Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–90 | Clinical Manual for Management of the HIV-Infected Adult/2006
P: Plan
Diagnostic Evaluation
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CD4 count is usually 90% of
PCP cases occur in patients with CD4 counts
300-500 IU is common. )
Thin-section chest computed tomography (CT)
scan may show ground glass opacities; in a patient
with clinical signs or symptoms of PCP, these are
suggestive but not diagnostic of PCP.
Chest x-ray typically shows bilateral interstitial
infiltrates, but atypical patterns with cavitation, lobar
infiltrates, nodules, or pneumothorax may occur, and
chest x-ray may be normal in some cases. Upper lobe
predominance is common if the patient is receiving
aerosolized pentamidine for PCP prophylaxis.
Sputum induction: The patient inhales saline mist
to mobilize sputum from the lungs. The respiratory
therapist collects expectorated sputum, which is
stained with Giemsa and examined for P jiroveci
organisms. This technique is useful because of its
noninvasive approach, but requires an experienced
technician, and may not be available at all centers.
Sensitivity varies widely (10-95%) depending on the
expertise of the center. If there is any chance that the
patient has TB, sputum induction should be done in
a confined space in a negative pressure area or near
an exhaust fan vented safely outside.
Bronchoscopy with bronchoalveolar lavage (BAL):
If induced sputum is negative for PCP organisms,
definitive diagnosis is made through detection
of organisms in BAL fluid obtained during
bronchoscopy. Sensitivity is >95% in experienced
centers. BAL fluid can be evaluated for bacteria,
mycobacteria, and fungi, as well as for P jiroveci.
Transbronchial biopsy may be done if lung disease is
progressive despite treatment, to look for diagnoses
other than PCP. Open lung biopsy is rarely done.
Treatment
Presumptive treatment is often initiated based on
clinical presentation, chest x-ray findings, and ABG
results, while definitive diagnostic tests are pending.
Table 1 shows the standard and alternative treatment
regimens.
Standard Therapy
Trimethoprim-sulfamethoxazole
Trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim,
Septra, cotrimoxazole) is the drug of choice: 15-20
mg/kg of theTMP component and 75-100 mg/kg of
the SMX component, divided into 3 or 4 doses daily
intravenously or orally for 21 days (a typical oral dose is
2 double-strength tablets 3 times daily). Adverse effects
of TMP-SMX are common (eg, rash, fever, leukopenia,
anemia, gastrointestinal intolerance), mostly mild, and
can usually be “treated through.” Patients who have had
previous reactions to sulfa drugs also may be successfully
desensitized (see chapter Sulfa Desensitization). TMP-
SMX requires dose adjustment in cases of renal
insufficiency.
Adjunctive corticosteroids
Adjunctive corticosteroids should be given if the room
air PO2 is 35
mm Hg. Corticosteroids should be given as early as
possible (preferably before or with the first dose of
antibiotic therapy) and within 36-72 hours of the start
of antipneumocystis therapy:
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Prednisone 40 mg twice daily days 1-5; 40 mg once
daily on days 6-10; 20 mg once daily on days 11-21.
Intravenous methylprednisolone can be given, as
75% of the prednisone dose.