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Therapeutics P3 Spring > Exam 5 lecture 1 > Flashcards

Exam 5 lecture 1 Flashcards

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1
Q

What are the big 3 pathogens that we use prophylaxis for in opportunistic infections

A

Pneumocystitis Jiroveii pneumonia (PJP)

Toxoplasma gondii encephalitis (TE)

Mycobacterium avium complex (MAC)

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2
Q

What is an OI

A

Infections more frequent or more severe because of HIV mediated immunosuppression

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3
Q

What are common historical OI

A

Pneumocystitis pneumonia and other pneumonias

Toxoplasma encephalitis

CMV retinitis

Cryptococcal meningitis

TB

Disseminated mycobacterium avium complex (MAC) disease)

Histoplasmosis

Kaposi’s Sarcoma and other lymphoma

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4
Q

Normal CD-4 count in adults

A

800-1200

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5
Q

What CD4 counts are associated with development of OIs

A

<500 and especially <200

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6
Q

What CD4 cell counts do specific OIs happen at

A

Mycobacterium TB, pneumonias and dermatomal varicella zoster can occur at any CD4 count

CD4 count < 500- candidiasis and leukoplakia

CD4 count < 200- PJP, CMV retinitis, toxoplasmosis, MAC, cryptococcus meningitis or diarrhea, lymphomas and kaposis

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7
Q

Which OIs can increase HIV viral load? WHat effect does this have?

A

TB and syphilis can Increase HIV viral load

It can increase risk of viral transmission and progression

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8
Q

define primary and secondary prophylaxis

A

primary- administration of an anti infective agent to prevent the first episode of an OI in a patient living with HIV

secondary- They have had OI already and need administration of anti infective therapy to prevent further recurrences of an OI

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9
Q

What situations should we start ART during OI

A

In situations when there are not good OI treatments

  • PML
    -Cryptosporidosis
    -Kaposi’s Sarcoma
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10
Q

for other OI’s why can it be disadvantageous to strart ART

A
  • potential development of immune reconstitution inflammatory syndrome (IRIS)
  • Overlapping or additive drug toxicities
  • Drug interactions between ART and OI therapy
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11
Q

What is IRIS (immune reconstitution inflammatory syndrome (IRIS) (what does it do? WHat is it seen with? Most likely to occur in who)

A

Fever, inflammation and worsening manifestation of the OI

Can be seen with MAC, TB, PJP, toxoplasmosis, Hep B and C, CMV, cryptococcus, histoplasmosis and V. zoster

More likely tp occur in pts with low CD4 count (<50) and high RNA levels (>100,000)

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12
Q

When is IRIS the most common

A

within 4-8 wks of starting ART

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13
Q

How to avoid IRIS

A

Wait for clinical response to OI therapy (2 wks) then start ART.

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14
Q

IRIS tx

A

Treat the OI

Mild disease- Use NSAIDs for fever or pain and inhaled corticosteroids for bronchospasms

Severe- prednisone 1-2 mg/kg daily for 1-2 wks followed by taper

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15
Q

When do infections with candida species occur in HIV

A

Any stage but most common when CD 4 is lower than 200

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16
Q

What infection does candida cause? What is it susceptible to?

A

albicans

Susceptible to flucanozole

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17
Q

Diagnosis of oropharyngeal candidiasis thrush

A

painless, creamy, white plaque like lesions on buccal mucosa, hard or soft.

Dry mouth and taste alterations

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18
Q

Preferred tx of oropharyngeal candidiasis

A

Flucanozole 200 mg loading dose, followed by 100-200 mg PO daily for 7-14 days

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19
Q

Duration of flucanozole tx for orpharyngeal candidiasis

A

7-14 days

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20
Q

Alternative tx for oropharyngeal candidiasis

A

topical agents for initial, mild and moderate episodes only.

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21
Q

advantage and disadvantage of topical flucanozole

A

advantage- less drug exposure, decreased risk DI and SE and decreased drug resistance

Disadvantage- Unpleasant taste, GI, SEs and multiple daily dosing

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22
Q

What are the two topical agents for flucanozole tx

A

Nystatin suspension (100,000 units/ml)

Clotrimazole troches 10 mg lozenge

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23
Q

For topical tx, what is the dose and duration of nystatin suspension?
Dose and duration of clotrimazole troches?

