The document provides guidelines for preventing opportunistic infections among HIV-infected persons. It summarizes major changes from previous editions, including updated recommendations for discontinuing prophylaxis when CD4 counts increase on antiretroviral therapy, emphasizing screening for hepatitis C virus, new information on human herpesvirus 8 and drug interactions, and revised vaccination recommendations. The guidelines are intended to help clinicians prevent 19 opportunistic infections through exposure prevention, primary prophylaxis, and secondary prophylaxis based on the latest evidence.
This document provides guidelines for preventing opportunistic infections among HIV-infected persons. It was updated in 2002 by the U.S. Public Health Service and Infectious Diseases Society of America. The guidelines contain recommendations for preventing 19 opportunistic infections or groups of infections. Major changes from the previous edition include updated recommendations for discontinuing prophylaxis based on CD4 count increases from antiretroviral therapy, emphasizing hepatitis C screening, new information on human herpesvirus 8, drug interactions, and immunization guidelines for HIV-infected persons. The goal is to provide evidence-based guidance to help clinicians caring for people living with HIV/AIDS.
The document describes the approach taken by one institution, Mayo Clinic, to implement individualized medicine into clinical practice through a standalone Individualized Medicine (IM) Clinic. The IM Clinic was designed to overcome barriers to translating genomic medicine into routine patient care. Initial services offered by the IM Clinic included whole exome sequencing for patients with undiagnosed genetic conditions (diagnostic odyssey) and tumor sequencing for cancer patients who have failed standard therapies. The IM Clinic utilizes a multidisciplinary team approach and coordinates various components including genomic counseling, sample collection, sequencing, data analysis, expert review boards, and communication of results to patients. The goals are to improve patient outcomes by enabling more targeted and personalized care approaches.
The document summarizes the January 2017 issue of the journal Diabetes Care, which focuses on the American Diabetes Association's Standards of Medical Care in Diabetes for 2017. It provides information on the purpose and scope of the standards, the process for developing and revising them, and an overview of the contents of the 2017 issue. The standards are intended to provide evidence-based guidelines and recommendations to help health care providers effectively manage care for patients with diabetes.
This document is the January 2017 issue of the journal Diabetes Care, which contains the American Diabetes Association's annual publication of the Standards of Medical Care in Diabetes. The Standards of Care provide evidence-based guidelines for healthcare professionals on the components of diabetes care and treatment goals. This issue includes revisions to the Standards as well as articles on promoting health and reducing disparities, classifying and diagnosing diabetes, lifestyle management, preventing and treating diabetes complications, managing diabetes in special populations and settings, and diabetes advocacy.
April 28, 2017
Transparency is a relatively new concept to the world of health and health care, considering that just a few short decades ago we were still in the throes of a “doctor-knows-best” model. Today, however, transparency is found on almost every short list of solutions to a variety of health policy problems, ranging from conflicts of interest to rising drug costs to promoting efficient use of health care resources, and more. Doctors are now expected to be transparent about patient diagnoses and treatment options, hospitals are expected to be transparent about error rates, insurers about policy limitations, companies about prices, researchers about data, and policymakers about priorities and rationales for health policy intervention. But a number of important legal and ethical questions remain. For example, what exactly does transparency mean in the context of health, who has a responsibility to be transparent and to whom, what legal mechanisms are there to promote transparency, and what legal protections are needed for things like privacy, intellectual property, and the like? More specifically, when can transparency improve health and health care, and when is it likely to be nothing more than platitude?
This conference aimed to: (1) identify the various thematic roles transparency has been called on to play in American health policy, and why it has emerged in these spaces; (2) understand when, where, how, and why transparency may be a useful policy tool in relation to health and health care, what it can realistically be expected to achieve, and when it is unlikely to be successful, including limits on how patients and consumers utilize information even when we have transparency; (3) assess the legal and ethical issues raised by transparency in health and health care, including obstacles and opportunities; (4) learn from comparative examples of transparency, both in other sectors and outside the United States. In sum, we hope to reach better understandings of this health policy buzzword so that transparency can be utilized as a solution to pressing health policy issues where appropriate, while recognizing its true limitations.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/2017-annual-conference
Navy Surgeon General Treatise of Patient and Family-Centerred CarePhilip C Ballard
This document provides information about the Journal of Healthcare, Science and the Humanities, including its mission, publication details, editorial board, and table of contents for volume 1, number 2 from 2011. It introduces the journal as a publication of the Navy Medicine Institute focusing on topics related to healthcare, sciences, and humanities. It lists the editor and contributors for this issue, and provides a brief overview of the articles and reports included in this volume.
The document provides an overview of the Canadian Consensus Document on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). It summarizes the development of the consensus document, which was spearheaded by the National ME/FM Action Network of Canada in response to the need for a clinical case definition and guidelines for diagnosis and treatment of ME/CFS. An expert panel of 11 clinicians and researchers with experience treating over 20,000 ME/CFS patients was selected to develop the consensus document. The panel held a funded workshop to reach consensus on a clinical case definition, diagnostic guidelines, and treatment guidelines for medical practitioners dealing with ME/CFS patients.
The natural medicine physician plays an important role within a new healthcare paradigm focused on wellness rather than just disease treatment. Conventional medicine has had successes but also problems like high costs, side effects, and not addressing the root causes of disease. Patients increasingly seek natural medicine due to these issues with conventional care. A wellness-oriented approach to primary care that emphasizes prevention, lifestyle, and addressing underlying causes can help reduce the disease burden and rising healthcare costs crisis. Research supports that addressing modifiable risk factors through lifestyle and behavioral changes can significantly reduce mortality and morbidity from chronic diseases. Overcoming political and reimbursement barriers can help create a system that better facilitates this wellness-focused approach.
This document provides guidelines for preventing opportunistic infections among HIV-infected persons. It was updated in 2002 by the U.S. Public Health Service and Infectious Diseases Society of America. The guidelines contain recommendations for preventing 19 opportunistic infections or groups of infections. Major changes from the previous edition include updated recommendations for discontinuing prophylaxis based on CD4 count increases from antiretroviral therapy, emphasizing hepatitis C screening, new information on human herpesvirus 8, drug interactions, and immunization guidelines for HIV-infected persons. The goal is to provide evidence-based guidance to help clinicians caring for people living with HIV/AIDS.
The document describes the approach taken by one institution, Mayo Clinic, to implement individualized medicine into clinical practice through a standalone Individualized Medicine (IM) Clinic. The IM Clinic was designed to overcome barriers to translating genomic medicine into routine patient care. Initial services offered by the IM Clinic included whole exome sequencing for patients with undiagnosed genetic conditions (diagnostic odyssey) and tumor sequencing for cancer patients who have failed standard therapies. The IM Clinic utilizes a multidisciplinary team approach and coordinates various components including genomic counseling, sample collection, sequencing, data analysis, expert review boards, and communication of results to patients. The goals are to improve patient outcomes by enabling more targeted and personalized care approaches.
The document summarizes the January 2017 issue of the journal Diabetes Care, which focuses on the American Diabetes Association's Standards of Medical Care in Diabetes for 2017. It provides information on the purpose and scope of the standards, the process for developing and revising them, and an overview of the contents of the 2017 issue. The standards are intended to provide evidence-based guidelines and recommendations to help health care providers effectively manage care for patients with diabetes.
This document is the January 2017 issue of the journal Diabetes Care, which contains the American Diabetes Association's annual publication of the Standards of Medical Care in Diabetes. The Standards of Care provide evidence-based guidelines for healthcare professionals on the components of diabetes care and treatment goals. This issue includes revisions to the Standards as well as articles on promoting health and reducing disparities, classifying and diagnosing diabetes, lifestyle management, preventing and treating diabetes complications, managing diabetes in special populations and settings, and diabetes advocacy.
April 28, 2017
Transparency is a relatively new concept to the world of health and health care, considering that just a few short decades ago we were still in the throes of a “doctor-knows-best” model. Today, however, transparency is found on almost every short list of solutions to a variety of health policy problems, ranging from conflicts of interest to rising drug costs to promoting efficient use of health care resources, and more. Doctors are now expected to be transparent about patient diagnoses and treatment options, hospitals are expected to be transparent about error rates, insurers about policy limitations, companies about prices, researchers about data, and policymakers about priorities and rationales for health policy intervention. But a number of important legal and ethical questions remain. For example, what exactly does transparency mean in the context of health, who has a responsibility to be transparent and to whom, what legal mechanisms are there to promote transparency, and what legal protections are needed for things like privacy, intellectual property, and the like? More specifically, when can transparency improve health and health care, and when is it likely to be nothing more than platitude?
This conference aimed to: (1) identify the various thematic roles transparency has been called on to play in American health policy, and why it has emerged in these spaces; (2) understand when, where, how, and why transparency may be a useful policy tool in relation to health and health care, what it can realistically be expected to achieve, and when it is unlikely to be successful, including limits on how patients and consumers utilize information even when we have transparency; (3) assess the legal and ethical issues raised by transparency in health and health care, including obstacles and opportunities; (4) learn from comparative examples of transparency, both in other sectors and outside the United States. In sum, we hope to reach better understandings of this health policy buzzword so that transparency can be utilized as a solution to pressing health policy issues where appropriate, while recognizing its true limitations.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/2017-annual-conference
Navy Surgeon General Treatise of Patient and Family-Centerred CarePhilip C Ballard
This document provides information about the Journal of Healthcare, Science and the Humanities, including its mission, publication details, editorial board, and table of contents for volume 1, number 2 from 2011. It introduces the journal as a publication of the Navy Medicine Institute focusing on topics related to healthcare, sciences, and humanities. It lists the editor and contributors for this issue, and provides a brief overview of the articles and reports included in this volume.
The document provides an overview of the Canadian Consensus Document on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). It summarizes the development of the consensus document, which was spearheaded by the National ME/FM Action Network of Canada in response to the need for a clinical case definition and guidelines for diagnosis and treatment of ME/CFS. An expert panel of 11 clinicians and researchers with experience treating over 20,000 ME/CFS patients was selected to develop the consensus document. The panel held a funded workshop to reach consensus on a clinical case definition, diagnostic guidelines, and treatment guidelines for medical practitioners dealing with ME/CFS patients.
The natural medicine physician plays an important role within a new healthcare paradigm focused on wellness rather than just disease treatment. Conventional medicine has had successes but also problems like high costs, side effects, and not addressing the root causes of disease. Patients increasingly seek natural medicine due to these issues with conventional care. A wellness-oriented approach to primary care that emphasizes prevention, lifestyle, and addressing underlying causes can help reduce the disease burden and rising healthcare costs crisis. Research supports that addressing modifiable risk factors through lifestyle and behavioral changes can significantly reduce mortality and morbidity from chronic diseases. Overcoming political and reimbursement barriers can help create a system that better facilitates this wellness-focused approach.
1. The document provides an overview of integrative medicine, discussing definitions of primary care, healthcare trends, evidence-based treatments, and the role of complementary and alternative medicine.
2. It describes a typical day in the life of a physician, including patient cases, medical education and certification requirements, and professional positions held.
3. The future of healthcare is discussed, focusing on healthcare reform, accountable care organizations, and rewriting medical education through programs like the MS ACP at National University of Health Sciences.
This document is an undergraduate thesis that examines the pharmaceutical industry and alternative medicine. It argues that while Western medicine has improved health outcomes for some acute illnesses, the over-reliance on drugs has significant downsides. Preventable medical errors are the third leading cause of death in the US, with pharmaceutical companies more focused on profits than patient safety. The document also suggests that several holistic doctors working on alternative cancer treatments may have been murdered to protect the financial interests of the pharmaceutical industry.
This article examines the role of clinical pharmacists in intensive care unit (ICU) medical teams and their impact on reducing mortality rates. It discusses how including pharmacists in daily ICU activities can optimize drug therapy, improve patient safety, and lower costs from medical errors and extended hospital stays. The article reviews literature showing that when pharmacists are involved in clinical decision making on medical teams, various clinical outcomes generally improve and mortality rates noticeably decrease.
This document provides an overview and table of contents for "The Partners In Health Manual of Ultrasound for Resource Limited Settings." It was edited by Sachita P Shah and Daniel D Price and contains chapters on fundamentals of ultrasound, trauma, echocardiography, obstetrics, liver, gallbladder, spleen, kidney, abdominal aortic aneurysm, deep venous thrombosis, volume status, bladder, skin, procedures, and vascular access. It is intended as a resource for healthcare providers using point-of-care ultrasound in resource-limited settings.
This document outlines guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It provides classifications for blood pressure levels, assessments of cardiovascular disease risk associated with blood pressure, and benefits of treating high blood pressure. The report recommends accurate office blood pressure measurements, ambulatory blood pressure monitoring, and self-monitoring of blood pressure. It also provides guidance on patient evaluation, laboratory tests, treatment options, and goals for controlling high blood pressure.
Peter Millett MD | Orthopaedic Surgeon | The Steadman Clinic Sports Medicine ...Peter Millett MD
Dr. Millett is a Partner at the Steadman Hawkins Clinic. An expert in shoulder disorders, he also specializes in disorders of the knee, and elbow as well as all sports-related injuries. He uses advanced open and arthroscopic surgical techniques to restore damaged joints, ligaments, and bones. A focus of his is complex and revision shoulder surgery. He held a faculty appointment at Harvard Medical School, and was formerly Co-Director of the Harvard Shoulder Service, and Co-director of the Harvard Shoulder Fellowship. He also directed the Musculoskeletal Proteomics Research Group at Harvard. His clinical practice in Boston was based at the prestigious Brigham & Women's and Massachusetts General Hospitals. He has authored over numerous peer-reviewed, scientific articles, numerous book chapters, and a review book on orthopaedics. His academic work has been recognized with awards from several international societies. Dr. Millett serves as a shoulder and sports medicine consultant for Bermuda. A member of numerous societies including AAOS, AOSSM, ASES, AANA, and ORS, Dr. Millett has cared for athletes from the NFL, MLB, NHL, USTA, PGA, US ski team, and X-games. Dr. Millett serves as a team physician for the U.S. Ski Team. He is a consultant to the Montreal Canadiens Professional Hockey Club and the Volkl/Marker ski companies. Dr. Millett has performed live surgery for courses in North America (Massachusetts, Florida, California, Colorado, Missouri, Illinois), Europe (Germany, The Netherlands, France) and the Caribbean (Bermuda).
