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![Page 1: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/1.jpg)
Treatment and Prevention of Opportunistic Infections:Options for the Caribbean
Region
Treatment and Prevention of Opportunistic Infections:Options for the Caribbean
Region
Excerpted from presentation by Jonathan E. Kaplan, M.D.
Excerpted from presentation by Jonathan E. Kaplan, M.D.
![Page 2: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/2.jpg)
What is the most frequent serious opportunistic infection in HIV-infected adults in the Caribbean region?
A. .Toxoplasma gondii encephalitis
B. .Tuberculosis
C. .Pneumocystis jiroveci pneumonia (PCP)
D. .Cryptosporidium spp. infection
E. .Hookworm infection
![Page 3: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/3.jpg)
Can you confirm the diagnosis of Pneumocystis jiroveci pneumonia (PCP) in your practice setting?
A. Yes
B. No
C. Don’t know
![Page 4: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/4.jpg)
What clinical specimens are collected to diagnose Pneumocysis infection? • Expectorated sputum
• Induced sputum
• Bronchial washings
• Lung biopsy
• Blood cultures
![Page 5: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/5.jpg)
How you confirm cryptococcal infection in your practice setting?
A. India Ink stain
B. Culture
C. Cryptococcal antigen test
![Page 6: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/6.jpg)
Chemoprophylaxis against Pneumocystis jiroveci pneumonia (PCP) with trimethoprim-sulfamethoxazole (TMP-SMZ) can also reduce the incidence of:
A. Non-typhoidal Salmonella disease
B. Toxoplasmic encephalitis
C. Bacterial pneumonia
D. Isosporiasis
E. All of the above
![Page 7: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/7.jpg)
Natural Course of HIV Infection and Common ComplicationsNatural Course of HIV Infection and Common Complications
00
100100
200200
300300
400400
500500
600600
700700
800800
900900
10001000
0 1 2 3 4 5 1 2 3 4 5 6 7 8 9 10 110 1 2 3 4 5 1 2 3 4 5 6 7 8 9 10 11
CD
4+ c
ell C
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nt
CD
4+ c
ell C
ou
nt
AsymptomaticAsymptomatic
HZVHZV
OHLOHL
OCOCPCPPCP
CMV, MACCMV, MACTBTB
TBTB
MonthsMonths Years After HIV InfectionYears After HIV Infection
Acute HIVAcute HIVinfectioninfectionsyndromesyndrome
Relative level of Plasma HIV-RNARelative level of Plasma HIV-RNA
CD4+ T cellsCD4+ T cells
![Page 8: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/8.jpg)
Caribbean Guidelines for the Treatment of Opportunistic Infections in Adults and Adolescents Infected with the Human Immunodeficiency Virus
![Page 9: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/9.jpg)
![Page 10: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/10.jpg)
Mucocutaneous Candidiasis: TreatmentMucocutaneous Candidiasis: Treatment
• Oral candidiasis (thrush)
• Esophageal candidiasis
Clotrimazole troches, 10 mg 5 times/day for 7 days
Fluconazole, 3-6 mg/kg/day for 1-2 weeks. Chronic maintenance therapy suggested for several months (fluconazole, 200 mg/day)
![Page 11: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/11.jpg)
![Page 12: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/12.jpg)
![Page 13: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/13.jpg)
Pneumocystis jiroveci (formerly carinii) Pneumonia (PCP)Pneumocystis jiroveci (formerly carinii) Pneumonia (PCP)
• History: subacute onset (days to weeks) of shortness of breath, dry cough, fever
• Physical exam: tachypnea and hypoxemia• CXR typically shows bilateral, diffuse,
interstitial pulmonary infiltrates• Diagnosis difficult: requires bronchoscopy or
sputum induction and special stains• Treatment: TMP-SMZ (cotrimoxazole, CTX),
15-20 mg/kg/day for 3-4 weeks• For severe cases, add prednisone, 40 mg/day
tapering over 3 weeks• Chronic maintenance therapy required (CTX
160/800 mg/day)
![Page 14: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/14.jpg)
![Page 15: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/15.jpg)
AFB SmearAFB Smear
AFB (shown in red) are tubercle bacilli
![Page 16: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/16.jpg)
Tuberculosis in HIV-Infected Persons
• Causes 11% of HIV-related deaths worldwide• Can occur at any CD4 count• Clinical presentation increasingly atypical as
CD4 count declines• In resource-poor areas, a significant percentage
of newly-diagnosed HIV-infected persons will be found to have active TB
• Should always consider TB in an HIV-infected persons with a pulmonary infiltrate
![Page 17: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/17.jpg)
![Page 18: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/18.jpg)
![Page 19: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/19.jpg)
Bacterial Pneumonia in HIV-Infected Persons• About 8 times more common in HIV-infected
vs non-HIV-infected persons• Pneumococcal bacteremia about 100 times
more common• Can occur at any CD4 count• Common etiologies: S. pneumoniae, H.
