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Terms in this set (76)
Why do OIs occur?
Poor access to / retention in care
Poor adherence to ART or OI prophylaxis
What is primary prophylaxis?
Prevention of 1st episode of OI
What is maintenance therapy / secondary prophylaxis?
Prevent recurrence of OI after acute infection
When does Mucocutaneous candidiasis occur?
CD4 < 200
Plaques, patches, or angular cheilosis
Burning pain in the chest, cannot swallow, fever, plaques +/- mucosal ulceration
Why is primary prophylaxis not recommended for mucocutaneous candidiasis?
Resistance to antifungal
Acute treatment is effective
Low mortality & morbidity w/ these infections
Preferred Treatment of Oropharyngeal Candidiasis
Fluconazole orally once daily (use topical tx in pregnancy)
Alternative Treatment of Oropharyngeal Candidiasis
Topical therapy (Clotrimazole, Nystatin Suspension)
Must be administered 4-5x daily
Liquids (Itraconazole, Posaconazole)
How long do you treat Oropharyngeal Candidiasis?
Preferred Treatment of Esophageal Candidiasis
Fluconazole PO / IV daily
Alternative Treatment of Esophageal Candidiasis
Amphotericin B (pregnancy)
How long do you treat Esophageal Candidiasis?
Is secondary prophylaxis recommended in candidiasis?
No, not unless they have frequent or severe recurrences
Risk Factors for PCP
CD4: <200 or CD4%: < 14%
Pt unaware for HIV infection
Not receiving ongoing HIV care
Prev. PCP infection
Recurrent bacterial pneumonia
History of thrush
When should PCP Prophylaxis be initiated?
CD4: <200 or CD4%: <14%
History of thrush
History of AIDS-defining illness
How long do you treat PCP?
Preferred Treatment for PCP
Bactrim (2 DS TID, dose more frequently if moderate/severe)
Alternative Treatment for PCP
Check G6PD deficiency test for Dapsone and Primaquine + Clindamycin
Preferred Primary Prophylaxis of PCP
Bactrim DS or SS (if ADRs) QD
Alternative Primary Prophylaxis of PCP
Bactrim DS (3x / week)
Dapsone (if TE, add pyrimethamine & leucovorin)
When do you use Atovaquone?
Pt has sulfonamide allergy, sigificant anemia, or G6PD deficiency
How should Atovaquone be taken?
Which medication must you check for G6PD deficiency before administering?
Which medications can be used as alternatives if the patient has a sulfa allergy?
MOA of Bactrim, Dapsone, & Pyrimethamine
Inhibit folic acid synthesis
ADR of Bactrim
Hemolysis in G6PD deficiency
DDI with Bactrim
Inhibits 2C9 (phenytoin, anticoagulants)
ADR of Dapsone & Pyrimethamine
Anemia (hemolytic anemia in G6PD deficient pts)
Prevents Pyrimethamine hematologic toxicity
Atovaquone (Mepron) MOA
Inhibits electron transport to mitochondria, decreasing synthesis of nucleic acids
Atovaquone (Mepron) Administration
Oral suspension taken with food
Atovaquone (Mepron) ADRs
Interferes w/ microbial RNA/DNA, phospholipids, and protein synthesis by inhibiting oxidative phosphorylation
IV/IM is used for treatment
Inhalation is used for prophylaxis
When is Pentamidine dose adjusted?
Severe renal impairment
Which PCP Prophylaxis provides prophylaxis against TE?
Bactrim + Atovaquone
What is the difference between Dapsone being used for PCP & TE?
When being used for TE, Dapsone must be used in combo with Pyrimethamine + Leucovorin
Risk Factors for TE
CD4 < 100 and positive Toxo IgG
Ingestion of undercooked meats
Contact w/ infected cat feces
When do you initiate prophylaxis for TE?
Toxoplasma IgG positive & CD4 <100
Primary Prophylaxis of TE
Bactrim PO daily
How long do you treat TE?
at least 6 weeks (IV)
Preferred Treatment for TE
Pyrimethamine + Leucovorin + Sulfadiazine
Treatment of TE in Patients w/ Sulfa Allergy
Pyrimethamine + Leucovorin + Clindamycin
(must add another agent for PCP prophylaxis bc Clinda does not cover that)
Secondary Prophylaxis of TE
Same thing as treatment, but lower doses and they are given orally instead of IV
Bone marrow suppression
Risk Factors for Cryptococcosis
CD4 < 100
Is primary prophylaxis usually indicated for Cryptococcosis?
How long do you treat Cryptococcosis?
at least 1 year
What are the three phases of Cryptococcosis treatment?
induction (first 2 weeks at least)
consolidation (at least 8 weeks)
secondary prophylaxis (one year at least)
Preferred Induction Therapy for Cryptococcosis
Amphotericin B (conventional or lipid formulation; lipid formulation for patients with renal disease) + Flucytosine
Preferred Consolidation Therapy for Cryptococcosis
Fluconazole high dose (400 mg) daily
Preferred Secondary Prophylaxis Therapy for Cryptococcosis
Fluconazole 200 mg daily for at least a year
Risk Factors for CMV
High viral loads (>100,000)
Not on ART or treatment failure
How long is CMV Retinitis treated for?
at least 3-6 months
Treatment for Sight-Threatening Lesions
Intravitreal (in the eye) injection of ganciclovir or foscarnet
PLUS one of systemic medications (valganciclovir, ganciclovir, foscarnet, or cidofovir)
Caution w/ renal problems
Treatment for Peripheral Lesions
No injection, only one of the systemic options (valganciclovir, ganciclovir, foscarnet, or cidofovir)
Secondary Prophylaxis for CMV Retinitis
Valganciclovir once daily
Ganciclovir & Valganciclovir ADRs
What interacts with TDF?
Ganciclovir, Valganciclovir, Cidofovir, Foscarnet
What interacts with Forscarnet?
Amphotericin B, Pentamidine (IV)
Risk Factors for MAC
CD4 < 50
High viral load
Previous colonization w/ MAC
Reduced immune response to MAC antigens
Preferred Primary Prophylaxis of MAC
Azithromycin once weekly or split twice weekly
Clarithyromycin BID & more DDIs than Azithro
Alternative Primary Prophylaxis of MAC
Cons of Rifabutin
Must rule out active TB
How long do you treat MAC infection?
at least 1 year
Preferred Treatment / Secondary Prophylaxis of MAC
Clarithromycin or Azithromycin PLUS Ethambutol
Drug Interactions with Macrolides
Clarithromycin is a major substrate & inhibitor of 3A4
Drug Interactions with Rifabutin
Major substrate & inducer of 3A4
Drug Interactions with Ethambutol
Aluminum hydroxide containing antacids
What infections is primarily prophylaxis indicated for?
PCP (if CD4 < 200, CD4% < 14%, pt has oral candidiasis or AIDS-defining illness)
TE (if CD4 <100 + Toxo IgG positive)
MAC (if CD4 <50)