17 Sept 2006
J Caperna, MD
UCSD Owen Clinic

Importance of Prevention

XDR-TB

16 Aug 2006 Int’l AIDS Conf,
Toronto, Canada
“High prevalence and mortality from extensively-drug resistant (XDR) TB in
TB/HIVcoinfected patients in rural South
Africa”
Author(s):N.R. Gandhi et al.

Ghandi et al 2006
 53 patients reported,
 identified retrospectively by resistance to all available drugs:(isoniazid,rifampin, ethambutol, streptomycin, ciprofloxacin, kanamycin)
 half died within 25 days and 52 of 53 died within 136 days,

Ghandi et al 2006
47 able to be HIV tested and all HIV positive.
 DNA fingerprinting (Spoligotyping) showed
90% of cases were from same source patient.
 6 of 53 were health care workers
(NOSOCOMIAL)

Tuberculosis
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The most common opportunistic infection in AIDS patients worldwide.
A common cause of death in AIDS patients worldwide.
After aggressive prevention efforts including treatment of latent asymptomatic tuberculosis infection, the incidence of
TB in the United States fell dramatically through the 1980’s, until incidence increased related to AIDS.
Today, over half of TB cases in the US are in immigrants.
Intensive Prevention Efforts are still needed in the US in immigrants and AIDS patients, which account for the majority of cases.
Prevention is effective only with adequate resources.

Importance of Preventing TB


Estimate in general that 1 active TB patient will infect 10 others.
TB outbreaks can be huge, in the 100’s or more.
 Recent South African example showed that
47 patients were potentially infected by the same person.
 Treatment is long, 6-12 months.
 Rare cases now of XDR-TB that are untreatable.

Goals of lecture:
At the end of the session, the participant will be able to:
1) Define Opportunistic Infection (OI);
2) State the associated disease states in which OI’s occur;

Goals of lecture:
At the end of the session, the participant will be able to:
3) Know the most frequently occurring OI’s, their environmental distribution, routes of exposure & how to prevent them.

Goals of lecture:
At the end of the session, the participant will be able to:
4) Discuss tuberculosis exposure;
5) Understand the public health principles used to recommend prophylaxis;
.
6) Identify indications for primary or secondary prophylaxis.

Prevention of OI’s
OUTLINE
1)
2) Prevention of Exposure to OI
3) Primary & Secondary Prophylaxis of
OI’s
4) CDC guidelines



 An infection by a microorganism that normally does not cause disease but becomes pathogenic when the body’s immune system is impaired.

Wikepedia

“… infections caused by organisms that usually do not cause disease in a person with a healthy immune system, but can affect people with a poorly functioning or suppressed immune system. They need an ‘opportunity’ to infect a person .”

Case Definition
 Definition based on a list of cases.


Each disease or a cluster of some of them defines the condition.
For AIDS, the CDC has a “case” definition, with a list of over 12 infections considered to be opportunistic if associated with HIV infection.

The 1993 AIDS Surveillance Case
Definition of the U.S. Centers for
Disease Control and Prevention
A diagnosis of AIDS is made whenever a person is HIV-positive and:
1) he or she has a CD4+ cell count below
200 cells per microliter OR
2) his or her CD4+ cells account for fewer than 14 percent of all lymphocytes OR
3) that person has been diagnosed with one or more of the AIDS-defining illnesses listed below.