A native of Pennsylvania, Dr. Millett received his undergraduate degree from the University of Scranton, and his medical degree from Dartmouth Medical School in Hanover, New Hampshire. He also served as a visiting research scholar at the University of Cambridge in England, where he was awarded a master’s degree in science (M.Sc.) for his work in skeletal biology.
Dr. Millett performed his orthopaedic residency training at the Hospital for Special Surgery in New York City, part of Cornell University's Medical School and the oldest and most prestigious orthopaedic residency program in the country. While there, he received the Lewis Clark Wagner Award for excellence in orthopaedic research as well as the American Orthopaedic Association – Zimmer Travel Award, a national award for orthopaedic research.
Dr. Millett earned additional subspecialty, fellowship training in sports medicine, knee and shoulder surgery at the internationally renown Steadman Hawkins Sports Medicine Foundation in Vail, CO. While there, he also served as an associate physician for the Denver Broncos professional football team, the Colorado Rockies Major League Baseball team, and the U.S. Ski Team.
Specialty:
Shoulder, knee, and elbow surgery
Sports medicine
Orthopaedic trauma
Joint replacement surgery
Orthopedic Surgery
SOME LEARNING GUIDELINE QUESTIONS OF MEDICAL SEMIOLOGY MULTIPLE CHOICE QUESTIONS
PHARMACY III STUDENT , UNIVERSITY OF RWANDA -COLLEGE OF MEDICINE AND HEALTH SCIENCES - SCHOOL OF MEDICINE AND PHARMACY -YEAR 2017-2018
This curriculum vitae summarizes the education and professional experience of Dr. Casey E. Gooden. She received her B.S. from the University of South Florida in 2007 and her M.D. from the University of South Florida College of Medicine in 2010. She completed an anatomic and clinical pathology residency at Emory University from 2010-2014, where she served as chief resident in 2013-2014. She is currently a hematopathology clinical instructor at the University of Pittsburgh Medical Center. Her professional experiences include publications in peer-reviewed journals and presentations at pathology conferences.
Diagnostic hemoglobinopathies Second Editionfssherwani
This document provides an editorial board and list of contributors for a book on diagnostic hemoglobinopathies. It includes three chapters that discuss hemoglobin structure and function, red blood cell morphology, and various laboratory methods for diagnosing hemoglobinopathies such as electrophoresis, chromatography, and DNA analysis. The book aims to provide information on diagnostic techniques and case studies to aid in the diagnosis and management of hemoglobin disorders.
This document contains abstracts from research, innovations, and clinical vignettes presented at the 2011 Hospital Medicine annual meeting. The abstracts are divided into sections for research, innovations, and clinical vignettes. Some of the abstracts presented include evaluations of HIV screening practices, the safety of arthrocentesis for patients on warfarin therapy, incidence of venous thromboembolism in homebound patients, and an assessment of pain in patients undergoing bone marrow biopsies. The abstracts cover a wide range of topics in hospital medicine and include results from studies, innovations, and case reports.
The document provides guidance on taking a thorough history for a wound patient. It outlines topics to cover such as when the patient first noticed the wound, any changes over time, pain levels, previous medical history including conditions like diabetes that could impact healing, and current medications. Gathering details on the wound characteristics, healing process, and the patient's overall health is essential for determining the cause of the wound and developing an appropriate treatment plan.
Digestive system part 3 liver etc 2nd editionmostafa hegazy
This document provides information about the editors and contributors of "The Netter Collection of Medical Illustrations Digestive System: Part III—Liver, Biliary Tract, and Pancreas, Volume 9, Second Edition". It lists the editors, their backgrounds and areas of expertise. It also provides brief biographies of some of the contributing illustrators and acknowledges the publishing team.
The document provides guidelines from the Infectious Diseases Society of America (IDSA) for diagnosing and treating diabetic foot infections. Some key points:
1. Diabetic foot infections typically begin in wounds and are classified based on severity as mild, moderate, or severe to help determine treatment approach.
2. Most infections are polymicrobial but gram-positive cocci like staphylococci are common causes. Appropriate cultures should be taken from infected wounds.
3. Guidelines recommend evaluation of the patient, foot, and wound. Treatment may involve wound debridement, antibiotics, imaging, surgery, wound care, and addressing ischemia or biomechanical issues.
4. A multidis
This summary covers a set of lecture notes for internal medicine created for medical students at Weill Bugando School of Medicine. The notes were created to teach the basic concepts of internal medicine and cover major topic areas. They are focused on teaching clinical management algorithms and are intended to be used alongside textbooks. The notes include sections on history taking, physical examination, cardiology, renal medicine, gastroenterology, infectious diseases and other areas. The goal is to provide a useful guide for both students and faculty in teaching internal medicine essentials.
Dr. John Catanzaro is a naturopathic physician specializing in integrative oncology and personalized medicine. He received his ND from Bastyr University and has additional certifications in genetics and theology. He has owned several wellness clinics and founded non-profits focused on cancer research. Currently, he works as a physician consultant providing functional genetics testing and counseling.
Physician-assisted suicide is a controversial issue that is only legal in five U.S. states. It allows terminally ill patients with less than six months to live to request lethal medication from their doctor to end their own lives. While some see it as giving patients control at the end of life, others argue it could encourage suicide or that terminally ill patients are not in a mental state to make such a decision. There are also concerns about how to protect vulnerable patients from being coerced into suicide. The document discusses the various perspectives on this complex issue and argues rules need to be put in place to allow physician-assisted suicide as an option while also protecting doctors' and patients' rights.
The document provides an introduction to bioethics and outlines several key topics including informed consent, advance directives, medical futility, Do Not Resuscitate (DNR) orders, confidentiality, and research. It discusses the role of the Department of Bioethics in providing ethics consultations and summaries key policies and guidelines related to complex ethical issues that may arise in patient care.
1. This document provides guidelines for the diagnosis, management, and treatment of hepatitis C virus (HCV) infection based on a formal review of recent literature and expert consensus.
2. It recommends screening high-risk groups for HCV infection, including current and former injection drug users, those with HIV, and prior blood transfusion recipients.
3. It also provides guidance on counseling HCV-infected individuals, including advising them to avoid behaviors that may spread the virus and informing them that properly performed tattooing and piercing pose a very low risk of transmission.
This document summarizes common neonatal morbidities that can result from complications during pregnancy and delivery. It discusses how conditions like diabetes, hypertension, infection, and nutritional imbalances in the mother can negatively impact the health of the newborn. The summary provides management considerations for treating infants born with various medical issues and outlines how close collaboration between obstetric and neonatal clinicians is important for counseling families and ensuring the best outcomes for both mother and baby.
This document provides guidelines from the Infectious Diseases Society of America (IDSA) for the management of cryptococcal disease. A group of medical mycology experts reviewed and updated the previous 2000 IDSA guidelines. The guidelines discuss management of cryptococcal meningitis in three at-risk groups and make recommendations for other sites of infection. Key principles include induction therapy with fungicidal regimens followed by suppressive therapy, early recognition and treatment of increased intracranial pressure and immune reconstitution inflammatory syndrome, and use of lipid formulations of amphotericin B for patients with renal impairment. While cryptococcosis remains challenging, adherence to these guidelines can lead to successful management for most patients.
A database is a collection of related data, while a database management system (DBMS) is software that allows users to add, view and manage data in a database. DBMSes enable users to perform tasks like entering, sorting and querying data, and common database structures include flat-file databases with one table and relational databases with multiple related tables. Key aspects of working with databases involve creating tables to organize fields and records, using filters and forms to view and enter data, and querying the database using languages like SQL to search for specific records.
1. The document provides an overview of integrative medicine, discussing definitions of primary care, healthcare trends, evidence-based treatments, and the role of complementary and alternative medicine.
2. It describes a typical day in the life of a physician, including patient cases, medical education and certification requirements, and professional positions held.
3. The future of healthcare is discussed, focusing on healthcare reform, accountable care organizations, and rewriting medical education through programs like the MS ACP at National University of Health Sciences.
This document is an undergraduate thesis that examines the pharmaceutical industry and alternative medicine. It argues that while Western medicine has improved health outcomes for some acute illnesses, the over-reliance on drugs has significant downsides. Preventable medical errors are the third leading cause of death in the US, with pharmaceutical companies more focused on profits than patient safety. The document also suggests that several holistic doctors working on alternative cancer treatments may have been murdered to protect the financial interests of the pharmaceutical industry.
This article examines the role of clinical pharmacists in intensive care unit (ICU) medical teams and their impact on reducing mortality rates. It discusses how including pharmacists in daily ICU activities can optimize drug therapy, improve patient safety, and lower costs from medical errors and extended hospital stays. The article reviews literature showing that when pharmacists are involved in clinical decision making on medical teams, various clinical outcomes generally improve and mortality rates noticeably decrease.
This document provides an overview and table of contents for "The Partners In Health Manual of Ultrasound for Resource Limited Settings." It was edited by Sachita P Shah and Daniel D Price and contains chapters on fundamentals of ultrasound, trauma, echocardiography, obstetrics, liver, gallbladder, spleen, kidney, abdominal aortic aneurysm, deep venous thrombosis, volume status, bladder, skin, procedures, and vascular access. It is intended as a resource for healthcare providers using point-of-care ultrasound in resource-limited settings.
This document outlines guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It provides classifications for blood pressure levels, assessments of cardiovascular disease risk associated with blood pressure, and benefits of treating high blood pressure. The report recommends accurate office blood pressure measurements, ambulatory blood pressure monitoring, and self-monitoring of blood pressure. It also provides guidance on patient evaluation, laboratory tests, treatment options, and goals for controlling high blood pressure.
Peter Millett MD | Orthopaedic Surgeon | The Steadman Clinic Sports Medicine ...Peter Millett MD
Dr. Millett is a Partner at the Steadman Hawkins Clinic. An expert in shoulder disorders, he also specializes in disorders of the knee, and elbow as well as all sports-related injuries. He uses advanced open and arthroscopic surgical techniques to restore damaged joints, ligaments, and bones. A focus of his is complex and revision shoulder surgery. He held a faculty appointment at Harvard Medical School, and was formerly Co-Director of the Harvard Shoulder Service, and Co-director of the Harvard Shoulder Fellowship. He also directed the Musculoskeletal Proteomics Research Group at Harvard. His clinical practice in Boston was based at the prestigious Brigham & Women's and Massachusetts General Hospitals. He has authored over numerous peer-reviewed, scientific articles, numerous book chapters, and a review book on orthopaedics. His academic work has been recognized with awards from several international societies. Dr. Millett serves as a shoulder and sports medicine consultant for Bermuda. A member of numerous societies including AAOS, AOSSM, ASES, AANA, and ORS, Dr. Millett has cared for athletes from the NFL, MLB, NHL, USTA, PGA, US ski team, and X-games. Dr. Millett serves as a team physician for the U.S. Ski Team. He is a consultant to the Montreal Canadiens Professional Hockey Club and the Volkl/Marker ski companies. Dr. Millett has performed live surgery for courses in North America (Massachusetts, Florida, California, Colorado, Missouri, Illinois), Europe (Germany, The Netherlands, France) and the Caribbean (Bermuda).
A native of Pennsylvania, Dr. Millett received his undergraduate degree from the University of Scranton, and his medical degree from Dartmouth Medical School in Hanover, New Hampshire. He also served as a visiting research scholar at the University of Cambridge in England, where he was awarded a master’s degree in science (M.Sc.) for his work in skeletal biology.
Dr. Millett performed his orthopaedic residency training at the Hospital for Special Surgery in New York City, part of Cornell University's Medical School and the oldest and most prestigious orthopaedic residency program in the country. While there, he received the Lewis Clark Wagner Award for excellence in orthopaedic research as well as the American Orthopaedic Association – Zimmer Travel Award, a national award for orthopaedic research.
Dr. Millett earned additional subspecialty, fellowship training in sports medicine, knee and shoulder surgery at the internationally renown Steadman Hawkins Sports Medicine Foundation in Vail, CO. While there, he also served as an associate physician for the Denver Broncos professional football team, the Colorado Rockies Major League Baseball team, and the U.S. Ski Team.
Specialty:
Shoulder, knee, and elbow surgery
Sports medicine
Orthopaedic trauma
Joint replacement surgery
Orthopedic Surgery
SOME LEARNING GUIDELINE QUESTIONS OF MEDICAL SEMIOLOGY MULTIPLE CHOICE QUESTIONS
PHARMACY III STUDENT , UNIVERSITY OF RWANDA -COLLEGE OF MEDICINE AND HEALTH SCIENCES - SCHOOL OF MEDICINE AND PHARMACY -YEAR 2017-2018
This curriculum vitae summarizes the education and professional experience of Dr. Casey E. Gooden. She received her B.S. from the University of South Florida in 2007 and her M.D. from the University of South Florida College of Medicine in 2010. She completed an anatomic and clinical pathology residency at Emory University from 2010-2014, where she served as chief resident in 2013-2014. She is currently a hematopathology clinical instructor at the University of Pittsburgh Medical Center. Her professional experiences include publications in peer-reviewed journals and presentations at pathology conferences.
Diagnostic hemoglobinopathies Second Editionfssherwani
This document provides an editorial board and list of contributors for a book on diagnostic hemoglobinopathies. It includes three chapters that discuss hemoglobin structure and function, red blood cell morphology, and various laboratory methods for diagnosing hemoglobinopathies such as electrophoresis, chromatography, and DNA analysis. The book aims to provide information on diagnostic techniques and case studies to aid in the diagnosis and management of hemoglobin disorders.
This document contains abstracts from research, innovations, and clinical vignettes presented at the 2011 Hospital Medicine annual meeting. The abstracts are divided into sections for research, innovations, and clinical vignettes. Some of the abstracts presented include evaluations of HIV screening practices, the safety of arthrocentesis for patients on warfarin therapy, incidence of venous thromboembolism in homebound patients, and an assessment of pain in patients undergoing bone marrow biopsies. The abstracts cover a wide range of topics in hospital medicine and include results from studies, innovations, and case reports.
The document provides guidance on taking a thorough history for a wound patient. It outlines topics to cover such as when the patient first noticed the wound, any changes over time, pain levels, previous medical history including conditions like diabetes that could impact healing, and current medications. Gathering details on the wound characteristics, healing process, and the patient's overall health is essential for determining the cause of the wound and developing an appropriate treatment plan.
