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Prophylaxis of Opportunistic Infections | Cotrimoxazole & Isoniazid - HAIVN Harvard

Learn about primary and secondary prophylaxis, including benefits and indications of cotrimoxazole. Understand the relationship between CD4 count and opportunistic infections. Discover how to provide isoniazid prophylaxis and manage cotrimoxazole allergy.

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Prophylaxis of Opportunistic Infections | Cotrimoxazole & Isoniazid - HAIVN Harvard

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  1. Prophylaxis of Opportunistic Infections HAIVN Harvard Medical School AIDS Initiative in Vietnam

  2. Learning Objectives By the end of this session, participants should be able to: • Differentiate between primary and secondary prophylaxis • Explain the benefits and indications of cotrimoxazole prophylaxis • Describe the process of cotrimoxazole desensitization • Describe how to provide isoniazid (INH) prophylaxis

  3. Relationship Between CD4 Count and Opportunistic Infections • The lower a person’s CD4 count is, the more vulnerable he/she is to opportunistic infections (OIs) • Different infections can occur based on how weak a person’s immune system is • The level of the CD4 count determines the OIs a person is at risk for

  4. Sample OIs per CD4 Count

  5. Two Types of OI Prophylaxis Primary prophylaxis: • Giving medication to prevent an OI from occurring in the first place Secondary prophylaxis: • Giving medication after an OI is treated to prevent it from recurring • Also known as maintenance therapy

  6. Cotrimoxazole Prophylaxis (CTP)

  7. Cotrimoxazole (1) Can prevent: • PCP • Cerebral toxoplasmosis • Malaria • Parasitic diarrheas • Non-typhoid salmonelloses • Streptococcus pneumoniae pneumonia

  8. Cotrimoxazole (2) Benefits • Decreases morbidity and mortality • Inexpensive • Well tolerated • Prepares patient for daily medication taking (adherence) Concerns • Hypersensitivity (allergic) rash • Anemia The benefits greatly outweigh the risks

  9. Cotrimoxazole Allergy (1) • Clinically: • Maculopapular rash • Can have fever • Usually within first few weeks of treatment • Epidemiology • No studies in Asia • In Africa, about 2% had allergy to CTX* • Resolves when drug is stopped * Lancet. 2004 Oct 16-22;364(9443):1428-34.

  10. CotrimoxazoleAllergy (2) – How to Manage? Vietnam MOH guidelines on treatment of HIV/AIDS, 2009

  11. Cotrimoxazole Desensitization • Desensitization is a rechallengefollowing an adverse reaction starting with low doses and gradually escalating • Review patient daily or give instructions on how to respond to any reaction:

  12. When to Start CTP in Vietnam? • Indications: • CD4 ≤ 350 (any clinical stage) • WHO Stage 3 or 4 regardless of CD4 count • If CD4 testing is not available: clinical stage 2, 3, 4 • Pregnant women can use CTX for entire pregnancy • Dose: • Adult: 960 mg/day or 960mg 3x /week • Pediatric: 5 mg/kg/day

  13. When to Stop CTP in Vietnam? • No ARV: continue lifelong • With ARV: stop cotrimoxazole when CD4 > 350

  14. What Should You Do When You Cannot Use Cotrimoxazole?

  15. Dapsone • Indications: • Prophylaxis of PCP in patients with allergy or adverse reaction to cotrimoxazole • Dose: • Adults: 100 mg daily • Pediatrics: 2 mg/kg once a day • Note: not effective against other OIs • Side effects (uncommon): rash, haemolytic anemia, hepatitis

  16. TB Prophylaxis Therapy

  17. Isoniazid Preventive Therapy (IPT) • Indication: • PLHIV with negative TB screening • Dose: Isoniazid 300 mg (5 mg/kg) once daily for 9 months • Must exclude active TB

  18. Case Study: Duong • Duong, a 23-year-old man is newly diagnosed with HIV • He is clinical stage 1 • His initial CD4 count returns at 89 cells/mm3 • You perform a TB symptom screen: • He denies fever, cough, sweats, and weight loss • What OIs is he at risk for? • What prophylaxis would you start?

  19. Primary Prophylaxis for Select OIs

  20. Secondary Prophylaxis

  21. Secondary Prophylaxis of OIs (1) • Also called “Maintenance Therapy” • OI medication is continued to prevent relapse • Continued for life or until the patient: • starts ART • has an increase in CD4 count which persists over a specified period of time

  22. Secondary Prophylaxis of OIs (2) • OIs which require secondary prophylaxis include: • PCP • Cerebral toxoplasmosis • Systemic fungal infections • Disseminated MAC infection • CMV disease

  23. Secondary Prophylaxis for Select OIs

  24. Case Study: Nga • Nga, a 25-year-old woman, presents to your clinic for follow-up of penicillium infection • She is about to complete 10 weeks of intensive phase treatment (Itraconazole 400 mg/day) • She has recently been started on ART • She is feeling well and wants to know whether she can stop the Itraconazole at the end of the 10 week course • What should you recommend regarding the Itraconazole? • When can she safely stop it?

  25. Key Points • Many OIs can be prevented with the use of primary or secondary • CTP is inexpensive, effective against many OIs, and reduces overall morbidity and mortality • IPT can prevent latent TB from becoming active TB

  26. Thank you! Questions?

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