AIDS-Defining Illnesses
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Candidiasis of bronchi, trachea, or lungs (see Fungal Infections)
Candidiasis , esophageal (see Fungal Infections)
Cervical cancer, invasive -HPV
Coccidioidomycosis, disseminated (see Fungal Infections)
Cryptococcosis, extrapulmonary (see Fungal Infections)
Cryptosporidiosis, chronic intestinal (>1 month duration) (see Enteric Diseases)
Cytomegalovirus disease (other than liver, spleen, or lymph nodes)
Cytomegalovirus retinitis (with loss of vision)
Encephalopathy, HIVrelated † (see Dementia)
Herpes simplex : chronic ulcer(s) (>1 month duration) or bronchitis, pneumonitis, or esophagitis
Histoplasmosis , disseminated (see Fungal Infections)
Isosporiasis , chronic intestinal (>1 month duration) (see Enteric Diseases)
Kaposi's sarcoma, HHV8
Lymphoma, Burkitt's, EBV
Lymphoma, immunoblastic
Lymphoma, primary, of brain (primary central nervous system lymphoma)
Mycobacterium avium complex or disease caused by M. Kansasii , disseminated
Disease caused by Mycobacterium tuberculosis , any site (pulmonary ‡ or extrapulmonary † ) (see
Tuberculosis)
Disease caused by Mycobacterium, other species or unidentified species, disseminated
Pneumocystis carinii pneumonia (aka jiroveci)
Pneumonia, recurrent ‡ (see Bacterial Infections)
Progressive multifocal leukoencephalopathy
Salmonella septicemia, recurrent (see Bacterial Infections)
Toxoplasmosis of brain (encephalitis)
Wasting syndrome caused by HIV infection †

OI’s by Kingdom
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Bacteria (MONERA)
•
Salmonella
•
Mycobacteria
•
TB, MAC, Kansasii, other
•
Pneumococcus
Fungi (FUNGI)
•
Candida
•
Crytpococcus
•
Coccidiomycosis
•
Histoplasmosis
•
Pneumocystis
 Protozoa/parasites (PROTISTA)
•
Toxoplasmosis
•
Cryptosporidium
•
Isospera

OI’s by Kingdom
Viruses (perhaps not living, and not in any kingdom)
•
CMV
•
HSV

Infections more frequent and more severe in HIV, but not in case definition of AIDS:
 Hep B
 Hep C
 HHV8
 HPV
 EBV
 Syphilis

Additional Illnesses That Are AIDS-Defining in
Children, But Not Adults
 Multiple, recurrent bacterial infections
 Lymphoid interstitial pneumonia/pulmonary lymphoid hyperplasia

Conditions of Suppressed Immunity other than AIDS:
1) Malnutrition
2) Immunosuppressive agents used for organ transplant
3) Prednisone
4) Chemotherapy for cancer
5) Genetic predisposition
6) Antibiotic treatment
7) Skin damage
8) Medical procedure

Primary Immunodeficiency Diseases
1.
Genetic conditions associated with immune disorders.
2.
Congenital versus acquired.
Deficiencies: a. Cellular b. Humeral c. Phagocytic d. Complement e. Combined f. Other

Primary Immunodeficiency Diseases
1)Severe Combined Immunodeficiency, or SCID
2) X-Linked Agammaglobulinemia (XLA)
3) Common Variable Immunodeficiency
4) Selective IgA Deficiency
5) IgG Subclass Deficiency
6) Hyper IgM Syndrome
7) DiGeorge Syndrome
8) Hereditary Ataxia-Telangectasia
9) Wiskott-Aldrich Syndrome
10) Phagocytic Deficiencies
11) Chronic Granulomatous Disease (CGD)
12) Chediak-Higashi Syndrome
13) Complement Deficiencies
14) Hyper IgE Syndrome (Job Syndrome)

Prevention of OI’s
OUTLINE
1) Definition of OI
2)
3) Primary & Secondary Prophylaxis of
OI’s
4) CDC guidelines

Types of Exposure

2002 MMWR June 14, /51(RR08);
47-52. Appendix:

“Recommendations To Help Patients
Avoid Exposure to or Infection from
Opportunistic Pathogens”

Prevention of Exposureno recommendations
Currently, there are no recommendations for preventing exposure to:
•
P jiroveci pneumonia (PCP) – no data to support isolation
•
M avium complex (MAC) – no data
•
S pneumoniae and H influenzae – not practical
•
Candidiasis – not practical
•
Cryptococcosis – not practical

