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Spring 2025 Therapeutics V > Exam 5: Opportunistic Infections > Flashcards

Exam 5: Opportunistic Infections Flashcards

(109 cards)

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1
Q

How does HIV cause immunosuppression?

A

It gets into CD4 cells and destroys them

-decline leads to immunosuppression and opportunistic infections occur

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2
Q

Historically, opportunistic infections occurred how long after infection with HIV?

A

7-10 years

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3
Q

What are the 4 most common opportunistic infections that occur in HIV patients?

A

Pneumocystis Jiroveii Pneumonia (PCP/PJP)

Toxoplasma gondii encephalitis

Mycobacterium avium complex (MAC)

Candida Infections

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4
Q

*What is the normal CD4 count in adults?

A

800-1200 cells/mm^3

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5
Q

What is the average rate of decline of CD4 cells in an untreated HIV patient?

A

Decrease in 50-100 cells/year

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6
Q

*CD4 counts of what number are associated with development of opportunistic infections?

A

<500

Especially <200

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7
Q

Which infections can occur at any CD4 count?

A

Mycobacterium TB

Pneumonias

Dermatomal Varicella Zoster

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8
Q

Which infections can occur at a CD4 count <500?

A

Candidiasis

Leukoplakia

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9
Q

Which infections can increase HIV viral load?

A

Tuberculosis

Syphilis

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10
Q

What effects can infections that increase HIV viral load have?

A

Increase the risk of HIV Transmission and Progression

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11
Q

What is primary prophylaxis and what is it used for?

A

Administration of an anti-infective agent to prevent the FIRST episode of a particular OI in an HIV patient when they are at risk for developing that OI based on their CD4 count

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12
Q

What is secondary prophylaxis and what is it used for?

A

(AKA chronic maintenance or chronic suppressive therapy)

Administration of anti-infective therapy to prevent FURTHER RECURRENCES of a particular OI in an HIV patient after they have been successfully treated for that OI but remain at risk for re-developing it based on their CD4 count

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13
Q

When do we start ART in the setting of an Acute Opportunistic Infection and which OI’s is ART the best therapy for?

A

Initiation of ART during an acute OI is useful to manage OIs that do not have an effective therapy available to treat them

These are:
-Progressive multifocal leukoencephalopathy (PML)
-Cryptosporidiosis
-Kaposi’s sarcoma

*Improvement of immune function from ART will help resolve these OIs

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14
Q

What is the biggest disadvantage of immediately starting ART with OI’s that we are afraid of?

A

Immune Reconstitution Inflammatory Syndrome (IRIS)

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15
Q

What is the clinical presentation of IRIS?

A

Fever
Inflammation
Worsening of the OI

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16
Q

What patients are more likely to experience IRIS?

A

Patients with:
Low CD4 cell counts <50 cells/mm^3
and
High HIV RNA levels >100,000 copies/mL

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17
Q

*How soon after starting ART does IRIS normally occur?

A

4-8 weeks

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18
Q

When do most clinicians initiate ART therapy in patients with OI’s?

A

They wait for a clinical response to OI therapy, usually 2 weeks

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19
Q

Which OI is the exception for when we should start ART therapy?

A

TB
-need to start SRT therapy within 2 weeks of starting TB treatment IF CD4 count <50

-OR need to start ART within 8 weeks if CD4 count >50

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20
Q

What is the treatment for IRIS with mild disease?

A

Treat the OI

NSAIDs for pain + fever

Inhaled corticosteroids for any bronchospasms

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21
Q

What is the treatment for IRIS with severe disease?

A

Treat the OI

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

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22
Q

For which 2 OI’s should we not use steroids to treat IRIS?

A

Cryptococcal meningitis

Kaposi’s sarcoma

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23
Q

What are the 2 types of Candida infections?

A

Oropharyngeal candidiasis (thrush)

Esophageal candidiasis

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24
Q

How does Candida get into the body?

