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♦ Atovaquone 1,500 mg orally twice daily + sulfadiazine 1,000-1,500 mg orally every 6 hours. Note: The regimens that contain sulfadiazine, TMP- SMX, or atovaquone also are effective in preventing Pneumocystis jiroveci pneumonia (PCP), so patients on these regimens do not need additional PCP prophylaxis. Adjunctive corticosteroids (eg, dexamethasone 4 mg orally or intravenously every 6 hours) may be indicated for patients with significant CNS edema or mass effect. Use is based on clinical judgment and should be discontinued as soon as clinically feasible. Anticonvulsant therapy should be given to patients with seizures. Ventilatory support may be necessary if severe CNS symptomatology is present. Chronic Maintenance Therapy After at least 6 weeks of initial therapy, and significant clinical and radiologic improvement, chronic maintenance therapy can be considered. Preferred ♦ Pyrimethamine 25-50 mg orally once daily + sulfadiazine 500-1,000 mg orally every 6 hours + folinic acid 10 mg orally once daily (also effective as PCP prophylaxis). Alternatives ♦ Pyrimethamine 25-50 mg orally once daily + clindamycin 300-450 mg orally every 6-8 hours + folinic acid 10 mg orally once daily. ♦ Pyrimethamine 25-50 mg orally once daily + atovaquone 1,500 mg orally once daily + folinic acid 10 mg orally once daily (also effective as PCP prophylaxis). Chronic maintenance therapy generally should be continued for life. For patients who complete acute therapy successfully, have resolution of signs and symptoms of toxoplasmosis, and have immune reconstitution (with CD4 counts >200 cells/µL) for more than 6 months on ART, it is reasonable to consider discontinuing maintenance therapy. Some specialists would require resolution of CNS lesions on radiologic studies before discontinuation of therapy. Patients must be observed for recurrence of symptoms, and treatment should be restarted if the CD4 count decreases to 100-200 cells/µL in response to ART. Inform patients that suppressive therapy must be continued to prevent recurrence. This therapy may be lifelong. It is essential for patients to take all medicines exactly as prescribed. If doses are missed, or if the medications are stopped and restarted, Toxoplasma can develop resistance to the medications. If patients are having trouble taking the medication on schedule, they should contact their health care providers immediately. Educate patients about the benefits of ART in strengthening the immune system and preventing opportunistic infections such as toxoplasmosis. Advise patients to return to clinic promptly if symptoms worsen or new symptoms develop. Toxoplasmosis is a late-stage HIV opportunistic infection and indicates profound immune suppression. Some patients may not respond to treatment or to ART. As with any patient who is at risk for a life-threatening HIV-related disease, clinicians should discuss advance directives and durable power of attorney with patients. Referral to a social worker, mental health clinician, or chaplain experienced in such issues may facilitate this discussion.
6–108| Clinical Manual for Management of the HIV-Infected Adult/2006 References ♦ ♦ ♦ ♦ ♦ ♦ Bartlett JG, Gallant JE. 2005-2006 Medical Management of HIV Infection. Baltimore: Johns Hopkins University Division of Infectious Diseases; 2005. Available online at hopkins-aids.edu/mmhiv/ order.html. Centers for Disease Control and Prevention, National Institutes of Health, HIV Medicine Association/Infectious Diseases Society of America. Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents. MMWR Recomm Rep. 2004 Dec 17; 53(RR15);1-112. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail. aspx?GuidelineID=14. Accessed June 1, 2006. Kirton C, ed. ANAC's Core Curriculum for HIV/ AIDS Nursing; 2nd ed. Thousand Oaks, CA: Sage; 2003:87-89. Liesenfeld O, Wang SY, Remington JS. Toxoplasmosis in the Setting of AIDS. In: Merigan TC, Bartlett JG, Bolognesi D, eds. Textbook of AIDS Medicine, 2nd Edition. Baltimore: Williams and Wilkins; 1999:225-259. Murray HW. Toxoplasmosis. In: Dolin R, Masur H, Saag M,S, eds. AIDS Therapy 1999. Philadelphia: Churchill Livingstone; 1999:307-327. Subauste CS. Toxoplasmosis and HIV. In: Peiperl L, Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]. San Francisco: UCSF Center for HIV Information; 2006. Accessed June 1, 2006.
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Clinical Manual for Management of t
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Cryptosporidiosis Background Crypto
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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Hepatitis C Infection Background He
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pregnancy. Ribavirin is teratogenic
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Herpes Simplex, Mucocutaneous Backg
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References ♦ ♦ ♦ ♦ ♦ Cent
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Kaposi Sarcoma Background Kaposi sa
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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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Page 346 and 347: Oral Health Background Examination
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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