Pathogens for which recommendations exist for prevention of exposure
 EXAMPLES
 Airborne: Tuberculosis, Histoplasmosis,
Coccidiomycosis
 Waterborne: Cryptosporidium, isospera
 Foodborne: Toxoplasmosis, enteric bacteria
 Blood/Sexual: Hepatitis C, Hep B, Syphilis, HPV,
Cytomegalovirus (CMV),
Herpes Simples Virus (HSV)
 Pets: toxoplasmosis (in cats)

Toxoplasmosis
 Test for Toxoplasma IgG antibody soon after diagnosis of HIV infection to detect latent infection
 Counsel all HIV-positive persons, particularly if IgG Ab negative, to avoid the various sources of toxoplasmic infection, including food, pet, soil exposures

Cryptosporidiosis
Educate and counsel HIV-infected persons about transmission of Cryptosporidium :
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Contact with infected adults and children
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Contact with infected animals
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Drinking or contact with contaminated water (eg, water from lakes, rivers)
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Drinking contaminated public water supplies
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Eating contaminated food
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Wash hands after gardening or soil contact, risk of cryptosporidium, toxoplasmosis.

Bacterial Enteric Infections
Food
•
Do not eat raw or undercooked eggs, raw or undercooked poultry, meat, seafood,sushi and other high-risk foods
•
180 F for poultry, 165 F for red meat.
•
Avoid soft cheeses, meat pates and cold deli items
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Avoid salad bars
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Avoid cross-contamination of foods and wash hands after preparation

Bacterial Enteric Infections
Pets
Avoid:
• new pets <6 months old, especially those that have diarrhea
• contact with animals that have diarrhea
• contact with pets' feces
• contact with reptiles, chicks, and ducklings because of the risk for salmonellosis
•
Bird feces has cryptococcus, histoplasmosis, mai
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Cats feces carries toxoplasmosis, Cat scratch can transmit Bartonella
Wash hands after handling pets

Bacterial Enteric Infections
Travel
•
The risk for food/water-borne infections is higher during travel to developing countries
•
Avoid high-risk foods and beverages: raw foods, tap water, items sold by street vendors
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Generally safe: steaming-hot foods and beverages, fruits that are peeled by the traveler, and bottled beverages
•
Boil water; use iodine or chlorine when boiling is not practical

Histoplasmosis
 Exposure in histoplasmosis-endemic areas cannot be avoided completely
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Patients with CD4 counts <200 cells/µL should avoid risky activities (eg, contact with dusty surface soil, chicken coops)

Cytomegalovirus Disease
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Persons in risk groups with low rates of CMV seropositivity should be tested for antibody
Counsel on consistent condom use
Counsel on risk of transmission from children
CMV-seronegative persons requiring blood transfusion should be given only CMV antibody-negative or leukocyte-reduced cellular blood products in nonemergency situations

Herpes Simplex Virus
 Consistent use of condoms to reduce risk of sexual exposure

Varicella-Zoster Virus
 If susceptible to VZV, avoid exposure to persons with zoster
 Immunize household contacts of HIVpositive persons

Human Herpesvirus 8
Infection
(Kaposi Sarcoma-Associated Herpes Virus)
 Counsel about deep kissing and sexual intercourse with high-risk persons
 Consistent use of condoms during sex
 Do not share IV drug equipment

Human Papillomavirus Infection
 Consistent use of condoms during sex.
Recentlh, some evidence that this reduces risk for HPV.

Prevention of OI’s
OUTLINE
1) Definition of OI
2) Prevention of Exposure to OI
3)
4) CDC guidelines

1)
2)
3)
4)
5)
6)
Principles to guide prophylaxis recommendations:
Environmental distribution,
Settings where exposure cannot be prevented,
Existence of effective prophylaxis,
Toxicity of prophylaxis,
Feasibility of prophylaxis (injections, meds by mouth, duration)
Cost of prophylaxis.

