Prevention of Opportunistic Infections

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Prevention of Opportunistic Infections

• Jose A. Montero MD, FACP
• Florida/Caribbean AETC Faculty
• Division of Infectious Diseases
• University of South Florida

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Disclosure of Financial Relationships

• This speaker has no significant financial
  relationships with commercial entities to
  disclose.

This slide set has been peer-reviewed to ensure
that there are no conflicts of interest
represented in the presentation.
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Risk of Opportunistic Infection

• Many correlate with CD4 count
• CD4 lt 200 Pneumocystis jiroveci
• CD4 lt 100 Toxoplasma gondii, Cryptococcus
  neoformans
• CD4 lt 50 Mycobacterium avium complex
  Cytomegalovirus monocytogenes, JC virus

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Risk of Opportunistic Infections contd -

• Others occur at varying CD4 counts
• Mycobacterium tuberculosis
• S. pneumoniae
• Varicella zoster virus
• Cryptosporidium
• Bartonella sp.
• Herpes simplex
• Candida sp. infections
• Hepatitis A, B, C
• STDs

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OI Prophylaxis

• Primary - prevention of the first episode of
  infection
• Secondary - prevention of recurrence of infection
  after a successful treatment course

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OIs for Which Primary Prophylaxis is Recommended

• Pneumocystis pneumonia
• Tuberculosis
• Toxoplasmosis
• M. avium complex
• Varicella zoster
• S. pneumoniae infections
• Hepatitis A B
• Influenza

medications
vaccines
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P. jiroveci Pneumonia

• Primary Prophylaxis
• Indication
• CD4 lt200 or thrush
• When to stop
• CD gt200 for gt 3 months
• When to restart
• CD4 falls to lt200
• Secondary prophylaxis
• Same as primary

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P. jiroveci Pneumonia

• Preferred Regimens
• TMP-SMX DS 1/d
• TMP-SMX SS 1/d
• Alternative Regimens
• Dapsone 100 mg/d
• Dapsone 50 mg/d Pyrim 50 mg/wk Leucovorin 25
  mg /wk
• Dapsone 200 mg/wk Pyrim 75 mg/wk Leuco 25
  mg/wk
• Atovaquone 1500 mg/d
• Aerosol pentamidine 300 mg/mo
• TMP-SMX DS 3/wk

Adequate for toxoplasmosis (CD4 lt100 pos
serology)
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Toxoplasmosis Primary Prophylaxis

• Indication
• Positive Toxo lgG CD4 lt100
• When to stop
• CD4 gt200 for 3 months
• When to restart
• CD4 falls to lt100-200

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Toxoplasmosis Primary Prophylaxis

• Preferred Regimen
• TMP-SMX DS 1/d po
• Alternative Regimen
• TMP-SMX SS 1/d
• Dapsone 50 mg/d Pyrim 50 mg/wk Leuco 25mg/wk
• Dapsone 200 mg/wk Pyrim 75 mg/wk Leuco
  25mg/wk
• Atovaquone 1500 mg/d Pyrim 25 mg/d Leuco 10
  mg/d

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ToxoplasmosisSecondary Prophylaxis

• Indication
• Completion of therapy for toxoplasmosis unless
  immune reconstitution occurs with HAART
• When to stop
• CD4 gt200 for 6 months completed initial
  treatment asymptomatic
• When to restart CD4 falls below 200

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ToxoplasmosisSecondary Prophylaxis

• Preferred Regimen
• Sulfadiazine 500-1000 mg qid Pyrimethamine
  25-50 mg/d Leucovorin 10-25 mg/d
• Alternative Regimen
• Clindamycin 300-450 mg q 6-8 hr Pyrimethamine
  25-50 mg/d Leucovorin10-25 mg/d
• Atovaquone 750 mg q 6-12 hr Pyrimethamine 25
  mg/d Leucovorin 10 mg/d

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MACPrimary Prophylaxis

• Indication CD4 lt50
• When to stop CD4 gt100 for 3 or more months
• When to restart CD4 falls to lt50-100

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MACPrimary Prophylaxis

• Preferred Regimen
• Azithromycin 1200 mg/wk or
• Clarithromycin 500 mg bid
• Alternative Regimen
• Rifabutin 300 mg/d or
• Azithromycin 1200 mg/wk Rifabutin 300 mg/d

