Opportunistic Infections

in HIV patients

OIs in HIV
2551 2555 62
HIV infection OIs infection
50
PCP 26.3
cryptococcus 8.3

OIs in HIV
1. TB
2. opportunistic infections

PCP
Cryptococcosis
Candidiasis
Toxoplasmic encephalitis
Penicilliosis and histoplasmosis
CMV
MAC

Tuberculosis
-HIV TB ,
TB HIV CD4 < 200 cell/mm3

- CXR Sputum AFB x 2

- Culture nontuberculous mycobacteria (NTM)
- CXR sputum AFB negative

-
- Molecular method : PCR

Tuberculosis

- 6 9 x-ray
2 9
- 12
9- 12

* pyridoxine 25-50 mg OD INH

Tuberculosis

multi-drug resistant TB INH

rifampicin 3- 4 1

Tuberculosis
steroid : meningitis ,pericarditis
Prednisolone 1 mg/kg/day 3 week
3 week

Tuberculosis

-
- CXR

- (intensive
phase) 2
2 INH rifampicin
- direct observe therapy (DOT)

Tuberculosis

antihistamine
steroid

INH Rifampicin ethambutol
pyrazinamide
3-5

Tuberculosis

INH, rifampicin pyrazinamide

ALP bilirubin
transaminase enzyme rifampicin
AST ALT > 5
> 3 INH, rifampicin
pyrazinamide ethambutol, quinolones, streptomycin

AST ALT < 2

total
bilirubin < 1.5 mg/dL
INH, rifampicin pyrazinamide
1

Tuberculosis

ALT > 3

2 2SIRE/7IR
,9IRE, 9RZE
1 2SIE/16IE,
18-24IE + quinolone

Tuberculosis

ethambutol metabolites pyrazinamide
CrCl < 30
mL/min

3
streptomycin

hemodialysis

Tuberculosis

- Rifampicin
CYP450 efflux multi-drug transporter
P-glycoprotein NNRTIs PIs

NNRTIs EFV NVP

PI
1. PI NNRTIs ( EFV NVP)
integrase
inhibitor ( RAL)
2. NNRTIs integrase inhibitor
2IEZ + quinolone/10-16IE + quinolone
streptomycin 2

Tuberculosis

CD4

Tuberculosis

2
rifampicin

rifampicin
1. EFV 600 mg
2. NVP 200 mg 2
lead-in
3. RAL 400 mg 2

NRTIs 2

Tuberculosis
(IRIS)
-

TB IRIS TB ARV
paradoxical TB IRIS
CD4

ARV
unmarking TB IRIS

:
3

2-4 week
Anti-TB ARV dose
prednisolone 1 mg/kg/day trapper off q 2 wk
4-8 week

PCP
-

Pneumocystis jirovecii
the most common opportunistic infection in persons with HIV
infection

PCP
A. Primary prophylaxis

-. CD4 < 200 cells/mm3

-. %CD4 < 14%
-. oropharyngeal candidiasis
-. AIDS-defining illness (TB)

PCP

trimethoprim-sulfamethoxazole (TMP-SMX) single-strength (SS)
tablet (TMP 80 mg-SMX 400 mg) 1-2 oral OD
2
toxoplasmosis

TMP-SMX
: dapsone 100 mg oral OD atovaquone 1,500 mg oral OD
clindamycin primaquine

PCP

PCP

CD4 200 cells/mm3 3
primary prophylaxis CD4
200
cells/mm3

PCP
B. Treatment

TMP-SMX TMP 15-20 mg/kg/day SMX 75-100
mg/kg/day
IV drip 1 . 3-4 21
TMP-SMX


(desensitization)

PCP

Clindamycin 600 mg iv drip q 6 . 900 mg iv drip q 8 .
300 mg oral q 6 . 450 mg 8.
primaquine 30 mg oral 21
Pentamidine isethionate 3-4 mg/kg iv drip 1
. 21
** PaO2 < 70 mmHg alveolar-arterial (A-a) gradient
35 mmHg prednisolone ( 72
)
40 mg oral bid x 5 then 40 mg oral OD x 5 then 20
mg oral OD 11