Two types of prophylaxis:
 PRIMARY
 SECONDARY

Two types of prophylaxis:
 PRIMARY---to prevent even first occurrence of infection.
 SECONDARY — to prevent a second occurrence of an infection that has already occurred at least once.

Prevention of OI’s
OUTLINE
1) Definition of OI
2) Prevention of Exposure to OI
3) Primary & Secondary Prophylaxis of
OI’s
4)

2004 CDC guidelines
 Treating Opportunistic Infections Among
HIV-infected Adults and Adolescents.
 MMWR 53 (RR15), pp 1-112.

Summary of OIs for Which
Prevention Is Recommended
Primary Prophylaxis
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Pneumocystis jiroveci pneumonia (PCP)*
Tuberculosis*
Toxoplasmosis*
Mycobacterium avium complex (MAC)*
Varicella-zoster*
S pneumoniae infections
†
Hepatitis A and B
†
Influenza
†
* Standard of care
† Generally recommended

Summary of OIs for Which
Prevention Is Recommended
Secondary Prophylaxis
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Pneumocystis jiroveci pneumonia (PCP)*
Toxoplasmosis*
Mycobacterium avium complex (MAC)*
Cryptococcosis*
Histoplasmosis*
Coccidioidomycosis*
Cytomegalovirus*
Salmonella bacteremia
†
* Standard of care
† Generally recommended

PRIMARY Prophylaxis for
Opportunistic Infections
WHEN TO START?
 CD4<200 PCP
 CD4<100 Toxoplasmosis
 CD4<50 MAC

What are the diseases we are trying to prevent?
 Pictures of pathogens and pathology.
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Three of the most common OI’s in AIDS.

Pneumocystis 1000X, each sperhical cyst 4-7microns

The cysts of Pneumocystis carinii in lung have the appearance of crushed ping-pong balls.

Toxoplasmosis

Toxoplasmosis—DISEASE

MAC

MAC—MILD LUNG DISEASE

MAC—DISEASE

MAC—DISEASE

OIs for Which Prevention Is
Not Routinely Indicated
Primary Prophylaxis
 Bacteria (neutropenia)
†
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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

Primary & Secondary Prophylaxis for
Opportunistic Infections
 When to start?
 When to stop?
 When to restart?

Indications for Possible Discontinuation of
Primary and Secondary Prophylaxis
Agent Recommendation
(only for patients on effective ART)
PCP
Toxo
MAC
Primary: CD4 >200 cells/µL for 3 months
Secondary: CD4 >200 cells/µL for 3 months
Primary: CD4 >200 cells/µL for 3 months
Secondary: CD4 >200 cells/µL for 6 months + initial toxo treatment + asymptomatic
Primary: CD4 >100 cells/µL for 3 months
Secondary: CD4 >100 cells/µL for 6 months + 12 months
MAC treatment + asymptomatic

Specific OI’s and specific recommendations
 OIs for which primary and secondary prophylaxis are recommended
 OIs for which only primary prevention generally is recommended
 OIs for which only secondary prevention generally is recommended
 Infections requiring other management strategies

December 2001
 These slides were created by John G. Bartlett,
MD and Richard W. Dunning, MHS based on the December 2001 Guidelines. They have been substantially revised and updated by
Susa Coffey, MD and Kirsten Balano, PharmD based on more recent guidelines and CDC publications.
Created 2001, reviewed 6/05

These slides were developed using the most recent treatment guideline information at the time of production.
However, in the rapidly changing field of HIV care, this information could become out of date quickly. Users are encouraged to compare the production date of this slide set with the publication date of the most recent guidelines.
Also, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.
AETC National Resource Center
Created 2001, reviewed 6/05

Created 2001, reviewed 6/05

 Primary Prophylaxis
Indication:
 CD4 <200 cells/µL or thrush
When to consider discontinuation:
 CD4 >200 cells/µL on ART >3 months
When to restart:
 CD4 falls to <200 cells/µL
Created 2001, reviewed 6/05

