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PHRM 865 > Exam 5: Opportunistic Infections > Flashcards

Exam 5: Opportunistic Infections Flashcards

1
Q

Normal CD4 count

A

500-1200 cells/mm

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2
Q

Average decline of cd4 cells per year without ART

A

50-100 cells/year

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3
Q

CD4 cell counts ___ and especially ____ are associated with the development of OI

A

<500

<200

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4
Q

What three infections may occur at any CD4 cell count but are more common at lower CD4 cell counts

A
  1. mycobacterium tuberculosis
  2. pneumococcal disease
  3. dermatomal zoster
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5
Q

OIs developing at CD4 counts <500

A

vulvovaginal candidiasis
thrush
oral leukoplakia

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6
Q

OIs developing at CD4 counts between 0 and 200

A
  1. PJP
  2. CMV
  3. Toxoplasma gondii encephalitis
  4. MAC
  5. cryptococcus neoforms meningitis
  6. cryptosporidum diarrhea
  7. CNS lymphoma
  8. Kaposi’s Sarcoma
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7
Q

what infections can increase plasma HIV viral load which accelerates HIV progression and increases risk of HIV transmission

A

TB

Syphilis

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8
Q

Initial ART therapy in the setting of an acute OI

A

Initiation of ART during an acute OI is very useful in the management of OIs for which effective therapy is not available, such as PML, cryptosporidiosis, and Kaposi’s sarcoma

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9
Q

Disadvantage of immediately starting ARTs in the setting of acute OI

A
  1. IRIS
  2. Overlapping or additive drug toxicities
  3. DIs b/w ART and OI therapy
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10
Q

What is IRIS

A

immune reconstitution inflammatory syndrome: when immune system begins to recover, it begins to respond to already acquired OI

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11
Q

IRIS characterization

A

fever and worsening clinical manifestations of the OI

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12
Q

What OIs can IRIS be seen in

A
  1. MAC
  2. TB
  3. PJP
  4. toxoplasma
  5. HBV and HCV
  6. Histoplasma
  7. Varicella
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13
Q

What patients are at risk for IRIS

A
  1. Low CD4 counts (<50)

2. High HIV viral load (>100,00)

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14
Q

Treatment of IRIS

A
  1. NSAIDs if Mild

2. Corticosteroid: Prednisone 1-2 mg/kg qd x1-2 weeks with taper if severe

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15
Q

Most common OIs

A

oropharyngeal and esophageal candidiasis

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16
Q

CD4 cell count when candida occurs

A

<200

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17
Q

Which has lower CD4 counts: oral or esophageal candidiasis

A

esophageal

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18
Q

Candida pathogenesis

A

Alterations in the host immune system, such as defects in cell-mediated immunity, can alter the commensal status of candida species so that invasion of host tissue and infection occurs

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19
Q

How can non-albicans candida species occur

A

develop in patients who have received repeated or long-term exposure to fluconazole

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20
Q

thrush clinical exam

A

painless, creamy white, plaque-like lesions on the buccal mucosa, hard or soft palate, oropharyngeal mucosa or tongue sulface

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21
Q

topical vs systemic therapy for thrush

A

systemic therapy is preferred and superior to topical therapy, especially in patients with multiple epidoses

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22
Q

topical treatment options for thrush

A
  1. nystatin suspension
  2. clotrimazole troches
  3. miconazole buccal tab
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23
Q

nystatin suspension thrush dosing

A

5ml swish and swallow qid x10-14 days

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24
Q

clotrimazole troches thrush dosing

A

10mg oral lozenge five times a day for 14 days

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25
Q

miconaole buccal tab thrush dosing

A

50mg tablet applied to mucosal surface qd x14

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26
Q

systemic DOC for thrush with dosing

A

fluconazole 100mg PO QD x7-14 days

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27
Q

esophageal candidiasis DOC with dosing

A

fluconazole 200mg (up to 400mg) IV or PO QD x14-21 days

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28
Q

can you use topical therapy for esophageal candidiasis

A

NO

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29
Q

-Azoles AE

A

GI upset and hepatotoxicity

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30
Q

-Azoles monitoring

A

Liver enzymes should be monitored periodically during prolonged therapy (>21 days)