Dose adjust for concurrent PI or NNRTI
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MACSecondary Prophylaxis

• Indication history of MAC
• When to stop
• CD4 gt 100 for gt6 months Rx 12 months
  asymptomatic
• When to restart CD4 falls below 100

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MACSecondary Prophylaxis

• Preferred Regimen
• Clarithromycin 500 mg bid Ethambutol 15 mg/kg/d
  Rifabutin 300 mg/d
• Alternative Regimen
• Azithromycin 500 mg/d Ethambutol 15 mg/kg/d
  Rifabutin 300 mg/d

Dose adjust for concurrent PI or NNRTI
Rifabutin reduces levels of clarithromycin by 50
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Comparison of Indications to Discontinue Primary
Secondary Prophylaxis
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Tuberculosis Prevention

• Tuberculosis skin testing at time of HIV Dx
• No routine anergy testing
• 5mm or more induration indicates ()PPD
• Annual testing for those who have ()PPD
• Treatment for latent TB indicated for
• ()PPD and no evidence of active TB
• Close contacts of those with infectious TB

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Treatment of Latent TB

• Preferred regimen
• INH daily for 9 months
• Pyridoxine should be given to avoid neuropathy
• Alternative regimens
• Rifampin daily for 4 months
• Careful with drug interactions with rifamycins
• Pyrazinamide Rif for 2 months
• Avoid use due to reports of severe liver injury

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OIs for Which Prevention Is Not Routinely
Indicated

• Primary Prophylaxis
• Bacteria (neutropenia)
• Cryptococcosis
• Histoplasmosis
• Cytomegalovirus

• Secondary Prophylaxis
• Herpes simplex virus
• Candida

Evidence for efficacy but not routinely
indicated
Recommended only if subsequent episodes are
frequent or severe
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OIs for Which Secondary Prevention is Recommended

• Cryptococcosis
• Histoplasmosis
• Coccidioidomycosis
• Cytomegalovirus
• Salmonella bacteremia

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Cytomegalovirus Disease Chronic maintenance
therapy following induction

• Preferred Regimen
• Ganciclovir IV or PO
• Foscarnet IV
• Ganciclovir implant PO (for retinitis)
• Alternative Regimen
• Cidofovir IV probenecid PO
• Fomivirsen injection in vitreous
• Valganciclovir PO

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Cytomegalovirus Disease Chronic maintenance
therapy following induction

• When to stop
• CD4 gt100-150 x 6 months - no active disease
  negative ophthalmologic exam
• When to restart CD4 below 100-150

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Prophylaxis Summary Fungal Agents
Consider if CD4 lt100 endemic area (gt10
cases/100 pts-yrs) CD4 gt 100-200 x 6 mo
complete initial therapy asymptomatic
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Salmonella Prevention of Recurrence

• Indication Salmonella septicemia
• Regimen
• Preferred Fluoroquinolones (ciprofloxacin) for
  susceptible organisms
• Evaluate household contacts for carriage so that
  hygienic measures and/or antimicrobial therapy
  can be instituted

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Vaccines

• Update tetanus
• Pneumovax
• Hepatitis B if negative titers - repeat titers
  after vaccine series
• Hepatitis A vaccine if negative titers
• Influenza - annually

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Common Sense

• Barrier precautions to prevent STDs
• Avoid
• Uncooked eggs
• Undercooked/raw meats
• Unpasteurized milk, soft cheeses
• Untreated water, untested well water
• Hand washing and personal hygiene

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Common Sense contd -

• Pets
• New pets puppies gt 6 months, cats gt 1 year
• Cats - change litter daily, avoid
  bites/scratches, flea control
• Avoid contact with reptiles
• Gloves to clean aquarium - M. marinum

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Common Sense contd -

• Travel - by all means do, but plan ahead
• Bottled water
• Thoroughly cooked foods
• Peel fresh fruits/vegetables
• Seek expert travel advice - know before you go
  - Vector avoidance, malaria prophy, endemic
  fungi, no live virus vaccines
• http//www.cdc.gov/travel/

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Acknowledgements

• 2001 USPHS/IDSA Guidelines for the Prevention of
  Opportunistic Infections in Persons Infected with
  Human Immunodeficiency Virus
• MMWR Recommendations to Help Patients Avoid
  Exposures to or Infection from Opportunistic
  Pathogens 51(RR08)47-52, 2002.