 Secondary Prophylaxis
Indication:
 Completion of PCP acute therapy
When to consider discontinuation:
 CD4 >200 cells/µL for >3 months on effective
ART
When to restart:
 CD4 falls to <200 cells/µL
Created 2001, reviewed 6/05

P jiroveci
Preferred Regimens:
 TMP-SMX DS 1 tablet PO QD*
 TMP-SMX SS 1 tablet PO QD
Alternative Regimens:
 TMP-SMX DS 1 tablet PO 3 times per week
 Dapsone 100 mg PO QD
 Dapsone 50 mg QD + pyrimethamine 50 mg per week + leucovorin
25 mg per week*
 Dapsone 200 mg per week + pyrimethamine 75 mg per week + leucovorin 25 mg per week*
 Atovaquone 1,500 mg PO QD*
 Aerosolized pentamidine 300 mg per month
* Adequate for toxoplasmosis (CD4 <100 cells/µL + positive serology)
Created 2001, reviewed 6/05

Primary Prophylaxis
Indication:
 Positive toxoplasma lgG + CD4 <100 cells/µL
When to consider discontinuation:
 CD4 >200 cells/µL for 3 months on effective ART
When to restart:
 CD4 falls to <100200 cells/µL
Created 2001, reviewed 6/05

Primary Prophylaxis
Preferred Regimen:
 TMP-SMX DS 1 tablet PO QD
Alternative Regimens:
 TMP-SMX SS 1 tablet PO QD
 Dapsone 50 mg PO QD + pyrimethamine 50 mg PO per week + leucovorin 25mg PO per week
 Dapsone 200 mg per week + pyrimethamine 75 mg per week + leucovorin 25mg per week
 Atovaquone 1,500 mg PO QD +/- pyrimethamine 25 mg PO QD + leucovorin 10 mg PO QD
Created 2001, reviewed 6/05

Secondary Prophylaxis
Indication:
 Should be initiated upon completion of acute therapy for toxoplasmosis, unless immune reconstitution occurs with effective ART
When to consider discontinuation:
 CD4 >200 cells/µL for 6 months on effective ART + completed acute therapy + asymptomatic
When to restart:
 CD4 falls to <200 cells/µL
Created 2001, reviewed 6/05

Secondary Prophylaxis
Preferred Regimen:
 Sulfadiazine 500-1,000 mg QID + pyrimethamine
25-50 mg PO QD + leucovorin 10-25 mg PO QD
Alternative Regimens:
 Clindamycin 300-450 mg PO Q 6-8 hours + pyrimethamine 25-50 mg QD + leucovorin 10-25 mg QD
 Atovaquone 750 mg PO Q 6-12 hours +/- pyrimethamine
25 mg QD + leucovorin 10 mg QD
Created 2001, reviewed 6/05

M avium
Primary Prophylaxis
Indication:
 CD4 <50 cells/µL
When to consider discontinuation:
 CD4 >100 cells/µL for >=3 months on effective
ART
When to restart:
 CD4 falls to <50100 cells/µL
Created 2001, reviewed 6/05

M avium
Primary Prophylaxis
Preferred Regimen:
 Azithromycin 1,200 mg PO per week or
 Clarithromycin 500 mg PO BID
Alternative Regimens:
 Rifabutin* 300 mg PO QD or
 Azithromycin 1,200 mg PO per week + rifabutin*
300 mg PO QD
* Adjust dosage for concurrent PI or NNRTI
Created 2001, reviewed 6/05

M avium
Secondary Prophylaxis
Indication:
 Upon completion of MAC treatment
When to consider discontinuation:
 CD4 >100 cells/µL for >=6 months on effective ART
+ 12 months treatment + asymptomatic
When to restart:
 CD4 falls to <100 cells/µL
Created 2001, reviewed 6/05

