Adult OI Table 1.     TOP

Tuberculosis and HIV   TOP

Latent TB and HIV Co-infection Candidates For Testing

• All HIV-infected patients without prior positive PPD test upon entry into HIV care
• Repeat testing annually for HIV-infected patients at risk of acquiring TB who have no prior positive tests
• All HIV-infected patients with prior negative skin test who are discovered to be contacts of pulmonary cases

Indications For Treatment of Latent Tuberculosis Infection
(MMWR 2000;49 RR-6)

• Positive PPD (≥ 5 mm induration) plus no prior completed prophylaxis or treatment for TB disease
• Recent contact with TB case (Recent contacts who are initially TST negative should have TST repeated 12 weeks after last exposure to TB case; those placed on prophylaxis should be discontinued if PPD negative at 12 weeks)
• History of inadequately treated TB that healed

Patients meeting skin test positivity criteria should be evaluated to rule out active TB disease before initiating treatment

Adult OI Table 2.     TOP

Adult OI Table 3.     TOP

Special Considerations for TB Treatment with HIV Co-infection     TOP

Treatment of Tuberculosis Disease

American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: Treatment of Tuberculosis. Am J Respir Crit Care Med 2003;167(4):603

Special Treatment Notes

PREGNANCY: INH regimens preferred for pregnant women. Some experts would use RIF plus PZA as alternate regimen in HlV-infected pregnant women. PZA should be avoided during first trimester.

MDR-TB Exposure

Expert consultation is recommended for persons who are likely to be infected with INH and RIF (multidrug) resistant-TB and at high risk of reactivation.

ART/TB Treatment Interactions

* Rifabutin should not be used with hard-gel saquinavir (as sole PI) or delavirdine.

Rifampin/Rifabutin

See Drug Table 7

Identical for General Population Except:

• CD4 <100/mm³: Continuation phase should be daily or 3x/week; once weekly rifapentine regimen should not be used
• Positive cultures at 2 months: “Strongly consider” 7 month continuation phase (total 9 mo)
• In absence of prior HIV therapy and CD4 < 350/mm³: delay antiretroviral drugs for 4-8 weeks
• RIF may be used with 2 NRTIs + EFV, RTV + SQV (Invirase or Fortovase) or AZT/3TC/ABC
• Rifabutin combined with other PIs and NNRTI requires dose adjustment of both; See: www.cdc.gov/nchstp/tb/ or www.medscape.com/updates/quickguide
• When starting NNRTI or PI in patient receiving RIF, substitute rifabutin 2 weeks prior to NNRTI or PI to give a 2 week washout period for RIF
• Paradoxical reaction: Frequency is 7-36%; clinical features: high fever, increased adenopathy, CNS lesions, pulmonary infiltrates and pleural effusions; treatment: symptomatic; if severe give prednisone 1 mg/kg and reduce dose at 1-2 weeks

Adult OI Table 4.     TOP

Adult OI Table 5.     TOP

Adult OI Table 6.   TOP

Management of Opportunistic Infections
(MMWR 2004; 53 RR 15)

Bartonella: Treat ≥ 3 mo

• Preferred: erythromycin 500 mg qid po or IV or doxycycline 100 mg bid po or IV x ≥ 3 mo
• Alternative: azithromycin 600 mg/d po or clarithromycin 500 mg bid po x ≥ 3 mo
• Note: If relapse: treat lifelong; CNS: Use IV or po doxycycline

Candida Thrush: Treat 7–14 days

• Preferred: clotrimazole troches 10 mg po 5x/d or Nystatin susp 5 mL qid or pastilles 4–5 x/d or fluconazole 100 mg po/d; all 7–14 day
• Fluconazole–refractory: Itraconazole oral solution ≥ 200 mg/d po or amphotericin B 0.3 mg/kg/d IV
• Recurrent disease: Consider chronic fluconazole or itraconazole

Candida Esophagitis: Treat 14–21 days

• Preferred: Fluconazole 100 mg/d (up to 400 mg/d) po or IV x 14–21 days
• Alternative: Itraconazole oral soln 200 mg/d, capsofungin 70 mg IV x 1, then 50 mg/d x 7 days or amphotericin B 0.3–0.7 mg/kg/d or voricomazole 200 mg/d po or IV or liposomal amphotericin 3–5 mg/kg/d