Digestive system part 3 liver etc 2nd editionmostafa hegazy
This document provides information about the editors and contributors of "The Netter Collection of Medical Illustrations Digestive System: Part III—Liver, Biliary Tract, and Pancreas, Volume 9, Second Edition". It lists the editors, their backgrounds and areas of expertise. It also provides brief biographies of some of the contributing illustrators and acknowledges the publishing team.
The document provides guidelines from the Infectious Diseases Society of America (IDSA) for diagnosing and treating diabetic foot infections. Some key points:
1. Diabetic foot infections typically begin in wounds and are classified based on severity as mild, moderate, or severe to help determine treatment approach.
2. Most infections are polymicrobial but gram-positive cocci like staphylococci are common causes. Appropriate cultures should be taken from infected wounds.
3. Guidelines recommend evaluation of the patient, foot, and wound. Treatment may involve wound debridement, antibiotics, imaging, surgery, wound care, and addressing ischemia or biomechanical issues.
4. A multidis
This summary covers a set of lecture notes for internal medicine created for medical students at Weill Bugando School of Medicine. The notes were created to teach the basic concepts of internal medicine and cover major topic areas. They are focused on teaching clinical management algorithms and are intended to be used alongside textbooks. The notes include sections on history taking, physical examination, cardiology, renal medicine, gastroenterology, infectious diseases and other areas. The goal is to provide a useful guide for both students and faculty in teaching internal medicine essentials.
Dr. John Catanzaro is a naturopathic physician specializing in integrative oncology and personalized medicine. He received his ND from Bastyr University and has additional certifications in genetics and theology. He has owned several wellness clinics and founded non-profits focused on cancer research. Currently, he works as a physician consultant providing functional genetics testing and counseling.
Physician-assisted suicide is a controversial issue that is only legal in five U.S. states. It allows terminally ill patients with less than six months to live to request lethal medication from their doctor to end their own lives. While some see it as giving patients control at the end of life, others argue it could encourage suicide or that terminally ill patients are not in a mental state to make such a decision. There are also concerns about how to protect vulnerable patients from being coerced into suicide. The document discusses the various perspectives on this complex issue and argues rules need to be put in place to allow physician-assisted suicide as an option while also protecting doctors' and patients' rights.
The document provides an introduction to bioethics and outlines several key topics including informed consent, advance directives, medical futility, Do Not Resuscitate (DNR) orders, confidentiality, and research. It discusses the role of the Department of Bioethics in providing ethics consultations and summaries key policies and guidelines related to complex ethical issues that may arise in patient care.
1. This document provides guidelines for the diagnosis, management, and treatment of hepatitis C virus (HCV) infection based on a formal review of recent literature and expert consensus.
2. It recommends screening high-risk groups for HCV infection, including current and former injection drug users, those with HIV, and prior blood transfusion recipients.
3. It also provides guidance on counseling HCV-infected individuals, including advising them to avoid behaviors that may spread the virus and informing them that properly performed tattooing and piercing pose a very low risk of transmission.
This document summarizes common neonatal morbidities that can result from complications during pregnancy and delivery. It discusses how conditions like diabetes, hypertension, infection, and nutritional imbalances in the mother can negatively impact the health of the newborn. The summary provides management considerations for treating infants born with various medical issues and outlines how close collaboration between obstetric and neonatal clinicians is important for counseling families and ensuring the best outcomes for both mother and baby.
This document provides guidelines from the Infectious Diseases Society of America (IDSA) for the management of cryptococcal disease. A group of medical mycology experts reviewed and updated the previous 2000 IDSA guidelines. The guidelines discuss management of cryptococcal meningitis in three at-risk groups and make recommendations for other sites of infection. Key principles include induction therapy with fungicidal regimens followed by suppressive therapy, early recognition and treatment of increased intracranial pressure and immune reconstitution inflammatory syndrome, and use of lipid formulations of amphotericin B for patients with renal impairment. While cryptococcosis remains challenging, adherence to these guidelines can lead to successful management for most patients.
A database is a collection of related data, while a database management system (DBMS) is software that allows users to add, view and manage data in a database. DBMSes enable users to perform tasks like entering, sorting and querying data, and common database structures include flat-file databases with one table and relational databases with multiple related tables. Key aspects of working with databases involve creating tables to organize fields and records, using filters and forms to view and enter data, and querying the database using languages like SQL to search for specific records.
Endometrial cancer arises from the uterine lining and is the most common gynecologic cancer in the US. There are two subtypes - a low-risk subtype associated with increased estrogen exposure, and a high-risk subtype not associated with estrogen. Symptoms include abnormal uterine bleeding. Diagnosis involves endometrial biopsy or D&C to obtain tissue samples. Treatment depends on staging and may involve surgery, radiation therapy, and adjuvant therapies depending on risk factors.
This document provides an overview of Canvas basics for organizational users. It introduces Canvas as the university's new learning management system and outlines the session goals of becoming familiar with communication tools, adding users, assignments, calendars, and file organization. Key features like the instructor guide, student view, speedgrader, muting assignments, and Canvas resources are also highlighted. Navigation, logging in, and publishing course components are briefly covered.
La química orgánica estudia compuestos que contienen carbono. El carbono puede formar múltiples enlaces con otros átomos debido a sus 4 electrones de valencia, lo que le permite formar una gran variedad de moléculas orgánicas. Los compuestos orgánicos se encuentran de forma natural en plantas, animales y otros organismos vivos y cumplen funciones estructurales y metabólicas importantes. Algunos ejemplos importantes son los aminoácidos, proteínas, azúcares y grasas.
This document provides guidelines for the prevention of intravascular catheter-related infections. It was created by a working group representing various medical professional organizations. The guidelines provide evidence-based recommendations in major areas such as education and training of healthcare personnel, use of maximal sterile barrier precautions during catheter insertion, skin antisepsis using chlorhexidine, and performance improvement efforts such as implementing bundled strategies and reporting compliance benchmarks. The recommendations are categorized based on the strength of scientific evidence supporting them. The guidelines are intended to help reduce rates of catheter-related infections in both adult and pediatric patients.
This document provides information about Board Review from Medscape, which is a self-assessment tool for internal medicine physicians. It contains summaries of 15 topics in internal medicine, including cardiovascular medicine, dermatology, endocrinology, gastroenterology, hematology, immunology/allergy, infectious disease, interdisciplinary medicine, metabolism, nephrology, neurology, oncology, psychiatry, respiratory medicine, and rheumatology. Each topic section includes chapters on various diseases and conditions addressed in internal medicine. The document outlines the editorial board and provides publishing details.
Drug Resistant Tuberculosis. A Survival Guide For Clinicians. Ntc.08Raul Rojas
This document is a guidebook for clinicians on drug-resistant tuberculosis created by the Francis J. Curry National Tuberculosis Center and the California Department of Public Health. It was funded by the Centers for Disease Control and Prevention and provides information to help clinicians diagnose and treat cases of drug-resistant tuberculosis. The guidebook was updated from a previous first edition and contains contributions from tuberculosis experts from various health departments and research institutions.
This document provides clinical guidelines for the identification, evaluation, and treatment of overweight and obesity in adults. An expert panel was convened by the National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases to develop the guidelines based on a thorough review of scientific evidence. The guidelines examine the health risks of overweight and obesity and various treatment strategies, providing recommendations to help practitioners effectively assess and treat overweight and obese patients.
This document summarizes the implications of COVID-19 for preventing and treating thrombotic complications. It was endorsed by several thrombosis societies and signed by over 60 experts. The key points are:
1) COVID-19 infection is associated with a prothrombotic state and increased risk of thrombotic complications including pulmonary embolism, deep vein thrombosis, ischemic strokes and arterial thromboses.
2) Clinicians should consider prophylactic anticoagulation for hospitalized COVID-19 patients, especially those with elevated D-dimer or inflammatory markers or who are immobilized.
3) Patients with confirmed VTE or arterial events should receive full anticoagulation treatment. Long-term
This document summarizes a presentation by Magda Peck on women's health advocacy. It discusses leading causes of death for women in the US including heart disease and cancer. It also provides statistics on health conditions affecting US women such as obesity and smoking rates. The document reviews recommendations from reports on improving women's health research and access to preventive services. It discusses the importance of annual well-woman visits and expanded insurance coverage of women's healthcare under the Affordable Care Act. The presentation emphasizes the role of women in making health decisions and advocating for their own health and the health of others.
This document provides an overview and table of contents for a book titled "Better EHR Usability, workflow & cognitive support in electronic health records". The book contains 21 chapters focused on improving the usability, workflow and cognitive support of electronic health records. It discusses frameworks and tools for EHR usability assessment, EHR design guidelines, clinical decision support, and more. The book is supported by a federal grant from the Office of the National Coordinator for Health Information Technology.
The document provides an update on the upcoming SGIM annual meeting with the theme of "Resilience and Grit: Pursuing Organizational Change and Preventing Burnout." It discusses the keynote speaker, Vivian Lee, and her work on healthcare efficiency. It also previews various session topics at the meeting related to leadership, diversity, and engaging new and senior members. The president's column discusses two upcoming patient visits and considers the value of annual checkups. It also summarizes SGIM's Choosing Wisely recommendations around routine health checks.
Nih the evidence report on obesity causes of weight gain and helpful tips for...Prab Tumpati
NIH evidence report on obesity is a comprehensive review of obesity.
Please feel free to share this free, public domain information
Thank you.
W8MD Medical Weight Loss Centers
Transition from allopathic to integrated modelLouis Cady, MD
Dr. Cady presented this presentation at the World Link Medical seminar in Salt Lake City, UT on January 27 for the 2012 Medical Seminar Series - Mastering the Protocols for Optimization of Hormone Replacement Therapy, Part 1. It will be presented twice more for World Link Medical in 2012.
These guidelines from the American College of Rheumatology update their 2008 recommendations for treating rheumatoid arthritis with disease-modifying antirheumatic drugs and biologics. The updates provide guidance on indications for treatment, switching between medications, using biologics in high-risk patients, tuberculosis screening, and vaccination. The recommendations were developed by reviewing evidence and forming consensus opinions among experts in rheumatology clinical practice and research.
This document provides updated guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology for screening and early detection of cervical cancer. The guidelines are based on evidence reviews and input from multiple working groups and organizations. The new screening recommendations address age-appropriate screening strategies and the use of cytology and HPV testing.
Introduction to Robert F. Kennedy Jr. book available on Amazon. https://amzn.to/365aF8V
I created this PDF file of the intro to his book to give people a good idea what the book is about. I had no idea what I was getting into when I got the book. No people or person should be given as much power as Fauci, big pharma and big tech has.
Many thanks to Robert F Kennedy Jr for the time and effort he spent putting this together for the world to read.
Consumer and Connected Health: A New Day in Health and Healthcare?Bradford Hesse
Two competing worldviews, the mechanistic and humanistic, are leading to errors in healthcare. The mechanistic view focuses on technologies while the humanistic view focuses on people. The Institute of Medicine calls for a sociotechnical system that considers both. New decision architectures are needed that incorporate patients, providers, and data to improve quality of care.
Pediatric Hospital Medicine Top 10 (ish) 2014rdudas
The article "The survival time of chocolates on hospital wards: covert observational study" studied how long chocolates lasted on hospital wards before being eaten. Researchers covertly placed chocolates in hospital wards and recorded how long they remained. On average, chocolates lasted only 75 minutes before being consumed, with large variations based on ward type and time of day. The study highlights issues around food security and integrity on hospital wards.
The document is the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. It was published in 2003 by the National Heart, Lung, and Blood Institute and aimed to provide guidelines for preventing and managing high blood pressure. The report was developed by a committee of experts in hypertension and related fields and reviewed by additional experts. It outlines recommendations for classifying and staging hypertension, as well as treating and controlling high blood pressure.
This document presents guidelines from the American College of Rheumatology (ACR) and Vasculitis Foundation for the management of polyarteritis nodosa (PAN). It describes the methods used to develop 16 evidence-based recommendations and 1 ungraded statement for diagnosing and treating PAN. Most recommendations received a conditional grade due to the lack of high-quality evidence from randomized controlled trials. Key recommendations include early treatment of severe PAN with cyclophosphamide and glucocorticoids, limiting long-term exposure to these therapies to minimize toxicity, and using imaging and tissue biopsy for disease diagnosis.
This document provides updated guidelines for the treatment of sexually transmitted infections (STIs) from the Centers for Disease Control and Prevention (CDC). The guidelines were updated after expert consultation and review of recent literature. Key changes and additions include: 1) Updated treatment recommendations for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) Addition of metronidazole to recommended treatment for pelvic inflammatory disease; 3) Alternative treatment options for bacterial vaginosis; 4) Management guidance for Mycoplasma genitalium; 5) Expanded human papillomavirus vaccine recommendations and counseling messages; 6) Expanded risk factors for syphilis
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise stimulates the production of endorphins in the brain which elevate mood and reduce stress levels.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
Gender and Mental Health - Counselling and Family Therapy Applications and In...PsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...TechSoup
Whether you're new to SEO or looking to refine your existing strategies, this webinar will provide you with actionable insights and practical tips to elevate your nonprofit's online presence.
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إضغ بين إيديكم من أقوى الملازم التي صممتها
ملزمة تشريح الجهاز الهيكلي (نظري 3)
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تتميز هذهِ الملزمة بعِدة مُميزات :
1- مُترجمة ترجمة تُناسب جميع المستويات
2- تحتوي على 78 رسم توضيحي لكل كلمة موجودة بالملزمة (لكل كلمة !!!!)
#فهم_ماكو_درخ
3- دقة الكتابة والصور عالية جداً جداً جداً
4- هُنالك بعض المعلومات تم توضيحها بشكل تفصيلي جداً (تُعتبر لدى الطالب أو الطالبة بإنها معلومات مُبهمة ومع ذلك تم توضيح هذهِ المعلومات المُبهمة بشكل تفصيلي جداً
5- الملزمة تشرح نفسها ب نفسها بس تكلك تعال اقراني
6- تحتوي الملزمة في اول سلايد على خارطة تتضمن جميع تفرُعات معلومات الجهاز الهيكلي المذكورة في هذهِ الملزمة
واخيراً هذهِ الملزمة حلالٌ عليكم وإتمنى منكم إن تدعولي بالخير والصحة والعافية فقط
كل التوفيق زملائي وزميلاتي ، زميلكم محمد الذهبي 💊💊
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How Barcodes Can Be Leveraged Within Odoo 17Celine George
In this presentation, we will explore how barcodes can be leveraged within Odoo 17 to streamline our manufacturing processes. We will cover the configuration steps, how to utilize barcodes in different manufacturing scenarios, and the overall benefits of implementing this technology.
