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2–34 | Clinical Manual for Management of the HIV-Infected Adult/2006 References ♦ ♦ Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR 2006;55(No. RR-11):1-100. U.S. Public Health Service, Infectious Diseases Society of America. Guidelines for preventing opportunistic infections among HIV-infected persons — 2002. MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih. gov/Guidelines/. Accessed May 19, 2006.
Opportunistic Infection Prophylaxis Background Prophylaxis against opportunistic infections (OIs) is treatment given to HIV-infected individuals to prevent either a first episode of an OI (primary prophylaxis) or the recurrence of infection (secondary prophylaxis). Prophylaxis is recommended to prevent 3 important OIs: Pneumocystis jiroveci pneumonia (PCP), Mycobacterium avium complex (MAC), and toxoplasmosis. Prophylaxis also is recommended to prevent tuberculosis (TB) in patients with latent Mycobacterium tuberculosis infection (See chapter Latent Tuberculosis). In certain situations, prophylaxis against some other OIs may be reasonable; see the OI prevention guidelines of the U.S. Public Health Service and the Infectious Diseases Society of America (USPHS/IDSA) (reference below) for additional information. Pneumocystis jiroveci Pneumonia Background PCP remains the most common life-threatening infection among U.S. residents with advanced HIV disease. Primary Prophylaxis: Indications ♦ ♦ Prophylaxis should be administered to all HIVinfected patients with a CD4 count of 200 cells/ µL in the presence of a CD4 percentage 100°F that persists for >2 weeks. In patients whose CD4 counts are declining toward 200 cells/µL, the CD4 count should be monitored closely. PCP prophylaxis should be considered for patients with a CD4 count between 200 and 250 cells/µL if laboratory monitoring will not be possible within 3 months. Section 2—Health Maintenance and Disease Prevention | 2–35 Prophylaxis Options: Recommended Regimen ♦ The recommended regimen is trimethoprimsulfamethoxazole (TMP-SMX; cotrimoxazole, Bactrim, Septra) 1 double-strength tablet daily. An alternative dosage is TMP-SMX 1 single-strength tablet daily, although the lower dosage may not be as effective. (Note: These regimens also are effective in preventing toxoplasmosis.) Warning: Many patients cannot tolerate sulfa medications. Severe reactions may include persistent neutropenia; rash, including severe erythroderma; and Stevens-Johnson syndrome (bullae and desquamation of the skin). Some patients with milder reactions (eg, rash without fevers or systemic symptoms) may undergo desensitization, but this must be done cautiously and requires diligence from the patient and careful management by the provider (see chapter Sulfa Desensitization). Prophylaxis Options: Alternative Regimens Other options for prophylaxis include the following: ♦ ♦ ♦ ♦ Dapsone 100 mg orally daily or 50 mg orally twice daily. (Note: These regimens do not prevent toxoplasmosis.) Dapsone 50 mg orally daily + pyrimethamine 50 mg orally once per week + leucovorin 25 mg orally once per week. (Note: This regimen also is effective in reducing the risk of toxoplasmosis.) Dapsone 200 mg orally + pyrimethamine 75 mg + leucovorin 25 mg, all once per week. (Note: This regimen also is effective in reducing the risk of toxoplasmosis.) ♦ Warning: Glucose-6-phosphate dehydrogenase (G6PD) deficiency can increase the risk of hemolytic anemia or methemoglobinemia in patients receiving dapsone. Screen for G6PD deficiency before starting dapsone. (G6PD deficiency is found in approximately 10% of African American males, and in 1-2% of males of Mediterranean, Indian, and Asian descent.)
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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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Page 67 and 68: Occupational Postexposure Prophylax
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Page 83: tablet daily of trimethoprim-sulfam
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Page 89 and 90: Latent Tuberculosis Background Late
Page 91 and 92: INH may cause liver toxicity and it
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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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♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
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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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Patient Education ♦ ♦ ♦ ♦
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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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♦ ♦ ♦ ♦ ♦ Some patients t
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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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Treatment Treatment of KS is not co
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Molluscum Contagiosum Background Mo
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Mycobacterium avium Complex Backgro
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Table 1. Interactions between Rifab
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Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Patient Education ♦ ♦ ♦ ♦
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Non-Hodgkin Lymphoma Background Non
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Patient Education ♦ ♦ ♦ ♦ S
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Toxoplasmosis Background Toxoplasma
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♦ Atovaquone 1,500 mg orally twic
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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