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Module 1: Prophylaxis Core A Training Slide Set Prepared by the AETC National Resource Center

2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected With Human Immunodeficiency Virus. Module 1: Prophylaxis Core A Training Slide Set Prepared by the AETC National Resource Center. Disclaimer.

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Module 1: Prophylaxis Core A Training Slide Set Prepared by the AETC National Resource Center

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  1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected With Human Immunodeficiency Virus Module 1: Prophylaxis Core A Training Slide Set Prepared by the AETC National Resource Center OI Guidelines 11/28/01

  2. Disclaimer These slides were developed using the most recent treatment guideline information at the time of production. However, in the rapidly changing field of HIV care this information could become out of date quickly. The user is encouraged to compare the date of this slide set with the date of the most recent guidelines. Also, it is intended that these slides be used, as prepared, without changes in either content or attribution. Users are asked to honor this intent. AETC National Resource Center OI Guidelines 11/28/01

  3. Primary Prophylaxis P. carinii* Tuberculosis* T. gondii* M. avium* Varicella zoster* S. pneumoniae† Hepatitis A & B† Influenza † Secondary Prophylaxis P. carinii* T. gondii* M. avium* Cryptococcosis* Histoplasmosis* Coccidioidomycosis* Cytomegalovirus* Salmonella bacteremia Summary of OIs for Which Prevention Is Recommended * Standard of care † Generally recommended OI Guidelines 11/28/01

  4. Primary Prophylaxis Bacteria (Neutropenia) † Cryptococcosis† Histoplasmosis† Cytomegalovirus † Secondary Prophylaxis Herpes simplex virus§ Candida§ OIs for Which Prevention Is Not Routinely Indicated § Recommended only if subsequent episodes are frequent or severe † Evidence for Efficacy but Not Routinely Indicated OI Guidelines 11/28/01

  5. OI Guidelines November, 2001Comparison of Indications to Discontinue Primary and Secondary Prophylaxis OI Guidelines 11/28/01

  6. OI Guidelines November, 2001 OIs for Which Primary and Secondary Prophylaxis Is Recommended OI Guidelines 11/28/01

  7. P. carinii Pneumonia Primary Prophylaxis Indication: CD4 < 200 or thrush When stop: CD > 200 for > 3 mo When restart: CD4 falls to < 200 Secondary prophylaxis Same as primary OI Guidelines 11/28/01

  8. P. carinii Pneumonia Preferred Regimens: • TMP-SMX DS 1/d* • TMP-SMX SS 1/d Alternative Regimens: • Dapsone 100 mg/d • Dapsone 50 mg/d + Pyrim 50 mg/wk + Leucovorin 25 mg /wk* • Dapsone 200 mg/wk + Pyrim 75 mg/wk + Leuco 25 mg/wk* • Atovaquone 1500 mg/d* • Aerosol pentamidine 300 mg/mo • TMP-SMX DS 3/wk * Adequate for toxoplasmosis (CD4 <100 + pos serology) OI Guidelines 11/28/01

  9. Toxoplasmosis: Primary Prophylaxis Indication: Pos lgG Toxo + CD4 < 100 When to stop: CD4 > 200 X 3 mo When to restart: CD4 falls to < 100-200 OI Guidelines 11/28/01

  10. Toxoplasmosis: Primary Prophylaxis Preferred Regimen: TMP – SMX DS 1/d po Alternative Regimen: • TMP – SMX SS 1/d • Dapsone 50 mg/d + Pyrim 50 mg/wk + Leuco 25mg /wk • Dapsone 200 mg/wk + Pyrim 75 mg/wk + Leuco 25/wk • Atovaquone 1500 mg/d + Pyrim 25 mg/d + leuco10 mg/d OI Guidelines 11/28/01

  11. Toxoplasmosis:Secondary Prophylaxis Indication:Completion of therapy for toxoplasmosis unless immune reconstitution occurs with HAART. When to stop: CD4 > 200 X 6 mo + completed initial treatment + asymptomatic When to restart: CD4 falls to < 200 OI Guidelines 11/28/01

  12. Toxoplasmosis:Secondary Prophylaxis Preferred Regimen : • Sulfadiazine 500-1000 mg qid + Pyrimethamine 25-50 mg/d + Leucovorin 10-25 mg/d Alternative Regimen : • Clindamycin 300-450 mg q 6-8 hr + Pyrimethamine 25-50 mg/d+ leucovorin10-25 mg/d • Atovaquone 750 mg q 6-12 hr + Pyrimethamine 25 mg/d + leucovorin 10 mg/d OI Guidelines 11/28/01

  13. MAC:Primary Prophylaxis Indication: CD4 < 50 When to stop: CD4 > 100 for > 3 month When to restart: CD4 falls to < 50-100 OI Guidelines 11/28/01