PCP
C. Secondary prophylaxis

PCP

primary prophylaxis

CD4 200 cells/mm3 3

CD4 < 200 cells/mm3

PCP CD4 > 200 cells/mm3 secondary
prophylaxis CD4

Cryptococcosis
-

cryptococcus neoformans
TB ,PCP
cryptocoocal antigen
CD < 100 cell/mm3

Cryptococcosis
A. Primary prophylaxis

CD4 < 100 cells/mm3
C. neoformans
cryptococcal antigen ()

Fluconazole 400 mg

CD4 100 cells/mm3 3

Cryptococcosis
B. Treatment
Induction phase: 2

Amphotericin B 0.7-1.0 mg/kg/day iv drip + fluconazole 800
mg/day oral or iv Tx. meningitis

Amphotericin B 1.0 mg/kg/day iv drip

fluconazole

Fluconazole 1,200 mg/day oral or iv drip

amphotericin B

Cryptococcosis
Consolidation phase: 8-10

Fluconazole 400-800 mg/day

Itraconazole 400 mg/day 2
cryptococcal antigen

(cryptococcal antigenemia) consolidation
phase

Cryptococcosis
C. Secondary prophylaxis

cryptococcosis induction
consolidation secondary prophylaxis

fluconazole 200-400 mg/day
fluconazole 6 mg/kg ( 200 mg)

itraconazole 200 mg/day
itraconazole 5 mg/kg ( 200 mg)

Cryptococcosis

cryptococcosis
1
CD4 100 cells/mm3 3
HIV (undetectable HIV VL)
CD4 100 cells/mm3

Candidiasis
mucocutaneous candidiasis oropharyngeal
candidiasis ,cervicovaginal candidiasis ,esophageal candidiasis

oropharyngeal candidiasis

CD4 < 100 cells/mm3, HIV VL , WBC < 500 cells/mm3

esophageal candidiasis herpes
simplex virus CMV esophagitis

Candidiasis
A. Primary prophylaxis

B. Treatment
1. Oropharyngeal candidiasis

Clotrimazole oral troches 10 mg 4-5 7-14
Fluconazole 100 mg 7-14

Nystatin oral solution 500,000 5
7-14
Itraconazole capsule 100 mg 7-14
Itraconazole oral solution 100 mg 7-14
Amphotericin B 0.3-0.5 mg/kg/day 714

Candidiasis
2. Esophageal candidiasis

Fluconazole 200 mg 14-21

Itraconazole capsule 200 mg 2 14-21
Itraconazole oral solution 200 mg 2 14-21
Amphotericin B 0.3-0.5 mg/kg/day 14-21
3. Cervicovaginal candidiasis

Clotrimazole vaginal cream 5 mg/day clotrimazole vaginal suppository
tablet 100 mg 3-7
Fluconazole 200 mg

Miconazole cream 5 mg/day miconazole vaginal suppository tablet 100
mg 7
Itraconazole capsule 200 mg 3
Itraconazole oral solution 200 mg 3

Candidiasis
Secondary prophylaxis

fluconazole 100-200 mg itraconazole 100-200 mg

fluconazole 3-6 mg/kg ( 200 mg) itraconazole

5 mg/kg ( 200 mg)

CD4 200 cells/mm3
6 %CD4 15%
6

Toxoplasmic encephalitis
Toxoplasma gondii

Toxoplasmic encephalitis
A. Primary prophylaxis

CD4 < 100 cells/mm3

TMP-SMX SS tablet 2 oral OD

TMP-SMX SS tablet 1 oral OD 2 oral 3day/week
Dapsone 50 mg pyrimethamine 50 mg

folinic acid (leucovorin) 25 mg

Dapsone 200 mg pyrimethamine 75 mg folinic acid 25
mg

** TMP-SMX primary prophylaxis PCP

Toxoplasmic encephalitis
B. Treatment

Pyrimethamine 200 mg 1 50 mg/day (. 60 kg)

75 mg/day (. > 60 kg) + sulfadiazine 1,000 mg (. 60

kg) 1,500 mg (. > 60 kg) 4 + folinic acid 10-25
mg/day oral OD 6

TMP-SMX TMP 5-10 mg/kg/day SMX 25-50 mg/kg/day
2
Pyrimethamine clindamycin 600 mg
6
Pyrimethamine azithromycin 1,000-1,250
mg/day

