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Management of AIDS-Related Opportunistic Infections: Key Guidelines and Treatment Options

This presentation by Dr. Judith A. Aberg at the IAS–USA/RWCA Clinical Conference highlights critical management strategies for AIDS-related opportunistic infections. It discusses common infections such as Pneumocystis jiroveci pneumonia, Mycobacterium avium complex, and Toxoplasmosis, providing insights on diagnosis, prophylaxis, and treatment options. The impact of antiretroviral therapy (ART) on opportunistic infections, including immune reconstitution syndrome, is extensively covered. Practical approaches to managing drug interactions and the timing of ART initiation in OI cases are also addressed.

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Management of AIDS-Related Opportunistic Infections: Key Guidelines and Treatment Options

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  1. Management of AIDS-Related Opportunistic Infections Judith A. Aberg, MD JA Aberg, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004. The International AIDS Society–USA

  2. Pneumocystis jiroveci pneumonia • Pneumocystis is a fungi that produces pneumonia in immunosuppressed patients • Wide range of severity • It is the most frequent form of presentation of AIDS • Usually CD4 count less than 200 cells/mm3 • Diagnosis: clinical, induced sputum, BAL

  3. PCP Prophylaxis • CD4+ T cell count < 200 ; H/O oral candidiasis; Unexplained fever > 2 weeks; Previous episode of PCP • TMP/SMX DS 1 tablet po daily • Dapsone 50 mg po b.i.d. or 100 mg daily • Atovaquone 1500 mg po daily • Pentamidine aerosol 300 mg monthly

  4. Treatment • TMP/SMX for 21 days • Pentamidine • TMP plus dapsone • Clindamycin plus primaquine • Atovaquone • Trimetrexate plus leucovorin • Corticosteroids : pO2< 70 mm/Hg or A-a gradient > 35 mm Hg

  5. Disseminated Mycobacterium avium • Usually late in the course of AIDS (CD4 <50) • Persistent fevers, night sweats, fatigue, weight loss, and anorexia • Hepatosplenomegaly, lymphadenopathy, and (rarely) jaundice • Anemia, leukopenia, elevated alkaline phosphatase levels are common

  6. Mycobacterium avium complex • Improved survival with 3 drugs vs 2: • CLR 500 mg po bid (AZ 500 mg daily) • EMB 15 mg/kg po qd • RBT 300 mg po qd (adjust for ART) • Failure to response/relapse • Susceptibility testing • Ciprofloxacin 500-750 mg po bid or levofloxacin 500 mg qd • Amikacin 10-15 mg/kg IV qd

  7. Toxoplasmosis • Standard therapy is pyrimethamine plus sulfadiazine • Sulfadiazine may not be available • Pyrimethamine 200 mg load the 50 mg daily plus clindamycin 600 mg qid plus leucovorin 10 mg daily. • SMX/TMP (based on 5 mg/kg TMP) bid • If no clinical/radiographic improvement in 2 weeks or clinical decline in one week: BIOPSY

  8. Differential for Toxo: Chagas • USA has second largest Latino population • Southern US, Latin America to central Argentina • Trypanosoma cruzi • Transmitted by “kissing” (reduviid) bugs, blood transfusions • 1:500 blood donors in LA positive • 1:600 donors positive in 3 SW states • Chagoma: portal of entry • Cardiac, GI, CNS • 16-18 million infected and 50,000 die annually

  9. Chagas Disease • Diagnosis • Serological : limited, not standardized • Buffy coat, GMS • Biopsy • ? Role of T. cruzi IgG: look for chronic carriers. Reactivation similar to toxo • PCR? • Treatment: Nifurtimox 8-10 mg/kg daily

  10. Leishmaniasis • Asia, Mid-East, India, Africa, Brazil, Spain, France, Italy • Sandflies • Weight loss, F/S, anemia, leukopenia, hepatosplenomegaly: weeks to months • Diagnosis: Liver, spleen or BM Biopsy (liver bx least helpful), Buffy coat, EIA and IFA • Treatment: Liposomal AMB drug of choice in HIV. Pentavalent antimonial drugs associated with high relapse and failure

  11. Cytomegalovirus • Immediate vision-threatening: GCV implant plus VGCV 900 mg po qd • Peripheral non-vision threatening: GCV implant • Duration of therapy: continue until immune reconstitution • GI: VGCV for 14-21 days • Neuro: Combined IV FOS and GCV

  12. Fungal Infections • Cryptococcosis and Histoplasmosis: Safe to stop secondary prophylaxis if CD4 >150 • Coccidioidomycosis: Do not stop prophylaxis • Penicilliosis • Asia particularly Thailand • Similar to Histo • AMB  ITZ 400 mg

  13. Human papillomavirus • Genital warts usually type 6 or 11 • Podofilox 0.5% solution or gel, apply bid for 3 days, cycle q 4 weeks (50 % response) • Imiquimod 5% cream. Apply at bedtime and wash off in am. Apply 3 non-consecutive nights per week up to 16 weeks (response variable) • Cryotherapy, Surgical Excision, TCA cauterization, cidofovir topical, podophyllin

  14. Anogenital dysplasia • Anal and cervical PAP smears • Colposcopsy indications: • Visible lesion on cervix regardless of PAP results • ASCUS (atypical squamous cells-undetermined significance). Treat for infectious etiology. F/U PAP 2-3 month after treatment. If no infection, repeat PAP q 4-6 months until 3 negative PAP over 2 year period. If second report of ASCUS, do colpo • ASCUS-H (cannot rule out high-grade disease) • ASCUS and previous h/o abnormal • LSIL or HSIL (squamous intraepithelial lesion) • High-resolution anoscopy (HRA) if LSIL or HSIL on anal PAP. Consider ASCUS or ASCUS-H. Biopsy

  15. Effect of ART on OIs • Multiple studies show reduction in OIs on ART • Decreased morbidity/mortality • Improvement in pathogen specific immunity • Parodoxical reactions • Immune reconstitution syndromes • Atypical manifestations

  16. What should we do with ART-naïve? • Risk vs benefit • First line: treat OI • Consider ART • Drug interactions • Drug toxicities • Risk of immune reconstitution syndrome • Consider wait • Consider steroids • If sub-optimal CD4 response??

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