M avium
Secondary Prophylaxis
Preferred Regimen:
 Clarithromycin 500 mg PO BID + ethambutol
15 mg/kg PO QD +/- rifabutin* † 300 mg PO QD
Alternative Regimen:
 Azithromycin 500 mg PO QD + ethambutol
15 mg/kg PO QD +/- rifabutin* 300 mg PO QD
* Adjust dosage for concurrent PI or NNRTI
† Rifabutin reduces levels of clarithromycin by 50%
Created 2001, reviewed 6/05

Created 2001, reviewed 6/05

Latent Infection
Screening:
 (5-TU) purified protein derivative (PPD) by the
Mantoux method
 When HIV infection is first recognized
 Annual test if PPD negative on initial evaluation and continued risk
 Routine evaluation for anergy is not recommended
Created 2001, reviewed 6/05

Treatment of Latent Infection
Indications:
 PPD >=5 mm induration at 48-72 hours
 History of positive PPD with no treatment
 TB contact (discontinue if PPD negative at 12 weeks
 All PPD positive patients should be evaluated for active TB, including chest X ray
Created 2001, reviewed 6/05

Treatment of Latent Infection
Recommended Regimen:
 INH 300 mg PO QD + pyridoxine 50 mg PO QD for 9 months (270 doses)
†
 INH 900 mg PO QD + pyridoxine 100 mg PO twice weekly for 9 months (76 doses )
†
† Directly observed therapy recommended
Created 2001, reviewed 6/05

Treatment of Latent Infection
Alternative Regimen:
 Rifampin 600 mg PO QD for 4 months
Note: Rifampin should not be used with protease inhibitors or nevirapine. Rifabutin can be substituted for rifampin for patients taking PI/NNRTIs with appropriate dosage adjustment.
Created 2001, reviewed 6/05

 Rifampin-pyrazinamide (RZ) for 2 months should NOT be given:
 High rate of severe liver toxicity*
*
MMWR 2003; 52, 31;735-9
Created 2001, reviewed 6/05

When to Restart:
 Patients previously treated for TB infection or
TB disease do not require retreatment based upon diminished immune function alone.
 Patients with known exposure to TB or suspicion of active TB infection may need treatment.
 In these instances, consultation with experts is strongly recommended.
Created 2001, reviewed 6/05

 Varicella vaccine is contraindicated in HIVinfected adults
 Following exposure to varicella, give varicellazoster immune globulin (VZIG) to susceptible
HIV-infected children and adults. Give ASAP but
<=96 hours after close contact with a person who has chickenpox or shingles
 No preventive measures are currently available for shingles
Created 2001, reviewed 6/05

Agent Indication
Hepatitis B HBsAb negative, HBsAg negative
Hepatitis A Risk* + HAV Ab (IgG) negative
S pneumoniae CD4 >200 cells/µL
(consider at any CD4 count)
Influenza Annually, October-December
*Risk = IDU, MSM, hemophilia, chronic HBV or HCV
Created 2001, reviewed 6/05

Give If Indicated:
 Cholera
 Japanese encephalitis
 Lyme disease
 Tetanus-diphtheria
 Typhoid inactivated (Typhim V
1
)
Created 2001, reviewed 6/05

Contraindicated (Live Virus):
 Varicella
 Yellow fever
 Typhoid live (Ty21a)
 Measles
 Vaccinia
Created 2001, reviewed 6/05

Created 2001, reviewed 6/05

Chronic Maintenance Therapy
(Following Induction)
Consult with a specialist
Preferred Regimen:*
 Valganciclovir 900 mg PO QD
 Foscarnet 90-120 mg/kg IV QD
 Ganciclovir implant + PO valganciclovir
Alternative Regimens:*
 Cidofovir IV + probenecid PO
 Fomivirsen intravitreous injection
*CDC/NIH/IDSA OI Treatment Guidelines, 12/04 Created 2001, reviewed 6/05

