreatitis;
Keep patient hydrated & closely monitor
renal function, electrolytes, and blood sugar
Clindamycin
+
Primaquine
Clindamycin 300-
600 mg po q6h
(600-900 mg IV
q6-8h) +
Primaquine base
po 15-30mg per
day for 21 days
Primaquine can cause nausea, vomiting &
epigastric pain which may be limited by
administering with meals.
Screen patients for G-6PD deficiency to
avoid hemolytic anemia.
Clindamycin can cause GI intolerance and
diarrhea.
Source: Johns Hopkins AIDS Service - Medical Management of HIV Infection. www.hopkins-aids.edu.
41. 41
Introductory Case: Meseret (cont.)
1. The treatment of choice for severe PCP is
Cotrimoxazole 15 mg/kg/day based on TMP oral or
IV divided q6-8h x21 days + Prednisone 40 mg bid
for 5 days, 40 mg qd for 5 days, 20 mg qd for 11
days
TRUE
IV therapy is required for severe PCP
• IV Cotrimoxazole dosing is based on weight
• Steroids are indicated for severe PCP
42. 42
Introductory Case: Meseret (cont.)
2. The treatment of choice for severe PCP is
Cotrimoxazole (TMP/SMX) 160/800 mg IV divided
q6-8h x 21 days + Prednisone 40 mg bid for 5 days,
40 mg qd for 5 days, 20 mg qd for 11 days
FALSE
Cotrimoxazole dose is weight based (15 mg/kg/day)
based on the TMP component
43. 43
Introductory Case: Meseret (cont.)
3. The treatment of choice for severe PCP is
Cotrimoxazole two DS tablets po TID X 21 days
FALSE
Severe PCP requires IV therapy
Oral therapy is appropriate for the treatment of mild to
moderate PCP. The typical oral dose is 2 DS tablets tid
x21 days.
Steroids are indicated for severe PCP
44. 44
Introductory Case: Meseret (cont.)
4. The treatment of choice for SEVERE PCP is
Cotrimoxazole 1 DS tablet po TID x21 days +
Prednisone 40 mg bid for 5 days, 40 mg qd for 5
days, 20 mg qd for 11 days
FALSE
Severe PCP requires IV therapy
Oral therapy is appropriate for the treatment of MILD to
moderate PCP. The typical oral dose for mild to moderate
PCP is 2 DS tablets tid x21 days
45. 45
Cotrimoxazole Pharmacology
Inhibits CYP2C9
Requires dose adjustment in renal failure
• 10-50 ml/min: half the dose
• Recommend avoid use of <10 ml, may use 1/3 dose
Mechanism of action – inhibits conversion of PABA
to folic acid and then to THF sequentially
Associated with a reduction in bacterial infections
Effective prophylaxis for toxoplasmosis
Adverse effects are dose-related and occur in ~50%
of HIV-infected patients
46. 46
Cotrimoxazole
Adverse Effects
Pruritis/rash
Bone marrow suppression
GI toxicity
Increased LFT’s
Renal effects
Dosing strategies if rash
occurs
Protocols are for patients with
normal renal function only
Desensitization
• Rapid
• Over 8 -15 days
Gradual dose initiation
47. 47
Cotrimoxazole IV Rapid Desensitization
Standing orders:
Epinephrine 1:1000 SQ PRN allergic reaction
Diphenhydramine 50 mg IV/PO before starting Bag
#1 (see next slide), then q6h thereafter
If the patient has a pO2 < 70 mm Hg begin
Prednisone 40 mg bid days 1-5, then 40 mg qd days
6-10, then 20 mg qd days 11-21; or Prednisolone 60
mg qd x7 days, 40 mg qd x7 days then 20 mg qd x7
days
48. 48
Cotrimoxazole IV Rapid Desensitization (2)
Use incremental doses every 20 minutes of the
following concentrations:
Bag #1:TMP 0.16 mg/SMX 0.8 mg in 50 mL D5W. Infuse
over 20 min
Bag #2:TMP 1.44 mg/SMX 7.2 mg in 50 mL D5W. Infuse
over 20 min
Bag #3:TMP 8 mg/SMX 40 mg in 50 mL D5W. Infuse over
20 min
Bag #4:TMP 16 mg/SMX 80 mg in 50 mL D5W. Infuse
over 20 min
49. 49
Cotrimoxazole IV Rapid Desensitization (3)
Concentrations cont.