Candida Vaginitis: Treat 3–7 days

• Preferred: Topical azole (clotrimazole, butoconazole, miconazole, ticonazole, terconazole) x 3–7 days or topical nystatin or fluconazole 150 mg x 1 day or itraconazole 200 mg bid x 1 day or 200 mg/d x 3 days
• Recurrent: Daily topical azole

Cryptococcoisis: Treat lifetime unless immune reconstitution

• Acute phase: Amphotericin B 0.7 mg/kg/d IV + flucytosine 25 mg/kg qid po x 14 days
• Consolidation phase: Fluconazole 400 mg/d po x 8 weeks
• Chronic maintenance phase: Fluconazole 200 mg/d po until CD4 > 100–200/mm³ x ≥ 6 mo
• Alternative — Acute phase: Amphotericin B 0.7 mg/kg/d x 14 days (without 5FC) or fluconazole 400–800 mg po or IV qd ± flucytocine 25 mg/kg/ qid po
• Alternative — Consolidation phase: Itraconazole 200 mg bid po
• Alternative — Chronic maintenance phase: Itraconazole 200 mg/d po until CD4 > 100–200/mm³ x ≥ 6 mo
• Note: Drain CSF if OP > 200 mL H₂O

Cryptosporidiosis

• Preferred: Symptomatic treatment + HAART
• Alternatives: Nitazoxanide 500 mg po bid or paromomycin 25–35 mg/kg/d in 2–3 doses

Cytomegalovirus retinitis

• Immediate sight-threatening lesions: Intraocular implant + valganciclovir 900 mg/d po
• Peripheral lesions: Valganciclovir 900 mg bid po x 14–21 days, then 900 mg/d
• Alternative: Ganciclovir 5 mg/kg q 12h IV x 14–21days, then 5 mg/kg/d or foscarnet 60 mg/kg IV q 8 h x 14–21 days, then 90–120 mg/kg/d single dose x 14 days or cidofovir 5 mg/kg/d weekly x 2 IV or 1 hr x 2 wks, then 5 mg/kg IV every other wk; patient must be hydrated with ≥ 1 L saline prior to cidofovir and receive probenecid 2 gm 3 hrs prior to cidofovir and 1 gm at 2 and 8 hrs after or fomivirsen intravitreal infections (relapses only)
• Maintenance therapy:
  • Preferred: Valganciclovir 900 mg po qd or foscarnet 90–120 mg/kg/d IV until: inactive disease, CD4 > 100–150 mm³ x 6 mo and consultation with ophthalmologist
  • Implant: Need replacement q 6–8 mo if CD4 < 100–150/mm³
  • Alternative: Maintenance ganciclovir, cidofovir
• Immune reconstitution uveitis (IRU): periocular steroids or short course systemic steroids

CMV esophagitis or colitis

• Preferred: Ganciclovir or foscarnet IV x 21–28 days or until symptoms resolve; valganciclovir po is appropriate if symptoms are not severe
• Maintenance: Not necessary except if there are relapses

CMV pneumonia

• Indication to treat: Histologic evidence of disease and failure to respond to other pathogens

CMV neurologic disease

• Preferred: Ganciclovir + foscarnet IV (above doses) until improvement
• Maintenance: Lifetime

Hepatitis B

• Indication for treatment: HBV: (HbeAg pos or HBV DNA >10⁵/mL) + (liver disease by histopathology or ALT > 2x ULN)
• HBV + HAART:
  • Preferred: TDF/FTC or TDF/3TC
  • Alternative: (3TC or FTC) + adefovir or entecavir
  • Preferred eAg pos: Peginterferon x 48 weeks
• HBV without HAART: Adofovir, entecavir or peginterferon

Hepatitis C

• Indications to treat: HCV RNA > 50 IU/mL, liver biopsy showing fibrosis or inflammation, no contraindications, stable HIV and (?) CD4 > 200/mm³
• Preferred: Peginterferon alfa2a 180ug or peginterferon alfa 2b 1.5 mg/kg, each SC q 9 weekly + ribavirin 400 mg bid po x 48 weeks