  14. MAC:Primary Prophylaxis Preferred Regimen: • Azithromycin 1200 mg/wk or • Clarithromycin 500 mg bid Alternative Regimen: • Rifabutin* 300 mg/d or • Azithromycin 1200 mg/wk + Rifabutin* 300 mg/d * Dose adjusted for concurrent PI or NNRTI OI Guidelines 11/28/01

  15. MAC: Secondary Prophylaxis Indication: Hx MAC When to stop: CD4 > 100 X > 6 mo and Rx 12 mo and asymptomatic When to restart: CD4 falls to < 100 OI Guidelines 11/28/01

  16. MAC: Secondary Prophylaxis Preferred Regimen: Clarithromycin 500 mg bid + Ethambutol 15 mg/kg/d ± Rifabutin* † 300 mg/d Alternative Regimen: Azithromycin 500 mg/d + Ethambutol 15 mg/kg/d ± Rifabutin* 300 mg/d * Dose adjusted for concurrent PI..NNRTI † Rifabutin reduces levels of clarithromycin by 50% OI Guidelines 11/28/01

  17. OI Guidelines November, 2001 OIs for Which Only Primary Prevention Is Generally Recommended OI Guidelines 11/28/01

  18. Tuberculosis: Latent Infection Screening: (5-TU) purified protein derivative (PPD) by the Mantoux method When HIV infection is first recognized. Annual test if TST negative on initial evaluation and continued risk. Routine evaluation for anergy is not recommended. OI Guidelines 11/28/01

  19. Tuberculosis: Treatment of Latent Infection Indications: PPD > 5 mm induration at 48-72h Hx PPD + no Rx TB contact (D/C if PPD neg at 12 wks) All PPD positives should be evaluated for active TB including chest x-ray. OI Guidelines 11/28/01

  20. Treatment of Latent TB Infection: CDC/ATS Guidelines, August 2001* Recommended Regimens: • No HIV: INH X 9 mo. • HIV: INH X 9 mo. (if compliance assured) RIF-PZA X 2 mo. Alternative: RIF/RBT alone X 4 mo. * Am J Resp Crit Care 2001; 164:1319 OI Guidelines 11/28/01

  21. Treatment of Latent TB Infection: CDC/ATS Guidelines, August 2001* Rationale for RIF-PZA in HIV Co-infection: • Compliance & risk of active disease. • Risk of  ALT greater with INH vs RIF-PZA in HIV co-infected. • 21 reported cases severe RIF-PZA hepatotoxicity, none had HIV. • Well tolerated in HIV co-infected patients. * Am J Resp Crit Care 2001; 164:1319 OI Guidelines 11/28/01

  22. Treatment of Latent TB Infection: CDC/ATS Guidelines, August 2001* RIF-PZA Regimen: HAART: Use RBT & dose adjustment Admonitions: • Not recommended: Liver disease or hx INH hepatotoxicity • Caution: Other hepatotoxic drugs or EtOH Prescription: Only 2 week supply * Am J Resp Crit Care 2001; 164:1319 OI Guidelines 11/28/01

  23. Treatment of Latent TB Infection: CDC/ATS Guidelines, August 2001* RIF-PZA Regimen: Monitoring: • Clinical: at 2,4,6,& 8 weeks. • Lab: ALT & Bili at baseline, 2,4, & 6 weeks. Discontinue: 1) Sx +  ALT 2) ALT > 5X ULN, or 3) Bili. * Am J Resp Crit Care 2001; 164:1319 OI Guidelines 11/28/01

  24. Tuberculosis: Treatment of Latent Infection - Regimens HAART/No HAART: INH 300 mg/d + pyridoxine 50 mg/d X 9 mo (270 doses) † INH 900 mg + pyridoxine 100 mg 2 X wk X 9 months (76 doses † † Assuming completion of treatment can be assured. OI Guidelines 11/28/01

  25. Tuberculosis: Treatment of Latent Infection - Regimens HAART: Rifabutin* daily X 4 months Rifabutin* + Pyrazinamide 20 mg/kg/d X 2 months (60 doses) No HAART: Rifampin 600 mg/d X 4 months Rifampin 600 mg/d + Pyrazinamide 20 mg/kg/d X 2 months (60 doses) * Dose adjusted for PI or NNRTI OI Guidelines 11/28/01

  26. Tuberculosis: Treatment of Latent Infection When to restart: patients previously treated for TB infection or TB disease do not require retreatment based upon diminished immune function alone. Patients with known exposure or suspected of acquiring TB infection may need retreatment. In these instances consultation with experts is strongly recommended. OI Guidelines 11/28/01