A

It is a normal inhabitant of the GI tract, oropharynx, and female genital tract

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25
The majority of candidiasis infections are caused by what?
Candida albicans
26
Candida albicans is susceptible to what drug?
Fluconazole
27
What is the preferred treatment for Oropharyngeal candidiasis?
Fluconazole 200 mg loading dose followed by 100-200 mg PO daily for 7-14 days
28
True or False: Fluconazole is as effective or superior to topical therapy for Oropharyngeal Candidiasis
True
29
When would we use topical agents to treat candidiasis?
Initial, mild to moderate episodes ONLY *NEVER USE FOR ESOPHAGEAL CANDIDIASIS*
30
What are the downsides to using topical agents for oropharyngeal candidiasis?
Unpleasant taste GI side effects Multiple daily dosing
31
What are the 2 topical products we can use for oropharyngeal candidiasis?
Nystatin Suspension (100,000 units/mL) Clotrimazole Troches (10 mg lozenge)
32
What is the dosing for Nystatin Suspension for oropharyngeal candidiasis?
Nystatin Suspension (100,000 units/mL) 5mL swish and swallow QID x 7-14 days
33
What is the dosing for Clotrimazole Troches for oropharyngeal candidiasis?
10 mg lozenge 5 times daily for 7-14 days
34
What is the duration of all oropharyngeal candidiasis treatment?
7-14 days
35
What are the important counseling points for Nystatin Suspension?
Should be thoroughly rinsed in mouth and retained in mouth for as long as possible before swallowing
36
What are the important counseling points for Clotrimazole Troches?
Dissolve slowly in mouth over 15-30 minutes
37
What is the treatment for esophageal candidiasis?
Fluconazole 200 mg (up to 400 mg) IV or PO daily for 14-21 days
38
What are the treatment options for uncomplicated vulvovaginal candidiasis?
Fluconazole 150mg PO x 1 dose or Topical azoles (clotrimazole, butoconazole, miconazole, tioconazole, or terconazole) for 3-7 days or Ibrexafungerp 300 mg PO BID x 1 day
39
What are the treatment options for severe vulvovaginal candidiasis?
Fluconazole 100-200 mg PO daily for >/= 7 days or Topical antifungals for >/= 7 days
40
What is the treatment option for azole-refractory vaginitis caused by C. glabrata?
Boric acid 600 mg vaginal suppository once daily for 14 days
41
Do candidiasis infections need prophylaxis?
NO primary and secondary prophylaxis are not recommended due to: -resistance risk -acute therapy being effective -drug interactions with treatment -cost *Only consider in patients with frequent or severe recurrences of esophagitis or vaginitis
42
With cryptococcal meningitis, what is a big concern?
IRIS is very common
43
When should we start ART with cryptococcal meningitis?
Delay until induction (first 2 weeks) and possibly the total induction/consolidation phases (10-12 weeks) to avoid IRIS
44
What are the phases of Cryptococcal Meningitis treatment?
Induction (2 weeks) Consolidation (8 weeks) Maintenance
45
What is the preferred induction medication for Cryptococcal Meningitis?
Amphotericin B 3-4 mg/kg IV daily + Flucytosine 25 mg/kg PO QID *for 2 weeks*
46
What is the preferred consolidation medication for Cryptococcal Meningitis?
Fluconazole 800 mg PO daily for *8 weeks* (400 mg PO daily in stable patients with sterile CSF culture and on ART)
47
What is the preferred maintenance therapy for Cryptococcal Meningitis?
Fluconazole 200 mg PO daily for 1 year or longer
48
Do we use prophylaxis in Cryptococcal Meningitis?
We use maintenance therapy for 1 year after the infection (secondary prophylaxis is required) DO NOT use primary prophylaxis
49
When can we discontinue maintenance medication for Cryptococcal Meningitis?
Patient has all of these: -Completed one year of therapy -Asymptomatic -CD4 count >/= 100 for 3 months -On ART with suppressed viral load
50
When do we restart Cryptococcal meningitis prophylaxis?
If patient's CD4 count is <100
51
Which HIV patients are at high risk for Mycobacterium avium Complex (MAC)?
CD4 count < 50 Viral replication despite ART Previous or concurrent OIs
52
What is the most common mode of transmission for MAC?
It is found in the environment and transmitted by: -Inhalation -Ingestion -Inoculation through respiratory and GI tract
53
How does MAC typically present in HIV patients with advanced immunosuppression not on ART?
Disseminated multi-organ infection
54
What is the most common symptom of MAC?
Night sweats
55
Lab tests may have what findings when testing for MAC?
Hepatomegaly, Splenomegaly, Lymphadenopathy Anemia Elevated liver alkaline phosphatase
56
When should we initiate ART with MAC?
As soon as possible! -can start the same day as MAC therapy
57
Initial treatment of MAC should include how many drugs?
At least 2 -may go up to 3 or 4
58
What is the preferred treatment for MAC?
*Clarithromycin 500 mg PO BID + Ethambutol 15 mg/kg PO daily or Azithromycin 500-600 mg PO daily + Ethambutol 15 mg/kg PO daily (for intolerance/drug interaction with clarithro)
59
In severe cases of MAC what drug do we add to the regimen?
Rifabutin
60
When do we consider a 4th drug in MAC therapy?
Severe disease High mortality risk Drug resistance likely CD4 < 50 High mycobacterial load in blood Ineffective ART
61
What 4th drugs can we consider in MAC therapy?
Levofloxacin or Moxifloxacin Amikacin or Streptomycin Linezolid or Tedizolid or Omadacycline
62
How long should disseminated MAC therapy last?