Herpes simplex: Moderate or severe mucocutaneous

• Preferred: Acyclovir 5 mg/kg q 8 h IV, then famciclovir 500 mg bid po or valacyclovir 1 gm bid po or acyclovir 400 mg tid po until lesions heal
• Acyclovir resistant: Foscarnet 120–200 mg/kg/d IV in 2–3 doses or cidofovir 5 mg/kg weekly until clinical response

Herpes zoster

• Dermatomal: Famciclovir 500 mg tid po or valciclovir 1 gm tid po x 7–10 days
• Extensive cutaneous or visceral: Acyclovir 10 mg/kg q 8 h IV until response

Microsporidiosis

• Preferred: HAART + symptomatic treatment
• Enterocytozoon bieneusi (80% of diarrheal disease due to microsporidia): Fumagillin 60 mg/d po
• Non-enterocytozoon bieneusi (20% of diarrheal disease): Albendazole 400 mg po bid until CD4 > 200/mm³
• Disseminated disease: Itraconazole 400 mg/d, albendazole 400 mg bid (Brachiola or Trachipleistophora)

Mycobacterium avium

• Preferred: Clarithromycin 500 mg bid po plus ethambutol 15 mg/kg/d po ± rifabutin 300 mg/d po until treatment ≥ 12 mo + asymptomatic + CD4 > 100/mm³ ≥ 6 mo
• Alternative: Azithromycin 500–600 mg/d po in place of clarithromycin
• Alternative “3rd drug”: ciprofloxacin 500–750 mg bid po or levofloxacin 500 mg/d po or amikacin 10–15 mg/kg/d IV
• Immune reconstitution: Moderately severe — NSAIDs; severe or persistent — prednisone 20–40 mg/d x 4–8 weeks

Mycobacterium tuberculosis (see Adult OI Tables on tuberculosis)

Pneumocystis jiroveci (also known as Pneumocystis carinii)

• Preferred: TMP–SMX 15–20 mg TMP/kg/d IV in 3–4 daily doses or 2 DS tid po x 21 days
• Alternative (IV therapy): Pentamidine 3–4 mg/kg IV infused over 1 hr or dapsone 100 mg/d po + TMP 15 mg/kg/d (3 daily doses) or primaquine 15–30 mg (base)/d po + clindamycin 600–900 mg q 6–8 h IV or 300–450 mg q 6–8 po or atovaquone 750 mg bid po (with food)
• PaO₂ < 70 mm/Hg room air or A–a gradient: Day 1–5 40 mg bid; Day 6–10 40 mg/d; Day 11–21 20 mg/d
• Maintenance
  • Preferred: TMP–SMX 1 DS/d or 1 DS bid po
  • Alternative: Dapsone 100 mg/d po or dapsone 50 mg/d + pyrimethamine 50 mg/wk po + leucovorin 25 mg/wk po or aerosolized pentamidine 300 mg q mo or atovaquone 1500 mg/d po; All until CD4 > 200/mm³ x ≥ 3 mo

Toxoplasmosis

• Preferred: Pyrimethamine 200 mg/d po x 1 then 50 mg/d (<60 kg) or 75 mg/d (> 60 kg) plus sulfadiazine 1000 mg q 6 h po (< 60 kg) or 1500 mg q 6 h po (> 60 kg) plus leucovorin 10–20 mg/d po (up to 50 mg/d) x ≥ 6 weeks
• Alternative: Pyrimethamine and leucovorin (above doses) plus
1. Clindamycin 600 mg q6 h IV or po or
2. Atovaquone 1500 mg bid po or
3. Azithromycin 900–1200 mg/d po
4. TMP–SMX 5 mg/kg TMP bid IV or atovaquone 1.5 gm bid po (with meals)
   
• Maintenance

• Preferred: Sulfadiazine 500–1000 mg qid po + leucovorin 10–25 mg/d
• Alternative:
  1. Clindamycin 300–400 mg q 6–8 h plus pyrimethamine 25–50 mg/d + leucovorin 10–25 mg/d
  2. Atovaquone 750 mg q 6–12 h ± pyrimethamine 25 mg/d + leucovorin 10 mg/d
     Continue until CD4 ≥ 100/mm³, continue maintenance until CD4 >200/mm³ x ≥ 6 months