This presentation was provided by Racquel Jemison, Ph.D., Christina MacLaughlin, Ph.D., and Paulomi Majumder. Ph.D., all of the American Chemical Society, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
1. Guidelines for the Prevention of
Opportunistic Infections Among
HIV-Infected Persons – 2002
Recommendations of the U.S. Public Health Service
and the Infectious Diseases Society of America
June 14, 2002
2. Contents
Introduction .............................................................................................................................................. 1
Major Changes in These Recommendations ......................................................................................... 3
Using the Information in this Report ..................................................................................................... 3
Disease-specific Recommendations ............................................................................................................. 4
PCP .............................................................................................................................................. 4
Toxoplasmic Encephalitis...................................................................................................................... 5
Cryptosporidiosis................................................................................................................................... 7
Microsporidiosis .................................................................................................................................... 8
Tuberculosis .......................................................................................................................................... 8
Disseminated MAC Infection ................................................................................................................ 10
Bacterial Respiratory Infections ............................................................................................................ 11
Bacterial Enteric Infections ................................................................................................................... 13
Bartonellosis .......................................................................................................................................... 14
Candidiasis ............................................................................................................................................ 15
Cryptococcosis....................................................................................................................................... 15
Histoplasmosis....................................................................................................................................... 16
Coccidioidomycosis............................................................................................................................... 17
Cytomegalovirus Disease ...................................................................................................................... 17
Herpes Simplex Virus Disease .............................................................................................................. 19
Varicella Zoster Virus Disease .............................................................................................................. 19
HHV-8 Infection (Kaposi's Sarcoma-Associated Herpes Virus)........................................................... 20
Human Papillomavirus Infection ........................................................................................................... 20
HIV Infection......................................................................................................................................... 21
References .............................................................................................................................................. 23
Tables .............................................................................................................................................. 28
Appendix: Recommendations to Help Patients Avoid Exposure to or Infection
From Opportunistic Pathogens ................................................................................................... 46
Page ii
Guidelines for Preventing Opportunistic Infections Among HIV-Infected Persons - 2002
3. U.S. Public Health Service and Infectious Diseases Society of
America Prevention of Opportunistic Infections Working Group
Co-Chairs:
Henry Masur, M.D. National Institutes of Health, Bethesda, Maryland
Jonathan E. Kaplan, M.D. Centers for Disease Control and Prevention, Atlanta, Georgia
King K. Holmes, M.D., Ph.D. University of Washington, Seattle, Washington
Members:
Beverly Alston, M.D. National Institutes of Health, Bethesda, Maryland
Miriam J. Alter, Ph.D. Centers for Disease Control and Prevention, Atlanta, Georgia
Neil Ampel, M.D. University of Arizona, Tucson, Arizona
Jean R. Anderson, M.D. Johns Hopkins University, Baltimore, Maryland
A. Cornelius Baker Whitman Walker Clinic, Washington, D.C.
David Barr Forum for Collaborative HIV Research, Washington, D.C.
John G. Bartlett, M.D. Johns Hopkins University, Baltimore, Maryland
John E. Bennett, M.D. National Institutes of Health, Bethesda, Maryland
Constance A. Benson, M.D. University of Colorado, Denver, Colorado
William A. Bower, M.D. Centers for Disease Control and Prevention, Atlanta, Georgia
Samuel A. Bozzette, M.D. University of California, San Diego, California
John T. Brooks, M.D. Centers for Disease Control and Prevention, Atlanta, GA
Victoria A. Cargill, M.D. National Institutes of Health, Bethesda, Maryland
Kenneth G. Castro, M.D. Centers for Disease Control and Prevention, Atlanta, Georgia
Richard E. Chaisson, M.D. Johns Hopkins University, Baltimore, Maryland
David Cooper, M.D., DS.c. University of New South Wales, Sydney, Australia
Clyde S. Crumpacker, M.D. Beth Isreal - Deaconess Medical Center, Boston, Massachusetts
Judith S. Currier, M.D., M.Sc. University of California-Los Angeles Medical Center, Los Angeles, California
Kevin M. DeCock, M.D., DTM&H Centers for Disease Control and Prevention, Atlanta, Georgia
Lawrence Deyton, M.D., MSPH U.S. Department of Veterans Affairs, Washington, D.C.
Scott F. Dowell, M.D., MPH Centers for Disease Control and Prevention, Atlanta, Georgia
W. Lawrence Drew, M.D., Ph.D. Mt. Zion Medical Center, University of California, San Francisco, California
William R. Duncan, Ph.D. National Institutes of Health, Bethesda, Maryland
Mark S. Dworkin, M.D., MPHTM Centers for Disease Control and Prevention, Atlanta, Georgia
Clare Dykewicz, M.D., MPH Centers for Disease Control and Prevention, Atlanta, Georgia
Robert W. Eisinger, Ph.D. National Institutes of Health, Bethesda, Maryland
Tedd Ellerbrock, M.D. Centers for Disease Control and Prevention, Atlanta, Georgia
Wafaa El-Sadr, M.D., MPH, MPA. Harlem Hospital, New York, New York
Judith Feinberg, M.D. Holmes Hospital, Cincinnati, Ohio
Kenneth A. Freedberg, M.D., M.Sc. Massachusetts General Hospital, Boston, Massachusetts
Keiji Fukuda, MD Centers for Disease Control and Prevention, Atlanta, Georga
Hansjakob Furrer, M.D. University Hospital, Berne, Switzerland
Jose M. Gatell, M.D., Ph.D. Hospital Clinic, Barcelona, Spain
John W. Gnann, Jr., M.D. University of Alabama, Birmingham, Alabama
Mark J. Goldberger, M.D., MPH U.S. Food and Drug Administration, Rockville, Maryland
Sue Goldie, M.D., MPH Harvard School of Public Health, Boston, Massachusetts
Eric P. Goosby, M.D. U.S. Department of Health and Human Services, Washington, D.C.
Fred Gordin, M.D. Veterans Administration Medical Center, Washington, D.C.
Peter A. Gross, M.D. Hackensack Medical Center, Hackensack University, New Jersey
Rana Hajjeh, MD Centers for Disease Control and Prevention, Atlanta, Georgia
Richard Hafner, M.D. National Institutes of Health, Bethesda, Maryland
Diane Havlir, M.D. University of California, San Diego, California
Scott Holmberg, M.D., MPH Centers for Disease Control and Prevention, Atlanta, Georgia
David R. Holtgrave, Ph.D. Centers for Disease Control and Prevention, Atlanta, Georgia
Thomas M. Hooton, M.D. Harborview Medical Center, Seattle, Washington
Douglas A. Jabs, M.D., M.B.A. Johns Hopkins University, Baltimore, Maryland
Mark A. Jacobson, M.D. University of California, San Francisco, CA
Harold Jaffe, M.D. Centers for Disease Control and Prevention, Atlanta, Georgia
Edward Janoff, M.D. Veterans Administration Medical Center, Minneapolis, Minnesota
Page iii
Guidelines for Preventing Opportunistic Infections Among HIV-Infected Persons - 2002
4. Jeffrey Jones, MD Centers for Disease Control and Prevention, Atlanta, Georgia
Dennis D. Juranek, D.V.M, MS.c. Centers for Disease Control and Prevention, Atlanta, Georgia
Mari Kitahata, M.D., Ph.D. University of Washington, Seattle, Washington
Joseph A. Kovacs, M.D. National Institutes of Health, Bethesda, Maryland
Catherine Leport, M.D. Hospital Bichat-Claude Bernard, Paris, France
Myron J. Levin, M.D. University of Colorado Health Science Center, Denver, Colorado
Juan C. Lopez, M.D. Hospital Universatario Gregorio Maranon, Madrid, Spain
Jens Lundgren, M.D. Hvidore Hospital, Copenhagen, Denmark
Michael Marco Treatment Action Group, New York, New York
Eric Mast, M.D., MPH Centers for Disease Control and Prevention, Atlanta, Georgia
Douglas Mayers, M.D. Henry Ford Hospital, Detroit, Michigan
Lynne M. Mofenson, M.D. National Institutes of Health, Bethesda, Maryland
Julio S.G. Montaner, M.D. St. Paul's Hospital, Vancouver, Canada
Richard Moore, M.D. Johns Hopkins Hospital, Baltimore, Maryland
Thomas Navin, M.D. Centers for Disease Control and Prevention, Atlanta, Georgia
James Neaton, Ph.D. University of Minnesota, Minneapolis, Minnesota
Charles Nelson National Association of People with AIDS, Washington, D.C.
Joseph F. O'Neill, M.D., MS, MPH Health Resources and Services Administration, Rockville, Maryland
Joel Palefsky, M.D. University of California, San Francisco, California
Alice Pau, Pharm.D. National Institutes of Health, Bethesda, Maryland
Phil Pellett, Ph.D. Centers for Disease Control and Prevention, Atlanta, Georgia
John P. Phair, M.D. Northwestern University, Chicago, Illinois
Steve Piscitelli, Pharm.D. National Institutes of Health, Bethesda, Maryland
Michael A. Polis, M.D., MPH National Institutes of Health, Bethesda, Maryland
Thomas C. Quinn, M.D. Johns Hopkins Hospital, Baltimore, Maryland
William C. Reeves, M.D., MPH Centers for Disease Control and Prevention, Atlanta, Georgia
Peter Reiss, M.D., Ph.D. University of Amsterdam, The Netherlands
David Rimland, M.D. Veterans Administration Medical Center, Atlanta, Georgia
Anne Schuchat, M.D. Centers for Disease Control and Prevention, Atlanta, Georgia
Cynthia L. Sears, M.D. Johns Hopkins Hospital, Baltimore, Maryland
Leonard Seeff, M.D. National Institutes of Health, Bethesda, Maryland
Kent A. Sepkowitz, M.D. Memorial Sloan-Kettering Cancer Center, New York, New York
Kenneth E. Sherman, M.D., Ph.D. University of Cincinnati, Cincinnati, Ohio
Thomas G. Slama, M.D. National Foundation for Infectious Diseases, Indianapolis, Indiana
Elaine M. Sloand, M.D. National Institutes of Health, Bethesda, Maryland
Stephen A. Spector, M.D. University of California, La Jolla, California
John A. Stewart, M.D. Centers for Disease Control and Prevention, Atlanta, Georgia
David L. Thomas, M.D., MPH Johns Hopkins Hospital, Baltimore, Maryland
Timothy M. Uyeki, M.D., MPH Centers for Disease Control and Prevention, Atlanta, GA
Russell B. Van Dyke, M.D. Tulane School of Medicine, New Orleans, Louisiana
M. Elsa Villarino, M.D., MPH Centers for Disease Control and Prevention, Atlanta, Georgia
Anna Wald, M.D. University of Seattle, Seattle, Washington
D. Heather Watts, M.D. National Institutes of Health, Bethesda, Maryland
L. Joseph Wheat, M.D. Indiana University School of Medicine, Indianapolis, Indiana
Paige Williams, Ph.D. Harvard School of Public Health, Boston, Massachusetts
Thomas C. Wright, Jr., M.D. Columbia University College ofmPhysicians and Surgeons, New York, New York
Page iv
Guidelines for Preventing Opportunistic Infections Among HIV-Infected Persons - 2002
5. Recommendations and Reports 1
Guidelines for the Prevention of Opportunistic Infections
Among HIV-Infected Persons — 2002
Recommendations of the U.S. Public Health Service
and the Infectious Diseases Society of America*
Prepared by
Jonathan E. Kaplan, M.D.1
Henry Masur, M.D.2
King K. Holmes, M.D., Ph.D.3
1 Division of AIDS, STD, and TB Laboratory Research
National Center for Infectious Diseases
and Division of HIV/AIDS Prevention — Surveillance and Epidemiology
National Center for HIV, STD, and TB Prevention
2 National Institutes of Health
Bethesda, Maryland
3 University of Washington
Seattle, Washington
Summary
In 1995, the U.S. Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) developed guidelines for
preventing opportunistic infections (OIs) among persons infected with human immunodeficiency virus (HIV); these guidelines were
updated in 1997 and 1999. This fourth edition of the guidelines, made available on the Internet in 2001, is intended for
clinicians and other health-care providers who care for HIV-infected persons. The goal of these guidelines is to provide evidencebased
guidelines for preventing OIs among HIV-infected adults and adolescents, including pregnant women, and HIV-exposed or infected
children. Nineteen OIs, or groups of OIs, are addressed, and recommendations are included for preventing exposure to
opportunistic pathogens, preventing first episodes of disease by chemoprophylaxis or vaccination (primary prophylaxis), and
preventing disease recurrence (secondary prophylaxis). Major changes since the last edition of the guidelines include 1) updated
recommendations for discontinuing primary and secondary OI prophylaxis among persons whose CD4+ T lymphocyte counts have
increased in response to antiretroviral therapy; 2) emphasis on screening all HIV-infected persons for infection with hepatitis C
virus; 3) new information regarding transmission of human herpesvirus 8 infection; 4) new information regarding drug interactions,
chiefly related to rifamycins and antiretroviral drugs; and 5) revised recommendations for immunizing HIV-infected adults and
adolescents and HIV-exposed or infected children.
Introduction Annals of Internal Medicine (3,8), American Family Physician
(9,10), and Pediatrics (11); accompanying editorials have
In 1995, the U.S. Public Health Service (USPHS) and the
appeared in JAMA (12,13). Response to these guidelines (e.g.,
Infectious Diseases Society of America (IDSA) developed
a substantial number of requests for reprints, website contacts,
guidelines for preventing opportunistic infections (OIs) among
and observations from health-care providers) demonstrates that
persons infected with human immunodeficiency virus (HIV)
they have served as a valuable reference for HIV health-care
(1-3). These guidelines, which are intended for clinicians and
providers. Because the 1995, 1997, and 1999 guidelines
health-care providers and their HIV-infected patients, were
included ratings indicating the strength of each recommenda-
revised in 1997 (4) and again in 1999 (5), and have been pub-
tion and the quality of supporting evidence, readers have been
lished in MMWR (1,4,5), Clinical Infectious Diseases (2,6,7),
able to assess the relative importance of each recommendation.