Bag #5:TMP 80 mg/SMX 400 mg in 100 ml D5W. Infuse
over 20 min
Bag #6:TMP 120 mg/SMX 600 mg in 150 ml D5W. Infuse
over 30 min
Bag #7:TMP 240 mg/SMX 1200 mg in 250 ml D5W. Infuse
over 60 min
Follow in 8 hours by 5 mg/kg (TMP component)
dosing every 8 hours (unless the patient has renal
dysfunction) for treatment of PCP
51. 51
Cotrimoxazole Gradual Initiation
Days 1-3: TMP 20 mg/SMX
100 mg = 2.5 mL of
Cotrimoxazole (TMP/SMX)
suspension 8 mg/40 mg per
mL
Days 4-6: TMP 40 mg/SMX
200 mg = 5 mL of
cotrimoxazole suspension
Days 7-9: TMP 60 mg/SMX
300 mg = 7.5 mL of
Cotrimoxazole suspension
Days 10-12:TMP 80
mg/SMX 400 mg = 1 SS
tablet (Single Strength)
Days 13-15:TMP 120
mg/SMX 600 mg = 1 & 1/2
tablet (Single Strength)
Days 16-22:TMP 160
mg/SMX 800 mg = 1 tablet
(Double Strength)
52. 52
Cotrimoxazole Desensitization Note
If a patient who has been desensitized to
Cotrimoxazole stops taking Cotrimoxazole at some
point:
They will need to undergo desensitization over again to
prevent a subsequent allergic reaction before starting
Cotrimoxazole therapy again
54. 54
IV Pentamidine
Often reserved for severe episodes
Inferior survival rate versus Cotrimoxazole
Most frequent toxicities: nephrotoxicity,
hypoglycemia, hypotension
Other adverse effects: hyperkalemia, pancreatitis,
hypomagnesemia, hypocalcemia, bone marrow
suppression, GI intolerance, elevated LFT’s
56. 56
PCP Prophylaxis
Who –
HIV-infected patients.
When:
CD4 count <350,
prior PCP,
history of oral thrush or unexplained fever for >2 weeks
All HIV patients with TB
WHO stage II,III and IV disease
57. PCP Prophylaxis
Indications to start
Primary prophylaxis
• CD4 < 350
• History of oral candidiasis
• WHO Stage II , III and IV disease
• Diagnosis of tuberculosis on HIV positive
• Unexplained fever
Secondary prophylaxis
• Treatment for clinical PCP
Duration of prophylaxis
Till CD4 is > 350 for three months
57
59. 59
Aerosolized Pentamidine
Antiprotozoal agent
Generally well-tolerated
Adverse effects: bronchospasm (usually in smokers
and asthmatics), cough, unpleasant taste
Disadvantages: high cost, need for a compressed air
source, lack of systemic prophylaxis for
extrapulmonary PCP infection
60. 60
PCP Prophylaxis Withdrawal
Criteria to
discontinue
1o
prophylaxis
Criteria to
restarting 1o
prophylaxis
Criteria to
initiate 2o
prophylaxi
s
Criteria to
discontinue 2o
prophylaxis
Criteria to
restart 2o
prophylaxis
CD4+ > 350
cells/uL for >3
months
CD4+ < 350
cells/uL
Prior PCP
episode
CD4+ >350
cells/uL for >3
months
CD4+ <>350
cells/uL
61. 61
Toxoplasmosis
Caused by a protozoan parasite Toxoplasma gondii
Source is cat feces and raw or undercooked meat
High prevalence of latent infection (80%)—disease is
likely through reactivation
Infection most frequently involves the CNS
Infection occurs when CD4 cells <100
62. 62
Toxoplasmosis Encephalitis (TE)
CNS is most common clinical presentation:
headache, confusion, lethargy, low-grade fever,
seizures (~25%), hemiparesis and speech
abnormalities
Diagnosis:
Ring-enhancing lesions on CT scan or MRI
Toxoplasma IgG antibodies are usually present but may be
negative in 5-10% patients with TE
63. 63
Toxoplasmosis Treatment
Treat acute infection for minimum of 6 weeks
Preferable to treat until 3 wks after resolution of
lesions by radiologic scan
After treatment, switch to chronic suppressive
therapy with reduced doses
Best therapy is immune reconstitution with HAART
64. 64
Acute Toxoplasmosis Treatment
Pyrimethamine 200 mg
once, followed by:50-75
mg/day
+
Sulfadiazine 1-2 gm p.o. 6h
Treatment of choice
Synergistic
