Guidelines for Prevention and Treatment of Opportunistic Infections among HIV-Infected Children...
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Guidelines for Prevention and Guidelines for Prevention and Treatment of Opportunistic Infections Treatment of Opportunistic Infections among HIV-Infected Childrenamong HIV-Infected Children
Bacterial InfectionsBacterial Infections
Recommendations from Centers for Disease Control and Prevention,
the National Institutes of Health, the HIV Medicine Association of
the Infectious Diseases Society of America, the Pediatric Infectious
Diseases Society, and the American Academy of Pediatrics
July 20092 www.aidsect.org
These slides were developed using the April 2008 Guidelines. The intended audience is clinicians involved in the care of patients with HIV.
Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent. Expert opinion should be sought for complex treatment regimens.
– AETC NRC
About This PresentationAbout This Presentation
July 20093 www.aidsect.org
Serious Recurrent Bacterial Infections: Serious Recurrent Bacterial Infections: EpidemiologyEpidemiology
Most common infection in pre-HAART era (15/100 child years)
Because of difficulties in obtaining appropriate diagnostic specimens, bacterial pneumonia is often a presumptive diagnosis in a child with fever, pulmonary symptoms, and an abnormal chest radiogram
Bacteremia more common in HIV-infected children with pneumonia
July 20094 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:Epidemiology Epidemiology (2)(2)
Bacteria isolated include Streptococcus pneumoniae, Haemophilus influenzae type B, Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, nontyphoid Salmonella
S pneumoniae accounts for >50% of bacteremia
Incidence of S pneumoniae and H influenzae may be lower in regions where vaccines are administered
July 20095 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:Epidemiology Epidemiology (3)(3)
Increased risk of Haemophilus influenzae B, invasive meningococcal disease
Gram-negative bacteremia more common in children with advanced disease
Case mortality with gram-negative bacteremia >40%
Central venous catheter increases risk of bacterial infections
July 20096 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:Clinical ManifestationsClinical Manifestations
Clinical presentation dependent on type of bacterial infection(eg, bacteremia, sepsis, vasculitis, septic arthritis, pneumonia, meningitis, sinusitis)
Presentation similar to that of HIV-uninfected children
Classical signs, symptoms, and laboratory tests may be missing in many HIV-infected children
July 20097 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:DiagnosisDiagnosis
Isolation of pathogenic organism from normally sterile sites: blood, bone marrow, CSF
Diagnosis of pneumonia by radiograph and physical findings
Culture of catheter tips Sputum cultures may be difficult to obtain Additional studies such as ultrasound should be
considered Assays for detection of bacterial antigens when
available may be helpful
July 20098 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:PreventionPrevention
Routine use of conjugated pneumococcal and Haemophilus influenzae B vaccine (not routinely available in resource-poor countries)
Avoid raw and undercooked foods, unsterilized water, unpasteurized milk products
Hand washing and other precautions Avoid pets Caution with all foods when traveling
July 20099 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:Prevention Prevention – H influenzaH influenza B B
Children <5 years of age should be given H influenza B (Hib) conjugate vaccine
Consider use in children >5 years Incompletely immunized children should
receive 2 doses >8 weeks apart Pneumococcal conjugate vaccines (A II) >5 years: consider Hib conjugate vaccine 2
doses 1-2 months apart Children 2-59 months should receive the
heptavalent pneumococcal vaccine (PCV) at 2, 4, 6, and 12-15 months
July 200910 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:Prevention Prevention – S pneumoniaeS pneumoniae
Previously unimmunized children aged 7-23 months should receive 2-3 doses of PCV
Incompletely immunized children should receive 2 doses of PCV >8 weeks apart
Children >2 years of age should receive 23 valent PCV (>2 months after last conjugate vaccine)
Reimmunize with PCV in 3-5 years in children aged <10 years or after 5 years in children aged >10 years
July 200911 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:PreventionPrevention
Trimethoprim sulfamethoxazole (TMP-SMX) prophylaxis reduces bacterial infection and new and recurrent episodes of malaria
Atovaquone plus azithromycin provides prophylaxis for MAC as well as PCP
Discontinue prophylaxis in children on ART with CD4 percentage >15% with caution
July 200912 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:TreatmentTreatment