Chronic Maintenance Therapy
(Following Induction)
When to Consider Discontinuation:
 Completed initial therapy + no active disease + negative ophthalmologic exam + CD4 >100-150 cells/µL for 6 months on effective ART
When to Restart:
 CD4 <100150 cells/µL
Created 2001, reviewed 6/05

Infection
Candida
Histoplasma
Cryptococcus
Coccidiodes
Prophylaxis
Primary Secondary
No
No*
Consider if severe or frequent
Yes
Discontinue
Secondary
Restart
Secondary
?
No -
-
No Yes Yes** CD4 <100
No Yes No -
* Consider if CD4 <100 cells/µL + endemic area (>10 cases/100 pts-yrs)
** CD4 >100200 cells/µL for 6 months on ART + complete initial therapy
+ asymptomatic
Created 2001, reviewed 6/05

Remember:
 Each fungal infection requires a specific prophylaxis.

Chronic Maintenance Therapy
Indication:
 Upon completion of acute therapy
When to Consider Discontinuation:
 Completed initial treatment + asymptomatic + CD4
>100200 cells/µL for 6 months on effective ARV therapy
When to Restart:
 CD4 falls to <100200 cells/µL
Created 2001, reviewed 6/05

Chronic Maintenance Therapy
Preferred Regimen:
 Fluconazole 200 mg PO QD
Alternative Regimen:
 Itraconazole 200 mg PO QD
Created 2001, reviewed 6/05

Lifelong Suppressive Therapy
Indication:
 Completion of acute therapy for histoplasmosis
When to Consider Discontinuation:
 Insufficient data (? CD4 >100 cells/µL on ART)
Created 2001, reviewed 6/05

Lifelong Suppressive Therapy
Preferred Regimen:
 Itraconazole 200 mg BID
Created 2001, reviewed 6/05

Lifelong Suppressive Therapy
Indication:
 Completion of acute therapy for coccidioidomycosis
When to Stop:
 Insufficient data (? CD4 >100 cells/µL on
ART)
Created 2001, reviewed 6/05

Lifelong Suppressive Therapy
Preferred Regimens:
 Fluconazole 400 PO QD, or
 Itraconazole 200 mg PO BID
Patients with meningeal disease require consultation with an expert.
Created 2001, reviewed 6/05

Prevention of Recurrence
Indication:
 Salmonella septicemia
Regimen:
 Preferred: fluoroquinolones (ciprofloxacin) for susceptible organisms
Other Management:
 Household contacts should be evaluated for carriage so that hygienic measures and/or antimicrobial therapy can be instituted and recurrent transmission can be prevented
Created 2001, reviewed 6/05

Created 2001, reviewed 6/05

Prevention
 Screen all HIV-infected patients
 If positive: check HCV RNA to confirm chronic infection, then:
 Avoid excessive amounts of alcohol
 Vaccinate against hepatitis A and hepatitis B
 Evaluate for chronic liver disease and for need for treatment
 Monitor liver enzymes in patients on ART
 ART should not be withheld routinely from patients coinfected with HIV and HCV
Created 2001, reviewed 6/05

Prevention
Genital Epithelial Cancers in HIV-Infected Women
 Pelvic exam + Pap smear twice in first year after
HIV diagnosis
 If normal, repeat Pap smear annually
 If abnormal, follow consensus guidelines* for management
Prevention of Recurrence
 Careful follow-up and monitoring after treatment
 No specific therapy recommended
*Wright TC Jr, JAMA 2002
Created 2001, reviewed 6/05

 HIV and HPV coinfected women and men, especially men who have sex with men, are at increased risk for HSIL and anal cancer
 To date, no formal guidelines recommend anal
Pap smear screening, but some specialists recommend this for all HIV-infected adults*
*CDC/NIH/IDSA OI Treatment Guidelines, 12/04
Created 2001, reviewed 6/05

For Additional Information:
Sources of Complete Guidelines, Slide
Sets and Summaries:
AETC Resource Center: www.aids-etc.org
AIDSInfo: www.aidsinfo.nih.gov

CLINICAL TRAINING