influenzae, P. aeruginosa, S. aureus• Treatment: penicillin/ampicillin +/-
aminoglycoside; or cephalosporin
![Page 20: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/20.jpg)
![Page 21: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/21.jpg)
Cryptococcal Meningitis
• History: severe headache, fever, mental disturbance
• Physical exam: no focal neurological signs• Differential: bacterial, TB• LP: high opening pressure, elevated protein,
low glucose, organisms• Treatment: amphotericin x 2 wks, then
fluconazole x 8-10 weeks• Chronic maintenance therapy: fluconazole,
200mg/day
![Page 22: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/22.jpg)
![Page 23: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/23.jpg)
Cerebral toxoplasmosisCerebral toxoplasmosis• History: headache, fever, confusion, motor
weakness
• Physical exam: focal neurological signs
• Diagnosis: demonstration of multiple mass lesions on CT or MRI
• Treatment: pyrimethamine plus sulfadiazine plus folinic acid for 8 weeks
• Chronic maintenance therapy: same
![Page 24: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/24.jpg)
WHO Integrated Management of Adolescent and Adult Illness
• Consists of 4 modules: Acute Care, Chronic HIV Care with ARV Treatment, General Principles of Good Chronic Care, Palliative Care
• Posted on WHO website in Dec 2003 (available at www.who.int/3by5/publications/imai/en/)
• Acute Care: syndromic treatment of illness
- appropriate for all patients, but with attention to
HIV;
- oriented to Health Center level
![Page 25: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/25.jpg)
Immune Reconstitution SyndromesImmune Reconstitution Syndromes
• Tuberculosis (“paradoxical reaction”)
• Mycobacterium avium complex (MAC)
• Pneumocystis jiroveci pneumonia (PCP)
• Toxoplasmosis
• Hepatitis B
• Hepatitis C
• Cytomegalovirus (CMV)
• Varicella Zoster Virus (VZV)
• Cryptococcosis
• Progressive multifocal leukoencephalopathy (PML)
![Page 26: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/26.jpg)
Caribbean Guidelines for the Prevention of Opportunistic Infections in Adults and Children Infected with Human Immunodeficiency Virus
![Page 27: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/27.jpg)
What diseases may be prevented?What diseases may be prevented?
• Pneumocystis jiroveci pneumonia (PCP)
• Cerebral toxoplasmosis
• Tuberculosis
• Mycobacterium avium complex (MAC) disease
• Disease caused by S. pneumoniae
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Prophylaxis against PCP
• Survival benefit demonstrated; first recommended in 1989
• Eligibility criteria: CD4 count <200 cells/uL or <14% or history of oral candidiasis
• Drug of choice: TMP-SMZ (CTX) 160/800 (1 double-strength tab) qd
![Page 29: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/29.jpg)
Cotrimoxazole ProphylaxisCotrimoxazole Prophylaxis
Can prevent:
• Pneumocystis jiroveci pneumonia• Cerebral toxoplasmosis• Disease caused by S. pneumoniae• Disease caused by non-typhoid Salmonella• Nocardiosis• Isosporiasis• Malaria
![Page 30: Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Excerpted from presentation by Jonathan E. Kaplan, M.D.](https://reader035.fdocuments.in/reader035/viewer/2022081602/551b77c5550346167e8b4594/html5/thumbnails/30.jpg)
CTX Prophylaxis: Other Advantages
• Cheap ($1 US/month)• Easy to administer: only contraindication is
history of sulfa allergy• Main adverse reaction is skin rash, but
uncommon in dark-skinned persons• Clinical monitoring is adequate• Adherence is not critical• Experience taking daily medication; good
preparation for ART
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Isoniazid Preventive Therapy (IPT)Isoniazid Preventive Therapy (IPT)
• International “best practice”• If skin testing available, may reserve for persons with
positive tuberculin skin test (> 5 mm induration)• Otherwise, IPT suggested for all HIV-positive patients
living in countries with high prevalence of TB• IPT also suggested for HIV-positive persons exposed
to case of active TB• Give isoniazid (INH), 300 mg per day for 9 mo• EXCLUSION OF ACTIVE TB IS CRITICAL
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Preventing Disease Recurrence: OIs that Require Preventive Therapy for LifePreventing Disease Recurrence: OIs that Require Preventive Therapy for Life
• PCP
• Cerebral toxoplasmosis
• Systemic (deep) fungal infections: cryptococcosis, histoplasmosis
• Disseminated MAC infection
• CMV disease
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Prophylaxis against First Episode of Opportunistic Disease in HIV-exposed/infected Infants and Children
Prophylaxis against First Episode of Opportunistic Disease in HIV-exposed/infected Infants and Children
Pathogen
Pneumocystis jiroveci
Mycobacterium tuberculosis
Indication
HIV-exposed/infected children 1-12 months; older HIV-infected children with CD4< 15%
Contact with person with TB
Drug
Cotrimoxazole
Isoniazid