Patients with suspected serious bacterial infections should be treated empirically and promptly without waiting for laboratory results
Consider local prevalence of resistance of common infectious agents
Response of mildly immunodeficient children is similar to that of HIV-uninfected children
July 200913 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:Treatment Treatment (2)(2)
Treat HIV-infected children outside the neonatal period with empiric therapy until cultures are available (A III)
Use extended spectrum cephalosporin such as ceftriaxone or cefotaxime
Consider addition of azithromycin for hospitalized patients with pneumonia
Add clindamycin or vancomycin if MRSA is suspected
July 200914 www.aidsect.org
Serious Recurrent Bacterial Infections:Serious Recurrent Bacterial Infections:Treatment FailureTreatment Failure
Consider bacterial resistance if treatment failure occurs
Consider nonbacterial cause such as TB, PCP, meningitis (Cryptococcus or TB)
Look for catheter-related infections Occult abscess
July 200915 www.aidsect.org
Bartonellosis: Bartonellosis: EpidemiologyEpidemiology
Bartonella henselae and Bartonella quintana are primary species causing bacillary angiomatosis and peliosis
Bartonella bacteremia also occurs in HIV-infected individuals but is relatively uncommon in HIV-infected children
Bartonella henselae is associated with cat scratch disease in the general population
July 200916 www.aidsect.org
Bartonellosis: Bartonellosis: Epidemiology Epidemiology (2)(2)
Household cat is the primary vector Eradication of flea infestation may be important
in preventing infection, as contamination of cat claws is a possible mechanism of human infection
90% of patients with cat scratch disease have a history of recent contact with cats
The vector for Bartonella quintana is the human body louse
July 200917 www.aidsect.org
Bartonellosis: Bartonellosis: Clinical ManifestationsClinical Manifestations
Clinical manifestations determined by host response
Localized disease consisting of suppurative regional lymphadenopathy is most common in patients with an intact immune system
Systemic infection is more common among immunocompromised individuals
July 200918 www.aidsect.org
Bartonellosis: Bartonellosis: Clinical Manifestations Clinical Manifestations – Bacillary angiomatosisBacillary angiomatosis
Rare disorder occurring in severely immunocompromised individuals
Characterized by cutaneous and subcutaneous angiomatous papules
Can be confused with Kaposi sarcoma Nodules may be observed in the subcutaneous
tissue and can erode to the skin
July 200919 www.aidsect.org
Bartonellosis: Bartonellosis: Clinical Manifestations Clinical Manifestations – Bacillary peliosisBacillary peliosis
Characterized by angiomatous masses in the visceral organs
The liver is most frequently infected Individuals with bacillary peliosis and bacillary
angiomatosis may have relapsing fevers Dissemination can result in osteomyelitis,
endocarditis, encephalopathy, seizures, neuroretinitis, and transverse myelitis
Nonspecific symptoms include fever, chills, night sweats, anorexia, weight loss, abdominal pain, vomiting, and diarrhea
July 200920 www.aidsect.org
Bartonellosis: Bartonellosis: DiagnosisDiagnosis
Diagnosis usually made by means of a biopsy with demonstration of small gram-negative bacilli
Isolated with difficulty from blood and tissue culture
Indirect fluorescent antibody and enzyme immunoassay tests are available at some laboratories
Cross-reactivity among Bartonella species and other bacteria is common
PCR is the most sensitive means of diagnosis
July 200921 www.aidsect.org
Bartonellosis: Bartonellosis: PreventionPrevention
Reduce exposure to cats and cat fleas Treat infestations of body lice Consider risk of ownership of cats, especially
for individuals who are severely immunocompromised
July 200922 www.aidsect.org
Bartonellosis: Bartonellosis: TreatmentTreatment
Treatment of cat scratch disease in immunocompetent individuals is mainly supportive
In vitro and in vivo antibiotic susceptibilities do not correlate well with efficacy
Drug of choice is erythromycin or doxycycline Clarithromycin and azithromycin treatment has
been associated with clinical responses
July 200923 www.aidsect.org
Bartonellosis: Bartonellosis: Treatment Treatment (2)(2)
Severe disease requires IV administration Treatment should be given for 3 months for
bacillary angiomatosis and 4 months for bacillary peliosis central nervous system disease, osteomyelitis and other severe systemic infections
Add rifampin to either erythromycin or doxycycline for severely infected immunocompromised individuals
July 200924 www.aidsect.org
Bartonellosis: Bartonellosis: Treatment FailureTreatment Failure
Immunocompromised individuals who experience treatment failure should be re-treated for 4-6 months
Immunocompromised HIV-infected adults who experience relapse have been treated with long-term suppression with doxycycline or a macrolide when CD4 counts are <200 cells/µL