Since acquired immunodeficiency syndrome (AIDS) was
* See inside front cover for list of working group members. first recognized 20 years ago, remarkable progress has been
made in improving the quality and duration of life for HIV-
infected persons in the industrialized world. During the first
The material in this report was prepared for publication by the National Center
for HIV, STD, and TB Prevention, Harold W. Jaffe, M.D., Acting Director,
decade of the epidemic, this improvement occurred because
the Division of HIV/AIDS Prevention — Surveillance and Epidemiology, of improved recognition of opportunistic disease processes,
Robert S. Janssen, M.D., Director; and the National Center for Infectious improved therapy for acute and chronic complications, and
Diseases, James M. Hughes, M.D., Director.
introduction of chemoprophylaxis against key opportunistic
6. 2 June 14, 2002
pathogens. The second decade of the epidemic has witnessed is unknown. Therefore, in this revision of the guidelines, in
extraordinary progress in developing highly active antiretroviral certain cases, ranges are provided for restarting primary or
therapies (HAART) as well as continuing progress in prevent secondary prophylaxis. For prophylaxis against Pneumocystis
ing and treating OIs. HAART has reduced the incidence of carinii pneumonia (PCP), the indicated threshold for restart
OIs and extended life substantially (14–16). HAART is the ing both primary and secondary prophylaxis is 200 cells/µL.
most effective approach to preventing OIs and should be con For all these recommendations, the Roman numeral ratings
sidered for all HIV-infected persons who qualify for such reflect the lack of data available to assist in making these
therapy (14–16). However, certain patients are not ready or decisions (Box).
able to take HAART, and others have tried HAART regimens During the development of these revised guidelines, work
but therapy failed. Such patients will benefit from prophy ing group members reviewed published manuscripts as well
laxis against OIs (15). In addition, prophylaxis against spe as abstracts and material presented at professional meetings.
cific OIs continues to provide survival benefits even among Periodic teleconferences were held to develop the revisions.
persons who are receiving HAART (15).
Clearly, since HAART was introduced in the United States BOX. System used to rate the strength of recommendations
in 1995, chemoprophylaxis for OIs need not be lifelong. and quality of supporting evidence
Antiretroviral therapy can restore immune function. The
period of susceptibility to opportunistic processes continues Rating Strength of recommendation
to be accurately indicated by CD4+ T lymphocyte counts for A Both strong evidence for efficacy and substan
patients who are receiving HAART. Thus, a strategy of stop tial clinical benefit support recommendation for
ping primary or secondary prophylaxis for certain patients use; should always be offered.
whose immunity has improved as a consequence of HAART B Moderate evidence for efficacy or strong evidence
is logical. Stopping prophylactic regimens can simplify treat for efficacy, but only limited clinical benefit, sup
ment, reduce toxicity and drug interactions, lower cost of care, ports recommendation for use; should usually
and potentially facilitate adherence to antiretroviral regimens. be offered.
In 1999, the USPHS/IDSA guidelines reported that stop C Evidence for efficacy is insufficient to support a
ping primary or secondary prophylaxis for certain pathogens recommendation for or against use, or evidence
was safe if HAART has led to an increase in CD4+ T lympho for efficacy might not outweigh adverse conse
cyte counts above specified threshold levels. Recommenda quences (e.g., drug toxicity, drug interactions)
tions were made for only those pathogens for which adequate or cost of the chemoprophylaxis or alternative
clinical data were available. Data generated since 1999 con approaches; use is optional.
tinue to support these recommendations and allow additional D Moderate evidence for lack of efficacy or for
recommendations to be made concerning the safety adverse outcome supports a recommendation
of stopping primary or secondary prophylaxis for other against use; should usually not be offered.
pathogens. E Good evidence for lack of efficacy or for adverse
For recommendations regarding discontinuing chemopro outcome supports a recommendation against use;
phylaxis, readers will note that criteria vary by such factors as should never be offered.
duration of CD4+ T lymphocyte count increase, and, in the
case of secondary prophylaxis, duration of treatment of the Rating Quality of evidence supporting the recommendation
initial episode of disease. These differences reflect the criteria I Evidence from >1 correctly randomized, con
used in specific studies. Therefore, certain inconsistencies in trolled trials.
the format of these criteria are unavoidable. II Evidence from >1 well-designed clinical trials
Although considerable data are now available concerning without randomization, from cohort or case-
discontinuing primary and secondary OI prophylaxis, essen controlled analytic studies (preferably from more
tially no data are available regarding restarting prophylaxis than one center), or from multiple time-series
when the CD4+ T lymphocyte count decreases again to levels studies, or dramatic results from uncontrolled
at which the patient is likely to again be at risk for OIs. For experiments.
primary prophylaxis, whether to use the same threshold at III Evidence from opinions of respected authorities
which prophylaxis can be stopped (derived from data in stud based on clinical experience, descriptive studies,
ies addressing prophylaxis discontinuation) or to use the thresh or reports of consulting committees.
old below which initial prophylaxis is recommended,
7. Recommendations and Reports 3
Major Changes in These Because of their length and complexity, tables in this report
Recommendations are grouped together and follow the references. Tables appear
Major changes in the guidelines since 1999 include the in the following order:
Table 1 Dosages for prophylaxis to prevent first episode
following:
of opportunistic disease among infected adults
• Higher level ratings have been provided for discontinu
ing primary prophylaxis for PCP and Mycobacterium and adolescents;
Table 2 Dosages for prophylaxis to prevent recurrence of
avium complex (MAC) when CD4+ T lymphocytes have
opportunistic disease among HIV-infected adults
increased to >200 cells/µL and >100 cells/µL, respectively,
for >3 months in response to HAART (AI), and a new and adolescents;
Table 3 Effects of food on drugs used to treat OIs;
recommendation to discontinue primary toxoplasmosis
Table 4 Effects of medications on drugs used to treat OIs;
prophylaxis has been provided when the CD4+ T lym
phocyte count has increased to >200 cells/µL for >3 Table 5 Effects of OI medications on drugs commonly
administered to HIV-infected persons;
months (AI).
Table 6 Adverse effects of drugs used to manage HIV
• Secondary PCP prophylaxis should be discontinued
among patients whose CD4+ T lymphocyte counts have infection;
Table 7 Dosages of drugs for preventing OIs for persons
increased to >200 cells/µL for >3 months as a consequence
with renal insufficiency;
of HAART (BII).
• Secondary prophylaxis for disseminated MAC can be Table 8 Costs of agents recommended for preventing OIs
among adults with HIV infection;
discontinued among patients with a sustained (e.g.,
Table 9 Immunologic categories for HIV-infected
>6-month) increase in CD4+ count to >100 cells/µL in
response to HAART, if they have completed 12 months children;
Table 10 Immunization schedule for HIV-infected
of MAC therapy and have no symptoms or signs attribut
children;
able to MAC (CIII).
• Secondary prophylaxis for toxoplasmosis and Table 11 Dosages for prophylaxis to prevent first episode
cryptococcosis can be discontinued among patients with of opportunistic disease among HIV-infected
infants and children;
a sustained increase in CD4+ counts (e.g. >6 months) to
>200 cells/µL and >100–200cells/µL respectively, in Table 12 Dosages for prophylaxis to prevent recurrence of
response to HAART, if they have completed their initial opportunistic disease among HIV-infected infants
and children; and
therapy and have no symptoms or signs attributable to
these pathogens (CIII). Table 13 Criteria for discontinuing and restarting OI
• The importance of screening all HIV-infected persons for prophylaxis for adult patients with HIV infection.
Recommendations advising patients how to prevent exposure
hepatitis C virus (HCV) is emphasized (BIII).
• Additional information concerning transmission of to opportunistic pathogens are also included in this report
human herpesvirus 8 infection (HHV-8) is provided. (Appendix).
This report is oriented toward preventing specific OIs among
• New information regarding drug interactions is provided,
chiefly related to rifamycins and antiretroviral drugs. HIV-infected persons in the United States and other industri
• Revised recommendations for vaccinating HIV-infected alized countries. Recommendations for using HAART, which
is designed to prevent immunologic deterioration, to restore
adults and HIV-exposed or infected children are provided.
immune function, and delay the need for certain chemopro
phylactic strategies described in this report, were originally
Using the Information in This Report published elsewhere (14) and are updated regularly (available
For each of the 19 diseases covered in this report, specific at http://www.hivatis.org) (16).
recommendations are provided that address 1) preventing Pamphlets related to preventing OIs can be
exposure to opportunistic pathogens, 2) preventing first epi obtained from the HIV/AIDS Treatment Information Service
sodes of disease, and 3) preventing disease recurrences. Rec (ATIS) by calling 800-448-0440, 301-519-0459 (inter
ommendations are rated by a revised version of the IDSA rating national), or 888-480-3739 (TTY). They also can be accessed
system (17). In this system, the letters A–E signify the strength on the CDC and ATIS websites at http://www.cdc.gov/hiv/
of the recommendation for or against a preventive measure, pubs/brochure.htm and http://www.hivatis.org, respectively.
and Roman numerals I–III indicate the quality of evidence
supporting the recommendation (Box).
8. 4 June 14, 2002
New data regarding preventing OIs among HIV-infected or reintroduction of TMP-SMZ at a reduced dose or frequency
persons are emerging, and randomized controlled trials (CIII); <70% of patients can tolerate such reinstitution of
addressing unresolved concerns related to OI prophylaxis are therapy (26).
ongoing. The OI Working Group reviews emerging data If TMP-SMZ cannot be tolerated, prophylactic regimens
routinely and updates the guidelines regularly. that can be recommended as alternatives include dapsone (BI),
(21) dapsone plus pyrimethamine plus leucovorin (BI) (29,30),
aerosolized pentamidine administered by the Respirgard II™
Disease-Specific Recommendations nebulizer (manufactured by Marquest, Englewood, Colorado)
(BI), (22) and atovaquone (BI) (31,32). Apparently,
PCP atovaquone is as effective as aerosolized pentamidine (31) or
dapsone (BI) (32) but is substantially more expensive than the
Preventing Exposure other regimens. For patients seropositive for Toxoplasma gondii
Although certain authorities might recommend that HIV- who cannot tolerate TMP-SMZ, recommended alternatives
infected persons who are at risk for PCP not share a hospital to TMP-SMZ for prophylaxis against both PCP and toxo
room with a patient who has PCP, data are insufficient to plasmosis include dapsone plus pyrimethamine (BI) (29,30)
support this recommendation as standard practice (CIII). or atovaquone with or without pyrimethamine (CIII). The
following regimens cannot be recommended as alternatives
Preventing Disease because data regarding their efficacy for PCP prophylaxis are
Initiating Primary Prophylaxis. HIV-infected adults and insufficient to do so:
adolescents, including pregnant women and those on HAART, • aerosolized pentamidine administered by other nebuliza
should receive chemoprophylaxis against PCP if they have a tion devices,
CD4+ T lymphocyte count of <200/µL (AI) or a history of • intermittently administered parenteral pentamidine,
oropharyngeal candidiasis (AII) (18–20). Persons who have a • oral pyrimethamine plus sulfadoxine,
CD4+ T lymphocyte percentage of <14% or a history of an • oral clindamycin plus primaquine, and
AIDS-defining illness, but do not otherwise qualify, should • intravenous trimetrexate.
be considered for prophylaxis (BII) (18–20). When monitor However, clinicians might consider using these agents in
ing CD4+ T lymphocyte counts for >3 months is not possible, unusual situations in which the recommended agents cannot
initiating chemoprophylaxis at a CD4+ T lymphocyte count be administered (CIII).
of >200, but <250 cells/µL, also should be considered (BII) Discontinuating Primary Prophylaxis. Primary
(19). pneumocystis prophylaxis should be discontinued for adult
Trimethoprim-sulfamethoxazole (TMP-SMZ) is the recom and adolescent patients who have responded to HAART with
mended prophylactic agent (AI) (20–23). One double-strength an increase in CD4+ T lymphocyte counts to >200 cells/µL
tablet daily is the preferred regimen (AI) (23). However, one for >3 months (AI). In observational and randomized studies
single-strength tablet daily (23) is also effective and might be supporting this recommendation, the majority of patients were
better tolerated than one double-strength tablet daily (AI). One taking antiretroviral regimens that included a protease inhibi
double-strength tablet three times weekly is also effective (BI) tor (PI), and the majority had a CD4+ T lymphocyte cell count
(24). TMP-SMZ at a dose of one double-strength tablet daily of >200 cells/µL for >3 months before discontinuing PCP
confers cross-protection against toxoplasmosis (25) and prophylaxis (33–41). The median CD4+ T lymphocyte count
selected common respiratory bacterial infections (21,26). at the time prophylaxis was discontinued was >300 cells/µL,
Lower doses of TMP-SMZ also might confer such protec and certain patients had a sustained suppression of HIV plasma
tion. For patients who have an adverse reaction that is not ribonucleic acid (RNA) levels below detection limits of the
life-threatening, treatment with TMP-SMZ should be con assay employed. Median follow-up ranged from 6 to 16
tinued if clinically feasible; for those who have discontinued months.
such therapy because of an adverse reaction, reinstituting TMP Discontinuing primary prophylaxis among these patients is
SMZ should be strongly considered after the adverse event recommended because, apparently, prophylaxis adds limited
has resolved (AII). Patients who have experienced adverse disease prevention (i.e., for PCP, toxoplasmosis, or bacterial
events, including fever and rash, might better tolerate reintro infections) and because discontinuing drugs reduces pill bur
duction of the drug with a gradual increase in dose (i.e., den, potential for drug toxicity, drug interactions, selection of
desensitization), according to published regimens (BI) (27,28) drug-resistant pathogens, and cost.
9. Recommendations and Reports 5
Restarting Primary Prophylaxis. Prophylaxis should be CD4+ T lymphocyte count thresholds (Table 11) (AII). The
reintroduced if the CD4+ T lymphocyte count decreases to safety of discontinuing prophylaxis among HIV-infected chil
<200 cells/µL (AIII). dren receiving HAART has not been studied extensively.