Effective but poorly tolerated
Effective as PCP prophylaxis
Pyrimethamine +
Sulfadoxine 1st line drug in
Ethiopia
May be effective as PCP
prophylaxis
Pyrimethamine +
clindamycin
Alternative treatment for sulfa-
intolerant patients
Clindamycin (poor CNS
penetration)
(All regimens include
leucovorin)
65. 65
Acute Toxoplasmosis Treatment (2)
Pyrimethamine + Sulfadiazine + Leucovorin
Pyrimethamine 100-200mg as loading dose, followed by
50-100mg daily (+)Sulfadiazine 1-1.5 gram every 6 hours
(+) Leucovorin 10mg every day
Treatment of choice (Ethiopian guideline)
Pyrimethamine + Clindamycin + Leucovorin
Pyrimethamine (+) Leucovorin (as listed above) (+)
Clindamycin 300-600 mg po q6h (600-1200mg IV q6h)
• Alternate choice as 1st line (Ethiopian guidelines)
Pyrimethamine + Sulfadoxine + Leucovorin
Pyrimethamine (+) Leucovorin (as listed above) (+)
Sulfadoxine (refer to Ethiopia dosing guidelines)
66. Acute Toxoplasmosis Treatment
1st line regimen in the Ethiopian context :
Sulfadoxine/pyrimethamine :
500 mg/ 25 mg po b.i.d for two days, followed by once daily both for
four (4) weeks is given together with Folinic acid (10 mg daily)
S/E: Occasional: anaemia- need Folinic Acid
Rare: pancytopenia; hepatitis; GI intolerance
C/I: Foliate deficiency
Dosage forms: 500/ 25 mg tabs or IV vials
PLUS
Folinic acid: 10-20 mg/d
(alternative regimen )
The drug of choice in Ethiopian context is cotrimoxazole 15 mg /Kg
Trimethoprim based in three divided doses daily
66
67. 67
Toxoplasmosis Treatment Adverse Effects
Pyrimethamine + sulfadoxine
Stevens-Johnson syndrome, megaloblastic anemia and
other blood dyscrasias, toxic nephrosis, hepatitis,
gastrointestinal toxicity, and kernicterus
Pyrimethamine + clindamycin
diarrhea, GI intolerance, dose related ataxia, tremors,
seizures, bone marrow suppression
Pyrimethamine + sulfadiazine
hypersensitivity with rash, drug fever, marrow suppression,
GI intolerance, dose related ataxia, tremors, seizures,
bone marrow suppression, renal failure
68. 68
Toxoplasmosis Primary Prophylaxis
Indications:
Patient who has never had toxoplasmosis
plus
Positive toxoplasma IgG serology
plus
CD4 count less than 100 cells/mm3
70. 70
Toxoplasmosis Prophylaxis Withdrawal
Criteria to
discontinue
1o
prophylaxis
Criteria to
restarting 1o
prophylaxis
Criteria to
initiate 2o
prophylaxis
(chronic
maintenance
therapy)
Criteria to
discontinue
2o
prophylaxis
(chronic
maintenance
therapy)
Criteria to
restart 2o
prophylaxis
(chronic
maintenance
therapy)
CD4+ >200
cells/uL for
>3 months
CD4+ <100-
200 cells/uL
Prior Toxo-
plasmosis
encephalitis
CD4+ >200
cells/uL
sustained (>6
mos) and
Completed
initial therapy
and
asymptomatic
for
CD4+ <200
cells/uL
71. Visceral Leishmaniasis (VL)
Also called Kala Azar “ Black disease’’
Fatal forms of Leishmaniasis
Most of the viscera/ organs are affected- spleen,
Bone marrow, Lymph nodes, Liver, Gastro intestine,
Respiratory Tract
Causative species L. Donovani complex
72. EPIDEMILOGY OF VL IN ETHIOPIA
VL is distributed throughout the lowlands of Ethiopia
Reported in five administrative regions of Ethiopia
It is reported from 40 different localities
It is estimated 4,500-5,000 cases/annually
Caused by L.Donvani and L.Infantum
73. HIV and Kalazar
Parasites can be in unusual sites
Presentations may be atypical
Mortality is high with co-infection (3.5-4 times higher)
Lower response rate for treatment
Treatment may have serious adverse effects
Relapse rate is very high
74. HIV-VL Co-infection - Treatment
Treatment is essentially similar to HIV-ve VL
Relapse is the rule usually within 1-8 months.