  27. Rifabutin Dose Modifications With ART Agents OI Guidelines 11/28/01

  28. Tuberculosis Prophylaxis Therapeutic Monitoring OI Guidelines 11/28/01

  29. Varicella-Zoster Virus Disease • Varicella vaccine contraindicated in HIV-infected adults. • Varicella zoster immune globulin (VZIG) for susceptible HIV-infected children and adults. Give ASAP but  96 hours after close contact with a person who has chickenpox or shingles. • No preventive measures are currently available for shingles. OI Guidelines 11/28/01

  30. VACCINES: ROUTINE USE * Risk = IDU, MSM, hemophilia, chronic HBV or HCV OI Guidelines 11/28/01

  31. VACCINES: OTHER Give if indicated: Cholera, Japanese encephalitis, Lyme disease, Tetanus-diptheria, Typhoid inactivated (Typhim V1) OI Guidelines 11/28/01

  32. VACCINES: OTHER Contraindicated(live virus): Varicella, Yellow Fever, Typhoid live (Ty21a), Measles, Vaccinia OI Guidelines 11/28/01

  33. OI Guidelines November, 2001 OIs for Which Only Secondary Prevention Is Generally Recommended OI Guidelines 11/28/01

  34. Cytomegalovirus Disease Chronic maintenance therapy following induction Preferred Regimen: • Ganciclovir IV orPO • Foscarnet IV • Ganciclovir implant + PO (for retinitis) Alternative Regimen: • Cidofovir IV + probenecid PO • Fomivirsen injection in vitreous • Valganciclovir PO When to stop: CD4 >100-150 X 6 mo + no active disease + negative ophthal exam. When to restart: CD4 < 100-150 OI Guidelines 11/28/01

  35. Prophylaxis Summary: Fungal Agents * Consider if CD4 < 100 + endemic area (>10 cases/100 pts-yrs) ** CD4 > 100-200 X 6 mo + complete initial therapy + asymptomatic OI Guidelines 11/28/01

  36. Cryptococcosis Chronic Maintenance Therapy Regimen:Preferred: Fluconazole (AI). Alternate: Amphotericin B, itraconazole When to stop:completed initial treatment + asymptomatic + CD4 >100 - 200 X 6 mo on HAART When to restart:CD4 falls to < 100 - 200 OI Guidelines 11/28/01

  37. Histoplasmosis Lifelong Suppressive Therapy Indication: Completion of therapy for histoplasmosis Agents:itraconazole (200 mg twice a day). When to stop:Insufficient data (? CD4+ >100 cells/µL) OI Guidelines 11/28/01

  38. Coccidioidomycosis Lifelong Suppressive Therapy Indication: Completion of therapy for coccidioidomycosis Regimen: fluconazole PO or itraconazole. Patients with meningeal disease require consultation with an expert. When to stop:Insufficient data (? CD4+ >100 cells/µL ) OI Guidelines 11/28/01

  39. Salmonella Prevention of Reccurrence: Indication:Salmonella septicemia Regimen:Preferred: Fluoroquinolones (ciprofloxacin) for susceptible organisms. Other Management: Household contacts should be evaluated for carriage so that hygienic measures and/or antimicrobial therapy can be instituted and recurrent transmission prevented. (Optional) OI Guidelines 11/28/01

  40. OI Guidelines November, 2001 Infections Requiring Other Management Strategies OI Guidelines 11/28/01

  41. Hepatitis C Virus Infection Prevention of Disease Recommend screening-if positive: do RIBA/ HCV PCR, then: Avoid excessive amounts of alcohol Vaccinate against hepatitis A Evaluated for chronic liver disease and for the possible need for treatment. Monitor liver enzymes on patients on HAART. HAART should not be routinely withheld from patients co-infected with HIV and HCV OI Guidelines 11/28/01

  42. Human Papillomavirus Infection Prevention of Disease Genital Epithelial Cancers in HIV-infected Women Pelvic exam + PAP X 2 in first year after HIV Dx. If normal, repeat PAP annually If abnormal, follow Interim Guidelines for Management of Abnormal Cervical Cytology (NCI) Prevention of Recurrence Careful follow-up and monitoring after treatment No specific therapy recommended. OI Guidelines 11/28/01

  43. OI Guidelines November, 2001 Cost Considerations OI Guidelines 11/28/01

  44. Drug Costs Of PCP Prophylaxis * Administration costs need to be considered. OI Guidelines 11/28/01

  45. VACCINE COSTS * * Average Wholesale Price OI Guidelines 11/28/01

  46. Drug Costs Exceeding $10,000/yr* * Average Wholesale Price OI Guidelines 11/28/01

  47. For Additional Information: Sources of Complete Guidelines: • AETC Resource Center: www.aids-etc.org • AIDS Treatment Information Service: www.hivatis.org OI Guidelines 11/28/01

  48. OI Guideline Slides December 2001 Author: John G. Bartlett, M.D. Editor: Richard W. Dunning, M.H.S. Reviewers: • Renslow Sherer, M.D. • Caroline Teter, PAC, M.P.H. OI Guidelines 11/28/01

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