There are no data for children
July 200925 www.aidsect.org
Syphilis: Syphilis: EpidemiologyEpidemiology
Perinatal transmission of Treponema pallidum at any stage of pregnancy or during delivery
Illicit drug use during pregnancy increases risk of maternal and congenital syphilis
Rate of congenital syphilis 50 times greater among infants born to HIV-infected mothers
Half of new infections are in women 15-24 years of age
July 200926 www.aidsect.org
Syphilis: Syphilis: Clinical ManifestationsClinical Manifestations
Untreated early syphilis in pregnancy leads to spontaneous abortion, stillbirth, hydrops, preterm delivery, death in up to 40% of pregnancies
47% of infants born to mothers with inadequately treated syphilis have clinical, radiographic, or laboratory findings consistent with congenital syphilis
July 200927 www.aidsect.org
Syphilis: Syphilis: Clinical Manifestations Clinical Manifestations (2)(2)
60% of infants with congenital syphilis have hepatomegaly, jaundice, skin rash, nasal discharge, anemia, thrombocytopenia, osteitis, periostitis, osteochondritis, or pseudoparalysis
Late manifestations include mental retardation, keratitis, deafness, frontal bossing, Hutchinson teeth, saddle nose, Clutton joints
July 200928 www.aidsect.org
Syphilis: Syphilis: DiagnosisDiagnosis
Use combination of physical, radiologic, serologic, and direct microscopic results, as standard serologic tests detect only IgG
All infants born to mothers with reactive nontreponemal and treponemal tests should be evaluated with a quantitative nontreponemal test (eg, slide test, RPR, automated reagin test)
July 200929 www.aidsect.org
Syphilis: Syphilis: Diagnosis Diagnosis (2)(2)
Darkfield microscopy or direct fluorescent antibody staining
Presumptive diagnosis – any infant, regardless of physical findings, born to an untreated or inadequately treated mother with syphilis
July 200930 www.aidsect.org
Syphilis: Syphilis: Prevention Prevention – Congenital Congenital SyphilisSyphilis
Routinely screen all pregnant women with serologic testing during first prenatal visit
Obtain information regarding the treatment of sexual partners for sexually transmitted diseases
Serologic testing of mothers serum is preferable Routine screening of newborns’ serum or
umbilical cord blood is not recommended
July 200931 www.aidsect.org
Syphilis: Syphilis: Prevention Prevention – Acquired Syphilis Acquired Syphilis
Routine discussion of sexual behaviors that place individuals at risk of syphilis and HIV
Routine serologic screening for syphilis annually for all sexually active HIV-infected individuals
The occurrence of syphilis in an HIV infected individual is an indication of high-risk behavior
Individuals undergoing screening or treatment for syphilis should be evaluated for all sexually transmitted diseases
July 200932 www.aidsect.org
Syphilis: Syphilis: Treatment Treatment – Congenital Syphilis Congenital Syphilis
Treat all infants whose mothers have untreated or inadequately treated syphilis; not treated or initiated treatment 4 weeks prior to delivery
Treat if mother treated with penicillin but no 4-fold decrease in nontreponemal antibody titer, or a 4-fold increase suggesting relapse or reinfection
Treat infants regardless of maternal history if examination suggests syphilis; darkfield or fluorescent antibody test positive or nontreponemal serologic titer = 4-fold higher than maternal level (A II)
July 200933 www.aidsect.org
Syphilis: Syphilis: Treatment Treatment – Congenital Syphilis Congenital Syphilis (2)(2)
Aqueous crystalline penicillin G: 100,000-150,000 units/kg/day given as 50,000 units/kg/dose IV Q12H for 7 days, followed by Q8H for a total of 10 days (A II)
Diagnosis after 1 month of age, increase dosage to 50,000 units/kg IV Q6H for 10 days
July 200934 www.aidsect.org
Syphilis: Syphilis: Treatment Treatment – Acquired Syphilis Acquired Syphilis
Treat acquired syphilis with single dose of benzathine penicillin G 50,000 units/kg IM
Treat late latent disease with benzathine penicillin G 50,000 units/kg IM once weekly for 3 doses (A III)
Alternative therapies among HIV-infected patients have not been evaluated
Treat neurosyphilis with aqueous penicillin G 200,000 to 300,000 units/kg IV Q6H for 10-14 days
Follow up with examinations at 1, 2, 3, 6, and 12 months and serologic tests at 3, 6, and 12 months; if titers continue to be positive or increase, consider retreatment (A III)
July 200935 www.aidsect.org
This presentation was prepared by Arthur Ammann, MD, Clinical Professor of Pediatrics University of California and President of Global Strategies for HIV Prevention for the AETC National Resource Center, in July 2009
See the AETC NRC website for the most current version of this presentation:
http://www.aidsetc.org
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