Children who have a history of PCP should be adminis
Preventing Recurrence
tered lifelong chemoprophylaxis to prevent recurrence (44)
Patients who have a history of PCP should be administered (AI). The safety of discontinuing secondary prophylaxis among
chemoprophylaxis for life (i.e., secondary prophylaxis or HIV-infected children has not been studied extensively.
chronic maintenance therapy) with the regimens listed (Table 2) Pregnant Women. Chemoprophylaxis for PCP should be
(AI), unless immune reconstitution occurs as a consequence administered to pregnant women as is done for other adults
of HAART (see the following recommendation). and adolescents (AIII). TMP-SMZ is the recommended pro
Discontinuing Secondary Prophylaxis (Chronic Main phylactic agent; dapsone is an alternative. Because of theoreti
tenance Therapy). Secondary prophylaxis should be discon cal concerns regarding possible teratogenicity associated with
tinued for adult and adolescent patients whose CD4+ T drug exposures during the first trimester, health-care provid
lymphocyte cell count has increased from <200 cells/µL to ers might choose to withhold prophylaxis during the first tri
>200 cells/µL for >3 months as a result of HAART (BII). mester. In such cases, aerosolized pentamidine can be
Reports from observational studies (37,41,42) and from a ran considered because of its lack of systemic absorption and the
domized trial (39), as well as a combined analysis of eight resultant lack of exposure of the developing embryo to the
European cohorts being followed prospectively (43), support drug (CIII).
this recommendation. In these studies, patients had responded
to HAART with an increase in CD4+ T lymphocyte counts to
>200 cells/µL for >3 months. The majority of patients were
Toxoplasmic Encephalitis
taking PI-containing regimens. The median CD4+ T lympho Preventing Exposure
cyte count at the time prophylaxis was discontinued was >300 HIV-infected persons should be tested for immunoglobu
cells/µL. The majority of patients had sustained suppression lin G (IgG) antibody to Toxoplasma soon after the diagnosis
of plasma HIV RNA levels below the detection limits of the of HIV infection to detect latent infection with T. gondii (BIII).
assay employed; the longest follow-up was 13 months. If the All HIV-infected persons, including those who lack IgG
episode of PCP occurred at a CD4+ T lymphocyte count of antibody to Toxoplasma, should be counseled regarding sources
>200 cells/µL, continuing PCP prophylaxis for life, regardless of toxoplasmic infection. They should be advised not to eat
of how high the CD4+ T lymphocyte count rises as a conse raw or undercooked meat, including undercooked lamb, beef,
quence of HAART, is probably prudent (CIII). pork, or venison (BIII). Specifically, lamb, beef, and pork
Discontinuing secondary prophylaxis for patients is recom should be cooked to an internal temperature of 165ºF–170ºF
mended because, apparently, prophylaxis adds limited disease (44,45); meat cooked until it is no longer pink inside usually
prevention (i.e., for PCP, toxoplasmosis, or bacterial infec has an internal temperature of 165ºF–170ºF and therefore,
tions) and because discontinuing drugs reduces pill burden, from a more practical perspective, satisfies this requirement.
potential for drug toxicity, drug interactions, selection of drug- HIV-infected persons should wash their hands after contact
resistant pathogens, and cost. with raw meat and after gardening or other contact with soil;
Restarting Secondary Prophylaxis. Prophylaxis should be in addition, they should wash fruits and vegetables well
reintroduced if the CD4+ T lymphocyte count decreases to before eating them raw (BIII). If the patient owns a cat, the
<200 cells/µL (AIII) or if PCP recurred at a CD4+ T lympho litter box should be changed daily, preferably by an HIV-
cyte count of >200 cells/µL (CIII). negative, nonpregnant person; alternatively, patients should
Special Considerations wash their hands thoroughly after changing the litter box (BIII).
Children. Children born to HIV-infected mothers should Patients should be encouraged to keep their cats inside and
be administered prophylaxis with TMP-SMZ beginning at not to adopt or handle stray cats (BIII). Cats should be fed
age 4–6 weeks (44) (AII). Prophylaxis should be discontinued only canned or dried commercial food or well-cooked table
for children who are subsequently determined not to be food, not raw or undercooked meats (BIII). Patients need not
infected with HIV. HIV-infected children and children whose be advised to part with their cats or to have their cats tested
infection status remains unknown should continue to receive for toxoplasmosis (EII).
prophylaxis for the first year of life. Need for subsequent pro
phylaxis should be determined on the basis of age-specific
10. 6 June 14, 2002
Preventing Disease Restarting Primary Prophylaxis. Prophylaxis should be
Initiating Primary Prophylaxis. Toxoplasma-seropositive reintroduced if the CD4+ T lymphocyte count decreases to
patients who have a CD4+ T lymphocyte count of <100/µL <100–200 cells/µL (AIII).
should be administered prophylaxis against toxoplasmic
Preventing Recurrence
encephalitis (TE) (AII) (25). Apparently, the double-strength
Patients who have completed initial therapy for TE should
tablet daily dose of TMP-SMZ recommended as the preferred
be administered lifelong suppressive therapy (i.e., secondary
regimen for PCP prophylaxis is effective against TE as well
prophylaxis or chronic maintenance therapy) (AI) (48,49)
and is therefore recommended (AII) (25). If patients cannot
unless immune reconstitution occurs as a consequence of
tolerate TMP-SMZ, the recommended alternative is dapsone-
HAART (see the following recommendation). The combina
pyrimethamine, which is also effective against PCP (BI)
tion of pyrimethamine plus sulfadiazine plus leucovorin is
(29,30). Atovaquone with or without pyrimethamine also can
highly effective for this purpose (AI). A commonly used regi
be considered (CIII). Prophylactic monotherapy with dap
men for patients who cannot tolerate sulfa drugs is
sone, pyrimethamine, azithromycin, or clarithromycin can
pyrimethamine plus clindamycin (BI); however, apparently,
not be recommended on the basis of available data (DII).
only the combination of pyrimethamine plus sulfadiazine
Aerosolized pentamidine does not protect against TE and is
provides protection against PCP as well (AII).
not recommended (EI) (21,25).
Discontinuing Secondary Prophylaxis (Chronic Main
Toxoplasma-seronegative persons who are not taking a PCP
tenance Therapy). Adult and adolescent patients receiving
prophylactic regimen known to be active against TE should
secondary prophylaxis (i.e., chronic maintenance therapy) for
be retested for IgG antibody to Toxoplasma when their CD4+
TE are, apparently, at low risk for recurrence of TE when they
T lymphocyte counts decline to <100/µL to determine whether
have successfully completed initial therapy for TE, remain
they have seroconverted and are therefore at risk for TE (CIII).
asymptomatic with regard to signs and symptoms of TE, and
Patients who have seroconverted should be administered pro
have a sustained increase in their CD4+ T lymphocyte counts
phylaxis for TE as described previously (AII).
of >200 cells/µL after HAART (e.g., >6 months) (41,42,47).
Discontinuing Primary Prophylaxis. Prophylaxis against
Although the numbers of patients who have been evaluated
TE should be discontinued among adult and adolescent
remain limited and occasional recurrences have been reported,
patients who have responded to HAART with an increase in
on the basis of these observations and inference from more
CD4+ T lymphocyte counts to >200 cells/µL for >3 months
extensive cumulative data indicating the safety of discontinu
(AI). Multiple observational studies (37,41,46) and two ran
ing secondary prophylaxis for other OIs during advanced HIV
domized trials (38,47) have reported that primary prophy
disease, discontinuing chronic maintenance therapy among
laxis can be discontinued with minimal risk for experiencing
such patients is a reasonable consideration (CIII). Certain
TE among patients who have responded to HAART with an
specialists would obtain a magnetic resonance image of
increase in CD4+ T lymphocyte count from <200 cells/µL to
the brain as part of their evaluation to determine whether
>200 cells/µL for >3 months. In these studies, the majority of
discontinuing therapy is appropriate.
patients were taking PI-containing regimens and the median
Restarting Secondary Prophylaxis. Secondary prophylaxis
CD4+ T lymphocyte count at the time prophylaxis was dis
(chronic maintenance therapy) should be reintroduced if the
continued was >300 cells/µL. At the time prophylaxis was dis
CD4+ T lymphocyte count decreases to <200 cells/µL (AIII).
continued, certain patients had sustained suppression of plasma
HIV RNA levels below the detection limits of available Special Considerations
assays; the median follow-up ranged from 7 to 22 months. Children. TMP-SMZ, when administered for PCP pro
Although patients with CD4+ T lymphocyte counts of <100 phylaxis, also provides prophylaxis against toxoplasmosis.
cells/µL are at greatest risk for experiencing TE, the risk for Atovaquone might also provide protection (CIII). Children
TE occurring when the CD4 + T lymphocyte count has aged >12 months who qualify for PCP prophylaxis and who
increased to 100–200 cells/µL has not been studied as rigor are receiving an agent other than TMP-SMZ or atovaquone
ously as an increase to >200 cells/µL. Thus, the recommenda should have serologic testing for Toxoplasma antibody (BIII)
tion specifies discontinuing prophylaxis after an increase to because alternative drugs for PCP prophylaxis might not be
>200 cells/µL. Discontinuing primary TE prophylaxis is rec effective against Toxoplasma. Severely immunosuppressed chil
ommended because prophylaxis apparently adds limited dis dren who are not receiving TMP-SMZ or atovaquone who
ease prevention for toxoplasmosis and because discontinuing are determined to be seropositive for Toxoplasma should be
drugs reduces pill burden, potential for drug toxicity, drug administered prophylaxis for both PCP and toxoplasmosis (i.e.,
interaction, selection of drug-resistant pathogens, and cost.
11. Recommendations and Reports 7
dapsone plus pyrimethamine) (BIII). Children with a history HIV-infected persons who wish to assume the limited risk for
of toxoplasmosis should be administered lifelong prophylaxis acquiring a puppy or kitten aged <6 months should request
to prevent recurrence (AI). The safety of discontinuing that their veterinarian examine the animal’s stool for
primary or secondary prophylaxis among HIV-infected chil Cryptosporidium before they have contact with the animal
dren receiving HAART has not been studied extensively. (BIII). HIV-infected persons should avoid exposure to calves
Pregnant Women. TMP-SMZ can be administered for pro and lambs and to premises where these animals are raised (BII).
phylaxis against TE as described for PCP (AIII). However, HIV-infected persons should not drink water directly from
because of the low incidence of TE during pregnancy and the lakes or rivers (AIII). Waterborne infection also might result
possible risk associated with pyrimethamine treatment, chemo from swallowing water during recreational activities. HIV-
prophylaxis with pyrimethamine-containing regimens can rea infected persons should be aware that lakes, rivers, and salt
sonably be deferred until after pregnancy (CIII). For water beaches and certain swimming pools, recreational water
prophylaxis against recurrent TE, health-care providers and parks, and ornamental water fountains might be contaminated
clinicians should be well-informed regarding benefits of life with human or animal waste that contains Cryptosporidium.
long therapy and concerns related to teratogenicity of They should avoid swimming in water that is likely to be
pyrimethamine. Guidelines provided previously should be used contaminated and should avoid swallowing water while
when making decisions regarding secondary prophylaxis for swimming or playing in recreational waters (BIII).
TE during pregnancy. Outbreaks of cryptosporidiosis have been linked to munici
In rare cases, HIV-infected pregnant women who have pal water supplies. During outbreaks or in other situations in
serologic evidence of remote toxoplasmic infection have trans which a community advisory to boil water is issued, boiling
mitted Toxoplasma to the fetus in utero. Pregnant HIV-infected water for 1 minute will eliminate the risk for cryptosporidiosis
women who have evidence of primary toxoplasmic infection (AI). Using submicron personal-use water filters† (home/
or active toxoplasmosis, including TE, should be evaluated office types) or bottled water§ also might reduce the risk (CIII).
and managed during pregnancy in consultation with appro The magnitude of the risk for acquiring cryptosporidiosis from
priate specialists (BIII). Infants born to women who have drinking water in a nonoutbreak setting is uncertain, and avail
serologic evidence of infections with HIV and Toxoplasma able data are inadequate to recommend that all HIV-infected
should be evaluated for congenital toxoplasmosis (BIII). persons boil water or avoid drinking tap water in nonoutbreak
settings. However, HIV-infected persons who wish to take
Cryptosporidiosis independent action to reduce the risk for waterborne
cryptosporidiosis might choose to take precautions similar to
Preventing Exposure those recommended during outbreaks. Such decisions should
HIV-infected persons should be educated and counseled be made in conjunction with health-care providers. Persons
concerning the different ways that Cryptosporidium can be who opt for a personal-use filter or bottled water should be
transmitted (BIII). Modes of transmission include having aware of the complexities involved in selecting appropriate
direct contact with infected adults, diaper-aged children, and
infected animals; drinking contaminated water; coming into
contact with contaminated water during recreational activi †
Only filters capable of removing particles 1 µm in diameter should be
ties; and eating contaminated food. considered. Filters that provide the greatest assurance of oocyst removal include
those that operate by reverse osmosis, those labeled as absolute 1-µm filters,
HIV-infected persons should avoid contact with human and and those labeled as meeting NSF (National Sanitation Foundation) Standard
animal feces. They should be advised to wash their hands after No. 53 for cyst removal. The nominal 1-µm filter rating is not standardized,
contact with human feces (e.g., diaper changing), after and filters in this category might not be capable of removing 99% of oocysts.
For a list of filters certified as meeting NSF standards, consult the International
handling pets, and after gardening or other contact with soil. Consumer Line at 800-673-8010 or http://www.nsf.org/notice/crypto.html.
HIV-infected persons should avoid sexual practices that might §
Sources of bottled water (e.g., wells, springs, municipal tap-water supplies,
result in oral exposure to feces (e.g., oral-anal contact) (BIII). rivers, and lakes) and methods for its disinfection differ; therefore, all brands
should not be presumed to be cryptosporidial oocyst-free. Water from wells
HIV-infected persons should be advised that newborn and and springs is much less likely to be contaminated by oocysts than water from
young pets might pose a limited risk for transmitting rivers or lakes. Treatment of bottled water by distillation or reverse osmosis
cryptosporidial infection, but they should not be advised to ensures oocyst removal. Water passed through an absolute 1-µm filter or a
filter labeled as meeting NSF Standard No. 53 for cyst removal before bottling
destroy or give away healthy pets. Persons contemplating will provide approximately the same level of protection. Using nominal 1-µm
acquiring a new pet should avoid bringing any animal that filters by bottlers as the only barrier to Cryptosporidia might not result in the
removal of 99% of oocysts. For more information, the International Bottled
has diarrhea into their households, should avoid purchasing a Water Association can be contacted at 703-683-5213 or at http://www.bottled
dog or cat aged <6 months, and should not adopt stray pets. water.org.