A

Nystatin- 5 ml swish and swallow QID x 7-14 days

clotrimazole- 10 mg oral lozenge 5 x daily for 7-14 days

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24
Q

Comments about nystatin and clotrimazole agent

A

Nystatin- should be thoroughly rinsed in mouth and retained in mouth for as long as possible before swallowing

Clotrimazole- should be dissolved in mouth over 15-30 mins

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25
Tx of esophageal candidiasis
Topical therapy not effective Flucanozole 200 mg loading dose, followed by 100-200 mg PO or IV for 14-21 days
26
Tx duration for esophageal candidiasis
14-21 days
27
Vulvovaginal candidiasis tx (uncomplicated)
FLucanozole 150 mg PO x 1 dose Topical azoles for 3-7 days Ibrexafungerp 200 mg PO BID x 1 day
28
Tx for severe vulvovaginal candidiasis tx
Flucanozole 100-200 mg PO or topical for > 7 days Topical azoles for 3-7 days Ibrexafungerp 300 mg PO BID x 1 days
29
How to treat azole refractory vulvovaginal candidiasis
Boric acid 600 mg vaginal suppository once daily for 14 days
30
Is prophylaxis recommended in vulvovaginal candidiasis
no
31
What CD4 counts do cryptococcus usually appear in
<100
32
s/s of cryptococcal meningitis
s/s may be mild- fever, headache, nausea, dizziness, lethargy, irritability, impaired memory and behavioral changes Classic s/s of neck stiffness and photophobia only present in 25-33% of patients
33
How is cryptococcal meningitis diagnosed
Increased ICP India ink stain positive Biofire PCR/CSF culture + Increased cryptococcal antigen titer in CSF and serum
34
when to start tx of cryptococcal meningitis
Do not start ART until after induction therapy for OI has finished (IRIS very common in cryptococcus patients) and possibly after induction + consolidation
35
cryptococcal meningitis tx
Induction- amphotericin B 3-4 mg/kg IV once daily + flucytosine 25 mg/kg PO QID for 2 weeks Consolidation- flucanozole 800 mg PO daily for > 8 wks (400 mg daily in stable patients with sterile CSF culture and on ART) maintenance- Flucanozole 200 mg daily for 1 year or longer
36
cryptococcal meningitis prophylaxis
NO PRIMARY PROPHYLAXIS secondary prophylaxis is the maintenance therapy
37
when can we stop secondary prophylaxis for cryptococcal meningitis
May dx if - has completed one year - is asymptomatic - has CD4 count > 100 for 3 months on ART with suppressed viral load Restart prophylaxis if the patients CD4 count drops below 100
38
s/s of histoplasmosis
Asymptomatic and self limited pulmonary disease up to disseminated disease. s/s- fever, fatugue, weightloss and hepatosplenomegaly cough and dyspnea in 50% of patients GI disease, N,V,D abdominal pain
39
what should we limit exposure to for histoplasmosis
soil chicken coups, bird/bat droppings Old buildings caves
40
histoplasmosis tx when to start
START ART AS SOON AS POSSIBLE after starting antifungal therapy. less concern for IRIS in histo patients
41
tx of mild histoplasmosis
mild-moderate- Itraconazole 200 mg TID x 3 days then 200 mg BID for 12 months Flucanozole 800 mg daily Voriconazole 400 mg BID x 1 days, then 200 mg BID Posaconazole- 300 mg BID x 1 day, then 300 mg daily
42
Tx of severe histoplasmosis
Liposomal amphotericin B 3 mg/kg IV daily for 2 wks followed by itraconazole 200 mg TID x 3 days, then 200 mg BID for at least 12 months If we cant use itraconazole use posa, vori or flucanozole
43
what CD4 count does histo occur at
<150
44
primary and secondary prophylaxis of histo
Primary- use itraconazole 200 mg PO qd, may stop if taking ART and CD4 > 150 for 6 months with viral suppression Secondary- Itraconazole 200 mg daily after maintenance therapy is complete
45
What CD4 count is MAC (mycobacterium avium coplex) occuring at
Higher risk- CD4 count < 50
46
How does MAC present itself as?
For HIV patients, not on ART, AMC presents as disseminated multi organ infection sx include- fever, night sweats, weight loss, doarrhea, abdominal pain and malaise/fatigue
47
What is a common effect seen in MAC that is not seen in other OIs
Night sweats
48
how is MAC diagnosed
COnfirmed diagnosis is based on s/s couple with isolation of MAC from acid-fst bacilli (AFB) cultures of blood, lymph fluid, bone marrow or other tissues/body fluids
49
When to start MAC therapy
Start ART as soon as possible, preferrably with initiation of MAC tx
50
How many drugs should treatment of MAC include?
At least 2 drugs as initial therapy to prevent or delay emergence of resistance
51
Preferred tx of MAC
Clarithromycin 500 mg PO BID + ethambutol 15 mg/kg PO QD or Azithromycin 500-600 mg PO daily + ethambutol 15 mg/kg PO QD
52
If MAC is very severe, what drug should be added