Toxoplasmic encephalitis
acquired CNS ocular systemic toxoplasmosis
-

Pyrimethamine 2 mg/kg/day ( 50 mg) 3

1 mg/kg/day (25 mg) folinic acid 1025 mg/day sulfadiazine25-50 mg/kg/dose ( 11.5 g/dose) 4 6

sulfadiazine clindamycin 5-7.5 mg/kg/dose

4 ( 600 mg/dose) pyrimethamine folinic acid

prednisolone dexamethasone
CSF
protein (>1,000 mg/dL)

pyrimethamine CBC

Toxoplasmic encephalitis
C. Secondary prophylaxis

toxoplasma

pyrimethamine 25-50 mg/day
sulfadiazine
500-1,000 mg 4 folinic acid 10-25 mg/day

pyrimethamine 25-50 mg/day
clindamycin
600 mg 8 . folinic acid 10-25 mg/day
TMP-SMX SS tablet 2
clindamycin 20-30 mg/kg/day 4
pyrimethamine 1 mg/kg folinic acid 5 mg 3

Toxoplasmic encephalitis



CD4 200 cells/mm3 6
CD4 200 cells/mm3

Penicilliosis & Histoplasmosis

Penicilliosis histoplasmosis

- CD4 100 cells/mm3 (penicilliosis)
- 150 cells/mm3 (histoplasmosis)
penicilliosis papulonecrotic skin
lesions
histoplasmosis


Wright stain
histoplasmosis
penicilliosis

65 penicilliosis

Penicilliosis & Histoplasmosis

A. Primary prophylaxis



CD4 100 ( penicilliosis) 150 (
histoplasmosis) cells/mm3

B. Treatment
Induction phase

Amphotericin B 0.6-0.7 mg/kg/day 7-14

Itraconazole 200 mg 3 3 200 mg
2 14

Penicilliosis & Histoplasmosis

Consolidation phase

Itraconazole 200 mg 2 10-12

Amphotericin B 0.4-0.5 mg/kg/day
10-12
Fluconazole 800 mg 10-12

Penicilliosis & Histoplasmosis

C. Secondary prophylaxis

penicilliosis histoplasmosis

itraconazole 200 mg

fluconazole 400 mg
Amphotericin B 0.6-0.7 mg/kg
malabsorption

Penicilliosis & Histoplasmosis

CD4 100 ( penicilliosis)

150 ( histoplasmosis) cells/mm3 6

CD4

CMV

CD4 < 50 cells/mm3

CMV retinitis
HIV
CD4 < 50 cells/mm3

screening CMV retinitis

4-6

CMV
A. Primary prophylaxis

CD4 100 cells/mm3
B. Treatment

Ganciclovir 5 mg/kg 12 . 2-3

3-6
Valganciclovir 900 mg 2 2-3

CMV

Ganciclovir intravitreous 2,000 g/dose 1

Ganciclovir implant 4.5 mg

vitreous 6-8
ganciclovir retinitis

ganciclovir CD4
HIV RNA

CMV
C. Secondary prophylaxis

CMV retinitis

valganciclovir 900 mg

ganciclovir 5 mg/kg/dose
Ganciclovir intravitreous 2,000 g 1 2-4

CMV

retinitis

CMV retinitis 3-6

CD4 100 cells/mm3 3-6

CD4 100 cells/mm3

3-6

MAC
MAC nontuberculous mycobacterium

CD4 < 50 cells/mm3

MAC

- mycobacteria
-

MAC
A. Primary prophylaxis
clarithromycin azithromycin

CD4 < 50 cells/mm3
2 MAC clarithromycin



CD4 < 50 cells/mm3

MAC

- clarithromycin 500 mg 2
- azithromycin 1,000-1,250 mg

CD4 100
cells/mm3
3 CD4
50
cells/mm3

MAC
Treatment

Clarithromycin 500 mg 2 ethambutol 15
mg/kg/day

Azithromycin 500 mg ethambutol 15
mg/kg/day

( 4-8

)
quinolones (ciprofloxacin 500-750 mg 2
levofloxacin 500 mg
moxifloxacin 400 mg ) amikacin 15 mg/kg

MAC

: clarithromycin
CYP3A4

CYP3A4
PIs

clarithromycin rifampicin, ergot alkaloids,
carbamazepine, cisapride azithromycin

rifampicin

MAC
B. Secondary prophylaxis

disseminated MAC

MAC 12
MAC
CD4 100 cells/mm3 6
CD4 100 cells/mm3

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