12. 8 June 14, 2002
products, the lack of enforceable standards for the destruc Preventing Recurrence
tion or removal of oocysts, costs of the products, and the No drug regimens are known to be effective in preventing
logistic difficulty of using these products consistently. the recurrence of cryptosporidiosis.
Patients who take precautions to avoid acquiring
cryptosporidiosis from drinking water should be advised that Special Considerations
ice made from contaminated tap water also can be a source of Children. No data indicate that formula-preparation prac
infection (BII). Such persons also should be aware that foun tices for infants should be altered to prevent cryptosporidiosis
tain beverages served in restaurants, bars, theaters, and other (CIII). However, in the event of a boil-water advisory, similar
places also might pose a risk because these beverages, as well precautions for preparing infant formula should be taken as
as the ice they contain, are made from tap water. Nationally for drinking water for adults (AII).
distributed brands of bottled or canned carbonated soft drinks
are safe to drink. Commercially packaged noncarbonated soft Microsporidiosis
drinks and fruit juices that do not require refrigeration until
after they are opened (i.e., those that can be stored Preventing Exposure
unrefrigerated on grocery shelves) also are safe. Nationally dis Other than general attention to hand-washing and other
tributed brands of frozen fruit juice concentrate are safe if personal hygiene measures, no precautions to reduce expo
they are reconstituted by the user with water from a safe source. sure can be recommended.
Fruit juices that must be kept refrigerated from the time they Preventing Disease
are processed to the time of consumption might be either fresh
No chemoprophylactic regimens are known to be effective
(i.e., unpasteurized) or heat-treated (i.e., pasteurized); only
in preventing microsporidiosis.
those juices labeled as pasteurized should be considered free
of risk from Cryptosporidium. Other pasteurized beverages and Preventing Recurrence
beers also are considered safe to drink (BII). No data are avail No chemotherapeutic regimens are known to be effective in
able concerning survival of Cryptosporidium oocysts in wine. preventing recurrence of microsporidiosis.
HIV-infected persons should avoid eating raw oysters
because cryptosporidial oocysts can survive in oysters for >2 Tuberculosis
months and have been found in oysters taken from certain
commercial oyster beds (BIII). Cryptosporidium-infected Preventing Exposure
patients should not work as food handlers, including if the HIV-infected persons should be advised that certain activi
food to be handled is intended to be eaten without cooking ties and occupations might increase the likelihood of expo
(BII). Because the majority of foodborne outbreaks of sure to tuberculosis (TB) (BIII). These include volunteer work
cryptosporidiosis are believed to have been caused by infected or employment in health-care facilities, correctional institu
food handlers, more specific recommendations to avoid tions, and shelters for the homeless, as well as in other settings
exposure to contaminated food cannot be made. identified as high-risk by local health authorities. Decisions
In a hospital, standard precautions (i.e., use of gloves and concerning whether to continue with activities in these set
hand-washing after removal of gloves) should be sufficient to tings should be made in conjunction with the health-care pro
prevent transmission of cryptosporidiosis from an infected vider and should be based on such factors as the patient’s
patient to a susceptible HIV-infected person (BII). However, specific duties in the workplace, prevalence of TB in the com
because of the potential for fomite transmission, certain spe munity, and the degree to which precautions are taken to pre
cialists recommend that HIV-infected persons, specifically vent TB transmission in the workplace (BIII). Whether the
those who are severely immunocompromised, should not share patient continues with such activities might affect the frequency
a room with a patient with cryptosporidiosis (CIII). with which screening for TB needs to be conducted.
Preventing Disease Preventing Disease
Rifabutin or clarithromycin, when taken for MAC prophy When HIV infection is first recognized, the patient should
laxis, have been found to protect against cryptosporidiosis receive a tuberculin skin test (TST) by administration of
(50,51). However, data are insufficient to warrant a recom intermediate-strength (5-TU) purified protein derivative
mendation for using these drugs as chemoprophylaxis for (PPD) by the Mantoux method (AI). Routine evaluation for
cryptosporidiosis. anergy is not recommended. However, situations exist in which
13. Recommendations and Report 9
anergy evaluation might assist in guiding decisions concern this group has not been demonstrated. Decisions concerning
ing preventive therapy (52,53). using chemoprophylaxis in these situations must be consid
All HIV-infected persons who have a positive TST result ered individually.
(>5 mm of induration) should undergo chest radiography and Although the reliability of TST might diminish as the CD4+
clinical evaluation to rule out active TB. HIV-infected per T lymphocyte count declines, annual repeat testing should be
sons who have symptoms indicating TB should promptly considered for HIV-infected persons who are TST-negative
undergo chest radiography and clinical evaluation regardless on initial evaluation and who belong to populations in which
of their TST status (AII). a substantial risk for exposure to M. tuberculosis exists (BIII).
All HIV-infected persons, regardless of age, who have a posi Clinicians should consider repeating TST for persons whose
tive TST result but have no evidence of active TB and no initial skin test was negative and whose immune function has
history of treatment for active or latent TB should be treated improved in response to HAART (i.e., those whose CD4+ T
for latent TB infection. Options include isoniazid daily (AII) lymphocyte count has increased to >200 cells/µL) (BIII) (52).
or twice weekly (BII) for 9 months; 4 months of therapy daily In addition to confirming TB infection, TST conversion in
with either rifampin (BIII) or rifabutin (CIII); or 2 months of an HIV-infected person should alert health-care providers to
therapy with either rifampin and pyrazinamide (BI) or the possibility of recent M. tuberculosis transmission and should
rifabutin and pyrazinamide (CIII) (52–54). Reports exist of prompt notification of public health officials for investiga
fatal and severe liver injury associated with treatment of latent tion to identify a possible source case. Administering bacille
TB infection among HIV-uninfected persons treated with the Calmette-Guérin (BCG) vaccine to HIV-infected persons is
2-month regimen of daily rifampin and pyrazinamide; there contraindicated because of its potential to cause disseminated
fore, using regimens that do not contain pyrazinamide among disease (EII).
HIV-infected persons whose completion of treatment can be
Preventing Recurrence
ensured is prudent (55). Because HIV-infected persons are at
risk for peripheral neuropathy, those receiving isoniazid should Chronic suppressive therapy for a patient who has success
also receive pyridoxine (BIII). Decisions to use a regimen con fully completed a recommended regimen of treatment for TB
taining either rifampin or rifabutin should be made after care is unnecessary (DII).
fully considering potential drug interactions, including those Special Considerations
related to PIs and nonnucleoside reverse transcriptase inhibi Drug Interactions. Rifampin can induce metabolism of all
tors (NNRTIs) (see the following section on Drug Interac PIs and NNRTIs. This can result in more rapid drug clear
tions). Directly observed therapy should be used with ance and possibly subtherapeutic drug concentrations of the
intermittent dosing regimens (AI) and when otherwise opera majority of these antiretroviral agents. Rifampin should not
tionally feasible (BIII) (53). be coadministered with the following PIs and NNRTIs:
HIV-infected persons who are close contacts of persons who amprenavir, indinavir, lopinavir/ritonavir, nelfinavir,
have infectious TB should be treated for latent TB infection, saquinavir, and delavirdine (54). However, it can be used with
regardless of their TST results, age, or prior courses of treat ritonavir, ritonavir plus saquinavir, efavirenz, and possibly with
ment, after a diagnosis of active TB has been excluded (AII) nevirapine. Rifabutin is an acceptable alternative to rifampin
(52–54). In addition to household contacts, such persons but should not be used with the PI hard-gel saquinavir or
might also include contacts in the same drug-treatment or delavirdine; caution is advised if the drug is coadministered
health-care facility, coworkers, and other contacts if transmis with soft-gel saquinavir because data are limited. Rifabutin
sion of TB is demonstrated. can be administered at one half the usual daily dose (i.e.,
For persons exposed to isoniazid- or rifampin-resistant TB, reduce from 300 mg to 150 mg/day) with indinavir, nelfinavir,
decisions to use chemoprophylactic antimycobacterial agents or amprenavir or with one fourth the usual dose (i.e., 150 mg
other than isoniazid alone, rifampin or rifabutin alone, every other day or three times a week), with ritonavir, ritonavir
rifampin plus pyrazinamide, or rifabutin plus pyrazinamide plus saquinavir, or lopinavir/ritonavir. When rifabutin is
should be based on the relative risk for exposure to resistant administered with indinavir as a single PI, the dose of indinavir
organisms and should be made in consultation with public should be increased from 800 mg/8 hours to 1,000 mg/8 hours.
health authorities (AII). TST-negative, HIV-infected persons Pharmacokinetic data indicate that rifabutin at an increased
from groups at risk or geographic areas with a high prevalence dose can be administered with efavirenz; doses of 450–600
of M. tuberculosis infection might be at increased risk for pri mg/day have been recommended (54). However, available
mary or reactivation TB. However, efficacy of treatment among information is limited concerning appropriate dosing if a PI
14. 10 June 14, 2002
is used concurrently with efavirenz and rifabutin; with such a than either drug alone; this combination should not be used
combination, the rifabutin dose might need to be reduced. (EI) (59). The combination of azithromycin with rifabutin is
Rifabutin can be used without dose adjustment with more effective than azithromycin alone; however, the addi
nevirapine. tional cost, increased occurrence of adverse effects, potential
Children. Infants born to HIV-infected mothers should have for drug interactions, and absence of a difference in survival
a TST (5-TU PPD) at or before age 9–12 months, and the when compared with azithromycin alone do not warrant a
infants should be retested >1 times/year (AIII). HIV-infected routine recommendation for this regimen (CI) (59). In addi
children living in households with TST-positive persons should tion to their preventive activity for MAC disease,
be evaluated for TB (AIII); children exposed to a person who clarithromycin and azithromycin each confer protection
has active TB should be administered preventive therapy after against respiratory bacterial infections (BII). If clarithromycin
active TB has been excluded, regardless of their TST results or azithromycin cannot be tolerated, rifabutin is an alterna
(AII). tive prophylactic agent for MAC disease, although rifabutin
Pregnant Women. Chemoprophylaxis for TB is recom associated drug interactions make this agent difficult to use
mended during pregnancy for HIV-infected patients who have (BI) (54). Tolerance, cost, and drug interactions are among
either a positive TST or a history of exposure to active TB, the concerns that should be considered in decisions regarding
after active TB has been excluded (AIII). A chest radiograph the choice of prophylactic agents for MAC disease. Particular
should be obtained before treatment and appropriate abdomi attention to interactions with antiretroviral PIs and NNRTIs
nal or pelvic lead apron shields should be used to minimize is warranted (see the following section on Drug Interactions).
radiation exposure to the embryo or fetus. When an HIV- Before prophylaxis is initiated, disseminated MAC disease
infected person has not been exposed to drug-resistant TB, should be ruled out by clinical assessment, which might
isoniazid daily or twice weekly is the prophylactic regimen of include obtaining a blood culture for MAC if warranted.
choice. Because of concerns regarding possible teratogenicity Because treatment with rifabutin could result in rifampin
associated with drug exposures during the first trimester, resistance among persons who have active TB, active TB should
health-care providers might choose to initiate prophylaxis also be excluded before rifabutin is used for prophylaxis.
after the first trimester. Preventive therapy with isoniazid Although detecting MAC organisms in the respiratory or
should be accompanied by pyridoxine to reduce the risk for gastrointestinal tract might predict disseminated MAC infec
neurotoxicity. Experience with rifampin or rifabutin during tion, no data are available regarding efficacy of prophylaxis
pregnancy is more limited, but anecdotal information with with clarithromycin, azithromycin, rifabutin, or other drugs
rifampin has not been associated with adverse pregnancy out among patients with MAC organisms at these sites and a nega
comes. Pyrazinamide should usually be avoided, chiefly in the tive blood culture. Therefore, routine screening of respiratory
first trimester, because of lack of information concerning fetal or gastrointestinal specimens for MAC cannot be recom
effects. mended (DIII).
Discontinuing Primary Prophylaxis. Primary MAC pro
Disseminated MAC Infection phylaxis should be discontinued among adult and adolescent
patients who have responded to HAART with an increase in
Preventing Exposure CD4+ T lymphocyte counts to >100 cells/µL for >3 months
Organisms of MAC are common in environmental sources (AI). Two substantial randomized, placebo controlled trials
(e.g., food and water). Available information does not sup and observational data have demonstrated that such patients
port specific recommendations regarding exposure avoidance. can discontinue primary prophylaxis with minimal risk for
experiencing MAC (37,60–62). Discontinuing primary pro
Preventing Disease phylaxis among patients meeting these criteria is recommended
Initiating Primary Prophylaxis. Adults and adolescents because, apparently, prophylaxis adds limited disease preven
who have HIV infection should receive chemoprophylaxis tion for MAC or for bacterial infections and because discon
against disseminated MAC disease if they have a CD4+ T lym tinuing drugs reduces pill burden, potential for drug toxicity,
phocyte count of <50 cells/µL (AI) (56). Clarithromycin drug interactions, selection of drug-resistant pathogens, and
(57,58) or azithromycin (59) are the preferred prophylactic cost.
agents (AI). The combination of clarithromycin and rifabutin Restarting Primary Prophylaxis. Primary prophylaxis
is no more effective than clarithromycin alone for chemopro should be reintroduced if the CD4+ T lymphocyte count
phylaxis and is associated with a higher rate of adverse effects decreases to <50–100 cells/µL (AIII).
