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

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
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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
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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:
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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.)
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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.)