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31
Q

use of primary prophylaxis for candidiasis

A

Not routinely recommended because of the effectiveness of therapy for acute infection, the low attributable mortality associated with mucosal candidiasis

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32
Q

Primary treatment for vulvovaginal candidiasis

A
  1. topical azoles for 3 to 7 days
  2. single dose fluconazole
  3. itraconazole solution
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33
Q

when to give oral fluconazole for vulvovaginal candidiasis

A

severe or recurrent episodes

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34
Q

Common CD4 count in cryptococcus neoformans

A

<100

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35
Q

Cryptococcal meningitis symptoms

A

mild and non-specific

fever, malaise, headache, nausea, dizziness, lethargy, irritability, impaired memory, behavioral changes

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36
Q

Cryptococcal meningitis diagnostics

A
  1. CSF analysis: increases opening and intracranial pressure
  2. few white blood cells
  3. encapsulated yeast forms
  4. positive serum cryptococcal antigen titer
37
Q

What can dissemintated cryptococcal infections causes

A

pneumonia

38
Q

treatment phases for Cryptococcal meningitis

A

induction, consolidation, and maintenance

39
Q

induction therapy for Cryptococcal meningitis

A

liposomal amphotericin B 3-4 mg/kg IV qd + oral flucytosine 25 mg/kg q 6 h PO >2 weeks

40
Q

consolidation therapy for Cryptococcal meningitis

A

fluconazole 400-800mg PO QD

41
Q

maintenance therapy for Cryptococcal meningitis

A

fluconazole 200mg qd for a year or longer

42
Q

ART therapy initiation while treating cryptococcal meningitis

A

initiation should be delayed until induction and possibly induction/consolidation to avoid IRIS

43
Q

use of primary prophylaxis for Cryptococcal meningitis

A

not routinely recommended because of relative infrequency of infection

44
Q

use of secondary prophylaxis for Cryptococcal meningitis

A

chronic maintenance or suppression therapy with oral fluconazole for at least one year is necessary due to high rate of relapse

45
Q

when can secondary prophylaxis for Cryptococcal meningitis be stopped

A
  1. pt completes one year of maintenance therapy
  2. pt is asymptomatic
  3. pt has sustained immune reconstitution with ART with CD4 >100 for more than three months
46
Q

flucytosine monitoring

A

flucytosine can cause decreased WBC or platelets: obtain CBC at least once or twice weekly

47
Q

amphotericin AE

A

nephrotoxicity, hypokalemia, hypomagnesemia, infusion related reactions

48
Q

CD4 count with PJP

A

<200

49
Q

PJP symptoms

A

subacute onset of progressive, exertional dyspnea, fever, non-productive cough, and chest discomfort that worsens over a period of days to weeks

50
Q

How are ABGs affected in PJP

A

hypoxemia may occur in pts: pO2<70

51
Q

chest xray in PJP

A

diffuse, bilateral, symmetrical ground glass interstitial infiltrates

52
Q

DOC for moderate to severe PJP

A

trimethoprim-sulfamethoxazole 15-20 mg/kg/day of the TMP component IV divided q6-8h for 21 days (may switch to PO after clinical improvement)

53
Q

____ should be given to patients with moderate to severe PJP when ______

A

adjunctive corticosteroids

PaO2 <75

54
Q

adjunctive corticosteroid DOC and dosing for PJP

A

Prednisone
40mg BID x5
40mg QD x5
20mg QD x11

55
Q

ART therapy initiation while treating PJP

A

ART should be initiated within 2 weeks of diagnosis of PJP

56
Q

use of primary prophylaxis for PJP

A
  1. CD4 <200
  2. CD4 percentage <14% of total lymphocute count
  3. CH4 >200 but <250 if initiation of ART is delayed
57
Q

primary prophylaxis for PJP

A

Bactrim DS or SS PO QD

or Dapsone 100mg QD

58
Q

use of secondary prophylaxis for PJP

A

must be given after completion of treatment for all patients

59
Q

When can primary or secondary prophylaxis for PJP stop

A

Both can be stopped when:

1. CD4 >200 for at least 3 months in response to ART therapy

60
Q

TMP-SMX AE

A 
rash
fever
leukopenia
thrombocytopenia
hyperkalemia
61
Q

TMP-SMX monitoring

A

CBC, Scr, and K at least 2-3

62
Q

Greatest risk of developing toxoplasma gondii

A

AIDS and CD4 <100

63
Q

toxoplasma manifestations

A

focal encephalitis with headache, confusion, motor weakness, and fever

64
Q

toxoplasma diagnostics

A
  1. serum toxoplasma gondii IgG antibody positive

2. Detection of T. gondii by PCR in CSF analysis

65
Q

Expensive treatment of choice for toxoplasma

A

pyrimethamine: 200mg X1 then 50-75 mg PO QD
+leucovorin: 10-25mg PO QD
+ sulfadiazine 1000-1500 mg PO q6h

all for 6 weeks

66
Q

Cheap treatment of choice for toxoplasmosis

A

TMP/SMX 10 mg/kg/day based on TMP component

67
Q

Treatment duration for toxoplasmosis

A

at least 6 weeks

68
Q

_____ should be given to patients with mass effect associated with focal lesions or associated edema and d/c as soon as feasible

A

adjunctive corticosteroids (dexamethasone)

69
Q

ART therapy initiation while treating toxoplasmosis

A

should be started within 2 to 3 weeks of the diagnosis/treatment of toxoplasmosis

70
Q

use of primary prophylaxis for toxoplasmosis and treatment

A

CD4 <100; treat with bactrim ds qd

71
Q

can primary prophylaxis for toxoplasmosis be d/c

A

Yes when:

  1. CD4 >200 for >3 months in response to ART
  2. CD4 is 100-200 and HIV RNA is below detection limit for at least 3-6 months
72
Q

use of secondary prophylaxis for toxoplasmosis

A

should be given to all patients after completion of treatment; treat with bactrim ds qd

73
Q

can secondary prophylaxis for toxoplasmosis be d/c

A

Yes when:

Cd4 >200 for >6 months

74
Q

pyrimethamine AE

A

rash, nausea, and bone marrow suppression (anemia, neutropenia, thrombocytopenia) than can be decreased or reversed by the concomitant administration of leucovorin

75
Q

MAC is the _____________ infection in patients with AIDS and can contribute substantially to their morbidity

A

most common systemic, bacterial

76
Q

When does MAC occur

A

late in HIV infection when CD4 <50

77
Q

MAC clinical presentation

A

gradual onset of systemic symptoms, including fever, dairrhea, night sweats, weight loss

78
Q

How to detect presence of MAC

A

AFB cultures of blood, bone marrow, lymph node, and stool

79
Q

MAC treatment guideline

A

2 or more antimycobacterial drugs to delay or prevent the emergency of resistance

80
Q

MAC treatment

A
  1. Clarithomycin 500mg BID
    2 Ethambutol 15mg/kg qD
  2. Rfiabutin 300mg QD
81
Q

Treatment duration for MAC

A

> 12 months

82
Q

ART therapy initiation while treating MAC

A

Should have ART initiated ASAP (preferably within initiation of MAC therapy

83
Q

use of primary prophylaxis for MAC

A

not recommended for adults who immediately initiate ART regardless of CD4 count

Azithromycin 1200mg weekly for pts not on ART and have CD4<50

84
Q

can primary prophylaxis for MAC be d/c

A

Yes when patients initiate effective ART

85
Q

use of secondary prophylaxis for MAC

A

secondary prophylaxis should be administered to ALL patients with MAC after one year of treatment: azithromycin 1200mg qw

86
Q

can secondary prophylaxis for MAC be d/c

A

Yes when CD4 increases to >100 for >6 months

87
Q

Azithromycin and clarithomycin AE

A

nausea, vomiting, adbominal pain

88
Q

ethambutol Ae

A

optic neuritis and hepatotoxicity

89
Q

rifabutin AE

A

hepatotoxicity, uveitis, red-orange discoloration of body fluids

PHRM 865 (59 decks)

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