Add rifabutin 300 mg PO daily
53
What to worry about with rifabutin
drug interactions
54
how long to continue treatment for MAC treatment
12 months at least
55
56
Primary prophylaxis in MAC?
If they start ART after HIV diagnosis, do not start primary prophylaxis If they are not on ART and CD4 count < 50 use azithro 1200 mg PO once a week
57
WHen to discontinue and restart primary prophylaxis in MAC? What to rule out before starting prophylaxis
Discontinue when patient is continuing on a suppressive ART regimen Restart if CD4 count falls < 50 AND if not fully suppressive ART rule out disseminating MAC disease before starting prophylaxis
58
secondary prophylaxis of MAC duration, drug, dose, when to stop and when to restart
Duration of treatment > 12 months Clarithromycin 500 mg PO BID with ethambutol 15 mg/kg daily +/- rifabutin 300 mg daily Can stop if it has been atleast 12 months, no s/s of MAC and >6 months with a CD4 count >100 in response to ART Restart if CD4 count falls <100 and patient does not have ART suppression
59
PJP symptoms
Fever is present and hypoxemia is the most characteristic lab abnormality Dyspnea, fever, non productive cough
60
PJP definitive diagnosis? (pneumocystitis Jiovenchy pneumonia)
Histopathologic demonstration of the organism in tissue, sputum or broncheoalveolar lavage (BAL) fluid= definitive diagnosis
61
PJP treatment? (mod-severe)
TMP-SMX- 15-20 mg/kg/day of the TMP component IV divided q6-8h for 21 days
62
duration for PJP
21 days
63
Alternative therapy for PJP in pts with sjs rxn to bactrim
primaquine + clindamycin Pentamidine
64
When to use corticosteroids in PJP tx? When to start
For moderate to severe PJP start within 72 hrs of starting PJP therapy
65
WHat drug to use of corticosteroids in PJP (use if O2 is less than 70%)
Prednisone 40 mg BID x 5 days, then 40 mg daily x 5 days, 20 mg daily for 11 days
66
side effects for TMP-SMX
hyperkalemia Renal dysfunction (renally adjusted) monitor Scr
67
mild- moderate PJP tx
TMP-SMX 15-20 mg/kg/day given in 3 doses, 21 DAYS!!!!! TMP-SMX two DS tabs PO TID
68
When should primary prophylaxis be give with PJP
If CD4 cell count is 100-200, if HIV RNA level above detection limits CD4 cell count < 100 regardless of HIV RNA level
69
When to give secondary prophylaxis to PJP patients? When to stop? When to restart?
ALL patoents who complete tx for acute episode of PJP stop prophylaxis when CD4 count increases from <200 to >200 for >3 months in response to ART Restart if CD4 count falls below 100, regardless of HIV RNA level
70
prophylaxis for PJP
bactrim DS or SS DS- M, W, F
71
Where is toxoplasma gindii found (TE)
found in raw or undercooked meat, shellfish, soil and cat feces
72
why does most TE occur
exclusively ccurs becayse of reactivation of latent tissue cysts
73
diagnosis of TE
CT scan or MRI scan reveals ring enhancing lesions in grey matter
74
duration of tx for toxoplasma gondii
6 weeks
75
anticonvulsant use in pts with toxoplasma gondii
Anticonvulsants should be used in patients with a history of seizures through the acute tx phase, but only prophylactically
76
when to start ART in pts with toxoplasmosis
initiate ART in patients within 2-3 wks of diagnosis and treatment of toxoplasmosis
77
preferred tx of acute toxoplasma gondii
Pyrimethamine 200 mg PO x 1 followed by weight-based dosing with sulfadazine q6h and leucovorin daily Body weight < 60 kg: pyrimethamine 50 mg PO daily + sulfadiazine 1,000 mg PO q6h + leucovorin 10-25 mg PO daily (can increase to 50 mg daily or BID) Body weight > 60 kg: pyrimethamine 75 mg PO daily + sulfadiazine 1,500 mg PO q6h + leucovorin 10-25 mg PO daily (can increase to 50 mg daily or BID) or TMP-SMX 5 mg/kg IV or PO BID 6 wks
78
Chronic maintenance tx of toxoplasma gondii
Pyrimethamine 25-50 mg PO qd + sulfadiazine 2000-4000 po daily + leucovorin daily or TMP-SMX DS one tab PO BID
79
when to use primary prophylaxis of toxoplasma? Preferred drug and regimen? When to stop? When to restart?
If toxoplasma IgG positive with CD4 count <100 we use TMP SMX DS one tab daily May stop when CD4 count >200 for >3 months in response to ART or if CD4 count 100-200 and HIV undetectable for at least 3-6 months Restart if CD4 cell count falls <100 OR if CD4 count is 100-200 and HIV is above detection limits
80
Do patient cases on april 2nd class
81
What to use for treatment of PJP if sulfa allergy?
Dapsone 100 mg PO QD Atovaquone 750 mg BID Primaquine+ clindamycin We need G6PD levels before initiation of dapsone or primaquine.
82
What to do if patient is found to have G6PD deficiency
do not use dapsone or primaquine
83

Therapeutics P3 Spring (33 decks)

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