Treat relapse if only symptoms are severe
Treat other OIs if diagnosed.
HAART is the key to postpone relapse
75. HIV-VL Co-infection - Treatment
All VL drugs are less effective in HIV patients
• High mortality due to concurrent illnesses and complications
(pneumonia, diarrhea, vomiting, anemia, bleeding, SSG
toxicity)
• Patients get less responsive to treatment with each
relapse, and eventually become unresponsive to all drugs
• Drug of choice in HIV co-infection is lyposomal
amphoterecin B
• Second choice is Amphoterecin B
• SSG is more toxic in HIV patients (pancreatitis)
76. 76
Mycobacterium Avium Complex (MAC)
MAC- Mycobacterium avium & M. intracelluare
Acid fast bacteria
Ubiquitous in the environment
No recommendations for prevention of exposure
No person to person transmission
Infection is due to recent acquisition
Colonization through GI and respiratory tracts
Manifests in late stage AIDS (CD4 cell <50)
77. 77
Mycobacterium Avium Complex (MAC)
Symptoms:
Local disease - Fever, lymphadenopathy
Disseminated Disease - Late stage AIDS illness.
Symptoms: fatigue, malaise, weight loss, fever, night
sweats, abdominal pain, diarrhea
MAC Prophylaxis:
Who: all HIV-infected patients
When: CD4<50
Drug of Choice: Azithromycin or Clarithromycin
78. 78
MAC Treatment Principles
Preferred regimen :
Azithromycin or Clarithromycin
plus Ethambutal
+/- Rifampin
Alternative (3rd) drug or additional (4th) drug
Ciprofloxacin
79. 79
Herpes Zoster
There is a high incidence of zoster in association
with HIV infection
More than 90% of adults have serologic evidence of
infection with varicella-zoster virus
Presentation is similar to immuno-competent patient;
duration may be longer and the risk of disseminated
infection is greater in HIV infected individuals
Lesions are painful, pruritic, grouped and can be
pustular on an erythematous base
82. 82
Herpes Zoster Treatment
Dermatomal
Acyclovir p.o. 800 mg 5x day for at least 7 days (until
lesions crust) or acyclovir IV 10 mg/kg/day tid
treat with in 72 hrs of onset of symptoms
Disseminated
Acyclovir 30-36 mg/kg/day IV at least 7 days
83. 83
Cytomegalovirus (CMV)
Herpes virus
High incidence
30-40% in general population are Ab+
90% or more in IVDU and MSM are Ab+
Able to establish a latent infection which can
reactivate
Late stage AIDS illness (CD4 < 100)
Clinical Manifestations
Retinitis, esophagitis, colitis
84. Diagnosis and Treatment of Common
Causes of Diarrhea in AIDS Patients
Agent CD4 Symptom Diagnosis Rx
E. histolytica any
bloody stool,
colitis
Stool
microscopy
Metronidazol
e
Giardia any Watery diarrhea “ “
Cryptosporidium <150 Watery diarrhea Modified AFB HAART
Isospora belli <100 Watery diarrhea Modified AFB TMP-SMX
Microsporidium <50 Watery diarrhea Giemsa stain
Albendazole
(20% respond
CMV <50
Watery to Bloody
stool, colitis
Biopsy,
barium study
Ganciclovir
85. 85
OIs and Immune Reconstitution
Inflammatory Syndrome (IRIS)
IRIS:
The worsening of signs and symptoms due to known
infections, or the development of disease due to occult
infections, that results from improvement in immune
function after the initiation of anti-retroviral therapy
May occur with certain OIs
TB, MAC, PCP, PML, CMV vitritis, mild herpes zoster,
cryptococcal meningitis
86. Management of HIV-TB Co-Infection 86
Immune Reconstitution Syndrome
Often occurs within days to weeks of starting ARV
(median = 15 days)
Constellation of signs and symptoms, including
fever, adenopathy, pulmonary infiltrates, serositis
(pleural, pericardial, ascites), skin lesions, CNS
lesions
Make certain that symptoms are not related to
treatment failure or another OI
87. 87
IRIS: Management
Not defined, dependent on disease involved
Most agree to maintain HAART and treat
symptomatically (NSAIDs and Steroids)
In other cases, the syndrome is treated as an active
infection
92. 92
Case Study: Solomon
Solomon is a 53 year-old male who was diagnosed
with HIV two months ago. He has developed severe
PCP with concomitant thrush. He experienced a
pruritic rash 5 days after starting therapy with
Cotrimoxazole for the treatment of his PCP.