15. Recommendations and Reports 11
Preventing Recurrence reduced because of this interaction. Azithromycin pharmaco
Adult and adolescent patients with disseminated MAC kinetics are not affected by the cytochrome P450 (CYP450)
should receive lifelong therapy (i.e., secondary prophylaxis or system; azithromycin can be used safely in the presence of PIs
maintenance therapy) (AII), unless immune reconstitution or NNRTIs without concerns of drug interactions.
occurs as a consequence of HAART (see the following recom Children. HIV-infected children aged <13 years who have
mendation). Unless substantial clinical or laboratory evidence advanced immunosuppression also can experience dissemi
of macrolide resistance exists, using a macrolide (i.e., nated MAC infections, and prophylaxis should be offered to
clarithromycin or, alternatively, azithromycin) is recommended children at high risk according to the following CD4+ T
in combination with ethambutol (AII) with or without lymphocyte thresholds:
rifabutin (CI) (63,64). Treatment of MAC disease with • children aged >6 years, <50 cells/µL;
clarithromycin in a dose of 1,000 mg twice/day is associated • children aged 2–6 years, <75 cells/µL;
with a higher mortality rate than has been observed with • children aged 1–2 years, <500 cells/µL; and
clarithromycin administered at 500 mg twice/day; thus, the • children aged <12 months, <750 cells/µL (AII).
higher dose should not be used (EI) (65,66). Clofazimine has For the same reasons that clarithromycin and azithromycin
been associated with adverse clinical outcomes in the treat are the preferred prophylactic agents for adults, they should
ment of MAC disease and should not be used (DII) (67). also be considered for children (AII); oral suspensions of both
Discontinuing Secondary Prophylaxis (Chronic Main agents are commercially available in the United States. No
tenance Therapy). Apparently, patients are at low risk for liquid formulation of rifabutin suitable for pediatric use is
recurrence of MAC when they have completed a course of commercially available in the United States. Children with a
>12 months of treatment for MAC, remain asymptomatic with history of disseminated MAC should be administered lifelong
respect to MAC signs and symptoms, and have a sustained prophylaxis to prevent recurrence (AII). The safety of discon
increase (e.g., >6 months), in their CD4+ T lymphocyte counts tinuing MAC prophylaxis among children whose CD4+ T lym
to >100cells/µL after HAART. Although the numbers of phocyte counts have increased in response to HAART has not
patients who have been evaluated remain limited and recur been studied.
rences could occur (41,42,68–70), on the basis of these obser Pregnant Women. Chemoprophylaxis for MAC disease
vations and on inference from more extensive data indicating should be administered to pregnant women as is done for other
the safety of discontinuing secondary prophylaxis for other adults and adolescents (AIII). However, because of concerns
OIs during advanced HIV disease, discontinuing chronic related to administering drugs during the first trimester of
maintenance therapy among such patients is reasonable (CIII). pregnancy, certain health-care providers might choose to with
Certain specialists recommend obtaining a blood culture for hold prophylaxis during the first trimester. Animal studies and
MAC, even for asymptomatic patients, before discontinuing anecdotal evidence of safety among humans indicate that, of
therapy to substantiate that disease is no longer active. the available agents, azithromycin is the drug of choice (BIII)
Restarting Secondary Prophylaxis. Secondary prophylaxis (71). Experience with rifabutin is limited. Clarithromycin has
should be reintroduced if the CD4+ T lymphocyte count been demonstrated to be a teratogen among animals and should
decreases to <100 cells/µL (AIII). be used with caution during pregnancy (72). For secondary
prophylaxis (chronic maintenance therapy), azithromycin plus
Special Considerations ethambutol are the preferred drugs (BIII) (71).
Drug Interactions. Rifabutin should not be administered
to patients receiving certain PIs and NNRTIs because the com
Bacterial Respiratory Infections
plex interactions have been incompletely studied, and the clini
cal implications of those interactions are unclear (16,54) (see Preventing Exposure
Drug Interactions in the Tuberculosis section). PIs can increase Because Streptococcus pneumoniae and Haemophilus
clarithromycin levels, but no recommendation to adjust the influenzae are common in the community, no effective way
dose of either clarithromycin or PIs can be made on the basis exists to reduce exposure to these bacteria.
of existing data. Efavirenz can induce metabolism of
clarithromycin. This can result in reduced serum concentra Preventing Disease
tion of clarithromycin but increased concentration of 14-OH Adults and adolescents who have a CD4+ T lymphocyte
clarithromycin, an active metabolite of clarithromycin. Al count of >200 cells/µL should be administered a single dose
though the clinical significance of this interaction is unknown, of 23-valent polysaccharide pneumococcal vaccine (PPV) if
the efficacy of clarithromycin in MAC prophylaxis could be they have not received this vaccine during the previous five
16. 12 June 14, 2002
years (BII) (73–77). One randomized placebo-controlled trial Preventing Recurrence
of pneumococcal vaccine in Africa paradoxically determined Clinicians can administer anti-biotic chemoprophylaxis to
that an increase had occurred in pneumonia among vaccinated HIV-infected patients who have frequent recurrences of seri
subjects (78). However, multiple observational studies in the ous bacterial respiratory infections (CIII). TMP-SMZ, admin
United States have not identified increased risk associated with istered for PCP prophylaxis, and clarithromycin or
vaccination and have identified benefit among this group azithromycin, administered for MAC prophylaxis, are appro
(73–77). The majority of HIV specialists believe that the priate for drug-sensitive organisms. However, health-care
potential benefit of pneumococcal vaccination in the United providers should be cautious when using antibiotics solely for
States outweighs the risk. Immunization should also be con preventing the recurrence of serious bacterial respiratory
sidered for patients with CD4+ T lymphocyte counts of <200 infections because of the potential development of drug-
cells/µL, although clinical evidence has not confirmed effi resistant microorganisms and drug toxicity.
cacy (CIII). Revaccination can be considered for patients who
were initially immunized when their CD4+ T lymphocyte Special Considerations
counts were <200 cells/µL and whose CD4+ counts have Children. HIV-infected children aged <5 years should be
increased to >200 cells/µL in response to HAART (CIII). The administered Hib vaccine (AII) and pneumococcal conjugate
recommendation to vaccinate is increasingly pertinent because vaccine (PCV) (79–81) (BII) in accordance with the guide
of the increasing incidence of invasive infections with lines of the Advisory Committee on Immunization Practices
drug-resistant (including TMP-SMZ–, macrolide-, and (74,76,79) and the American Academy of Pediatrics (80).
ß-lactam–resistant) strains of S. pneumoniae. Children aged >2 years should also receive 23-valent PPV (BII).
The duration of the protective effect of primary pneumo Revaccination with a second dose of the 23-valent PPV should
coccal vaccination is unknown. Periodic revaccination can be usually be administered after 3–5 years to children aged <10
considered; an interval of 5 years has been recommended for years and after 5 years to children aged >10 years (BIII).
persons not infected with HIV and also might be appropriate To prevent serious bacterial infections among HIV-infected
for persons infected with HIV (CIII) (76). However, no children who have hypogammaglobulinemia (IgG <400 mg/
evidence confirms clinical benefit from revaccination. dL), clinicians should use intravenous immune globulin (IVIG)
Incidence of H. influenzae type B (Hib) infection among (AI). Respiratory syncytial virus (RSV) IVIG (750 mg/kg body
adults is low. Therefore, Hib vaccine is not usually recom weight), not monoclonal RSV antibody, can be substituted
mended for adult use (DIII). TMP-SMZ, when administered for IVIG during the RSV season to provide broad anti-
daily for PCP prophylaxis, reduces the frequency of bacterial infective protection, if RSV IVIG is available.
respiratory infections. This should be considered in selecting To prevent recurrence of serious bacterial respiratory infec
an agent for PCP prophylaxis (AII). However, indiscriminate tions, antibiotic chemoprophylaxis can be considered (BI).
use of this drug (when not indicated for PCP prophylaxis or However, health-care providers should be cautious when
other specific reasons) might promote development of TMP using antibiotics solely for this purpose because of the poten
SMZ-resistant organisms. Thus, TMP-SMZ should not be tial development of drug-resistant microorganisms and drug
prescribed solely to prevent bacterial respiratory infection toxicity. Administering IVIG should also be considered for
(DIII). Similarly, clarithromycin administered daily and HIV-infected children who have recurrent serious bacterial
azithromycin administered weekly for MAC prophylaxis might infections (BI), although such treatment might not provide
be effective in preventing bacterial respiratory infections; this additional benefit to children who are being administered daily
should be considered in selecting an agent for prophylaxis TMP-SMZ. However, IVIG can be considered for children
against MAC disease (BII). However, these drugs should not who have recurrent serious bacterial infections despite receiv
be prescribed solely for preventing bacterial respiratory infec ing TMP-SMZ or other antimicrobials (CIII) (82).
tion (DIII). Pregnant Women. Pneumococcal vaccination is recom
An absolute neutrophil count that is depressed because of mended during pregnancy for HIV-infected patients who have
HIV disease or drug therapy is associated with an increased not been vaccinated during the previous 5 years (BIII). Among
risk for bacterial infections, including pneumonia. To reduce nonpregnant adults, vaccination has been associated with a
the risk for such bacterial infections, health-care providers transient burst of HIV replication. Whether the transient vire
might consider taking steps to reverse neutropenia, either by mia can increase the risk for perinatal HIV transmission is
stopping myelosuppressive drugs (CII) or by administering unknown. Because of this concern, when feasible, vaccination
granulocyte-colony-stimulating factor (G-CSF) (CII). can be deferred until after HAART has been initiated to
prevent perinatal HIV transmission (CIII).
17. Recommendations and Reports 13
Bacterial Enteric Infections Salmonella, and Campylobacter. HIV-infected persons should
wash their hands after handling pets, including before eating,
Preventing Exposure and should avoid contact with pets’ feces (BIII). HIV-infected
Food. Health-care providers should advise HIV-infected persons should avoid contact with reptiles (e.g., snakes,
persons not to eat raw or undercooked eggs, including lizards, iguanas, and turtles) as well as chicks and ducklings
specific foods that might contain raw eggs (e.g., certain because of the risk for salmonellosis (BIII).
preparations of hollandaise sauce, Caesar and other salad dress Travel. The risk for foodborne and waterborne infections
ings, certain mayonnaises, uncooked cookie and cake batter, among immunosuppressed, HIV-infected persons is magni
and egg nog); raw or undercooked poultry, meat, seafood (raw fied during travel to economically developing countries. Per
shellfish in particular); unpasteurized dairy products; unpas sons who travel to such countries should avoid foods and
teurized fruit juices; and raw seed sprouts (e.g., alfalfa sprouts beverages that might be contaminated, including raw fruits
or mung bean sprouts). Poultry and meat are safest when and vegetables, raw or undercooked seafood or meat, tap
adequate cooking is confirmed by thermometer (i.e., internal water, ice made with tap water, unpasteurized milk and dairy
temperature of 180ºF for poultry and 165ºF for red meats). If products, and items sold by street vendors (AII). Foods and
a thermometer is not used, the risk for illness is decreased by beverages that are usually safe include steaming hot foods, fruits
consuming poultry and meat that have no trace of pink color. that are peeled by the traveler, bottled (including carbonated)
Color change of the meat (e.g., absence of pink) does not beverages, hot coffee and tea, beer, wine, and water brought
always correlate with internal temperature (BIII). Produce to a rolling boil for 1 minute (AII). Treatment of water with
should be washed thoroughly before being eaten (BIII). iodine or chlorine might not be as effective as boiling but can
Health-care providers should advise HIV-infected persons be used when boiling is not practical (BIII).
to avoid cross-contamination of foods. Uncooked meats,
including hot dogs, and their juices should not come into Preventing Disease
contact with other foods. Hands, cutting boards, counters, Prophylactic antimicrobial agents are not usually recom
knives, and other utensils should be washed thoroughly after mended for travelers (DIII). The effectiveness of these agents
contact with uncooked foods (BIII). depends on local antimicrobial-resistance patterns of gas
Health-care providers should advise HIV-infected persons trointestinal pathogens, which are seldom known. Moreover,
that, although the incidence of listeriosis is low, it is a serious these agents can elicit adverse reactions and promote the emer
disease that occurs with unusually high frequency among gence of resistant organisms. However, for HIV-infected trav
severely immunosuppressed HIV-infected persons. An immu elers, antimicrobial prophylaxis can be considered, depending
nosuppressed, HIV-infected person who wishes to reduce the on the level of immunosuppression and the region and dura
risk for acquiring listeriosis as much as possible can choose to tion of travel (CIII). Use of fluoroquinolones (e.g.,
do the following (CIII): 1) avoid soft cheeses (e.g., feta, Brie, ciprofloxacin, 500 mg/day) can be considered when prophy
Camembert, blue-veined, and such Mexican-style cheese as laxis is deemed necessary (CIII). As an alternative (e.g., for
queso fresco). Hard cheeses, processed cheeses, cream cheese children, pregnant women, and persons already taking TMP
(including slices and spreads), cottage cheese, or yogurt need SMZ for PCP prophylaxis), TMP-SMZ might offer limited
not be avoided; 2) cook leftover foods or ready-to-eat foods protection against traveler’s diarrhea (BIII). Risk for toxicity
(e.g., hot dogs) until steaming hot before eating; 3) avoid foods should be considered before treatment with TMP-SMZ is
from delicatessen counters (e.g., prepared salads, meats, initiated solely because of travel.
cheeses) or heat/reheat these foods until steaming before eat Antimicrobial agents (e.g., fluoroquinolones) should be
ing; 4) avoid refrigerated pâtés and other meat spreads, or heat/ administered to patients before their departure, to be taken
reheat these foods until steaming. Canned or shelf-stable pâté empirically (e.g., 500 mg of ciprofloxacin twice daily for 3–7
and meat spreads need not be avoided; 5) avoid raw or unpas days) if severe traveler’s diarrhea occurs (BIII).
teurized milk (including goat’s milk) or milk-products, or foods Fluoroquinolones should be avoided for children aged <18
that contain unpasteurized milk or milk-products. (CIII). years and pregnant women, and alternative antibiotics should
Pets. When obtaining a new pet, HIV-infected persons be considered (BIII). Travelers should consult a physician if
should avoid animals aged <6 months (BIII). HIV-infected their diarrhea is severe and does not respond to empirical
persons also should avoid contact with any animals that have therapy, if their stools contain blood, if fever is accompanied
diarrhea (BIII). HIV-infected pet owners should seek veteri by shaking chills, or if dehydration occurs. Antiperistaltic
nary care for animals with diarrheal illness, and a fecal sample agents (e.g., loperamide) can be used to treat mild diarrhea.
from such animals should be examined for Cryptosporidium, However, use of these drugs should be discontinued if symptoms