93. 93
Case Study: Solomon (2)
Solomon’s physician wants to switch to another
agent to treat his PCP. Which option below would
you recommend? Explain why your choice is the
most appropriate
A. Clindamycin 600 mg IV q6h + Primaquine 15 mg po qd
B. TMP 220 mg IV q6h + Dapsone 100 mg po qd
C. Pentamidine 240 mg IV QD
D. Rapid Cotrimoxazole desensitization, followed by 21 days
of Cotrimoxazole IV therapy
94. 94
Case Study: Solomon Follow-up (3)
During Solomon’s hospital stay, he is found to have
a CD4 count of 110 cells/mm3 and a viral load of 89,
503
He tolerated a rapid oral desensitization protocol and
is currently on day 5 of IV Cotrimoxazole
His physician would like to begin treatment for his
thrush
95. 95
Case Study: Solomon (4)
Which of the following would you recommend?
Why?
A. Nystatin oral suspension 500,000 units 5 times per day
B. Nystatin pastilles 100,000 units:1 to 2 pastilles (200,000
to 400,000 units) 4 to 5 times daily
C. Fluconazole 100 mg daily
D. Itraconazole capsule 200mg daily with food
E. Miconazole oral gel
F. Ketoconazole 200mg po 1 to 2 times per day
Any other ideas?
97. 97
Case Study: Sara
Sara is a 24 year-old HIV-infected woman from
Jimma who presents to your pharmacy
She has prescriptions for her current medications:
dapsone (for PCP prophylaxis) and miconazole oral
gel (for thrush). At this time she is not taking
antiretroviral therapy
She just received results from her doctor’s visit:
serologic testing detects antibodies to Toxoplasma
(IgG) and her current CD4 count is 85 cells/mm3
She has a history of rash from Cotrimoxazole
98. 98
Case Study: Sara (2)
Which of the following statements is most true
regarding Toxoplasmosis prevention for Sara?
A.Since the patient is IgG+ to Toxoplasma you have
evidence of immunity to infection and she does not need
prophylaxis for Toxoplasmosis
B.The patient does not need prophylaxis for Toxoplasmosis.
She is taking dapsone for PCP prophylaxis which will
provide protection against Toxoplasmosis
C.If possible, the patient should be desensitized to and then
treated with Cotrimoxazole for prophylaxis against both
PCP and Toxoplasmosis
D.The patient should be prescribed pyrimethamine in addition
to dapsone, which would cover both PCP and
Toxoplasmosis
100. 100
Case Study: Berhan
Berhan is a 50 year-old male who is being
discharged from the hospital after completing
treatment for PCP
CD4: 32, VL: 500,000
Berhan’s physician decides he is ready for HAART.
He is given prescriptions for lamivudine, stavudine
and efavirenz. The physician then asks you to
recommend an appropriate therapy for PCP
prophylaxis
101. 101
Case Study: Berhan (2)
Based on the guidelines, which option below do you
consider to be the best option for Berhan? And
why?
A. Atovaquone 750 mg po qd
B. Cotrimoxazole DS or SS qd
C. Dapsone 100mg po qd
D. Cotrimoxazole DS once weekly
102. 102
Key Points
Opportunistic infections are those that develop as a
result of HIV-inflicted damage to the immune system
As immunosuppression progresses, the overall
incidence of OIs increases
The most common OIs encountered in Ethiopia include
oropharyngeal candida, TB, CNS manifestations,
sepsis, herpes zoster, and pneumonia
OIs may be bacterial, viral, fungal or protozoal, or non
infectious
The origin of OIs, severity of disease, drug-drug
interactions, and drug toxicities impact choice of
therapy