>/= 12 months
63
What criteria must be met for us to consider stopping MAC therapy?
CD4 count > 100 for >/= 6 months
64
When would we not start prophylaxis for MAC?
Patients who immediately initiate ART after HIV diagnosis (if they are going to start ART then they do not need primary prophylaxis)
65
What type of prophylaxis is used in MAC therapy?
Both primary and secondary
66
What patients do need primary prophylaxis for MAC?
CD4 count <50 AND Not receiving ART OR remains viremic on ART OR has no options for a fully suppressive ART regimen
67
Before starting primary prophylaxis for MAC we need to rule out what?
Disseminated MAC
68
What is the preferred regimen for MAC prophylaxis?
Azithromycin 1200 mg PO once weekly
69
When can we discontinue primary prophylaxis for MAC?
If the patient is continuing on a fully suppressive ART regimen
70
When should we restart primary prophylaxis for MAC?
CD4 falls to <50 Patient not on fully suppressive ART
71
How long should secondary prophylaxis treatment last for MAC therapy?
At least 12 months
72
What treatment options do we have for secondary prophylaxis for MAC?
Clarithromycin 500 mg PO BID AND Ethambutol 15 mg/kg PO daily +/- Rifabutin 300 mg PO daily (same as normal treatment)
73
What criteria must be met for us to stop secondary prophylaxis for MAC?
Completed >/= 12 months of therapy + No signs/symptoms of MAC + > 6 months with CD4 count > 100 in response to ART
74
What type of organism is Pneumocystis Jirovecii Pneumonia (PJP)?
Classified as a fungus but shares characteristics with protozoa
75
How is Pneumocystis Jirovecii Pneumonia (PJP) spread?
Airborne route
76
What is the most characteristic lab value for Pneumocystis Jirovecii Pneumonia (PJP)?
Hypoxemia (<70 mmHg)
77
What is the presentation of Pneumocystis Jirovecii Pneumonia (PJP) on a chest x-ray?
Diffuse, bilateral, symmetrical "ground glass" interstitial infiltrates in a butterfly pattern
78
True or False: If untreated, PJP is fatal
True
79
What is true about the initiation of PJP therapy?
After treatment initiation, patients with AIDS tend to get sicker before they improve and they make take a longer time to show a clinical response
80
When should we initiate ART in Pneumocystis Jirovecii Pneumonia (PJP)?
As soon as possible and within 2 weeks of diagnosis of PJP
81
*What is the preferred treatment for moderate-severe PJP?
Trimethoprim-sulfamethoxazole 15-20 mg/kg/day of the TMP component IV divided q6-8h for 21 days -switch to PO after clinical improvement
82
What are the alternative therapies for moderate-severe PJP?
Primaquine 30 mg PO once daily + Clindamycin IV or PO Pentamidine 4 mg/kg IV once daily infused over >60 min
83
When do we use adjunctive corticosteroids in PJP therapy?
Moderate/Severe PJP pO2 <70 on room air
84
With what timing should we start adjunctive corticosteroids in PJP therapy?
Within 72 hours of initiating PJP therapy
85
What is the corticosteroid regimen used in PJP?
Prednisone 40 mg PO BID x 5 days, then 40 mg PO daily x 5 days, then 20 mg daily x 11 days
86
What is the preferred treatment for Mild-Moderate PJP?
TMP-SMX 15-20 mg/kg/day PO in 3 divided doses or TMP-SMX 2 DS tablets PO TID
87
What are the alternative therapies for Mild-Moderate PJP?
Dapsone PO + TMP PO Primaquine PO + Clindamycin PO Atovaquone
88
Which 2 drugs used in PJP therapy require G6PD levels to be checked before use?
Dapsone Primaquine
89
How long is PJP therapy?
Always 21 days total
90
What kind of prophylaxis is needed with PJP?
Primary and Secondary
91
Who should receive primary PJP prophylaxis?
All HIV-infected patients with: CD4 cell count 100-200 if HIV RNA level is detectable CD4 cell count < 100 (regardless of RNA)
92
Who should receive secondary prophylaxis for PJP?
ALL PJP patients after completion of therapy
93
When can we discontinue secondary prophylaxis for PJP?
CD4 increases from <200 to >/= 200 for >3 months Consider when CD4 is 100-200 if RNA remains undetectable for >/=3-6 months
94
When should we restart PJP prophylaxis?
CD4 < 100 regardless of RNA level
95
Clinical disease of toxoplasma gondii encephalitis almost occurs exclusively because of what?
Reactivation of latent tissue cysts
96
What are the most common symptoms of toxoplasma gondii?
Focal encephalitis -headache -focal neurologic deficits (hemiparesis) -fever
97
What imaging finding is used to diagnose toxoplasma gondii?
One or more ring-enhancing lesions in grey matter of the cortex or basal ganglia
98
Therapy for acute toxoplasma gondii should be continued for how long?
6 weeks
99
What patients with toxoplasma gondii should receive adjunctive corticosteroids?
Those with mass effect associated with focal lesions or associated edema -discontinue as soon as feasible
100
Who should receive anticonvulsants with toxoplasma gondii?
Those with seizure history only *give at least through the period of acute treatment *DO NOT give as prophylaxis
101
When should we initiate ART therapy in toxoplasma gondii?
Within 2-3 weeks of diagnosis
102
What are the treatment options for Acute toxoplasma gondii infections?
Pyrimethamine 200 mg PO x 1 followed by weight-based dosing 60 kg: * Pyrimethamine 75 mg PO daily * + Sulfadiazine 1500 mg PO q6h * + Leucovorin 10-25 mg PO daily OR: TMP-SMX 5 mg/kg of TMP IV or PO BID
103
What are the regimens used for chronic maintenance therapy in toxoplasma gondii?
Pyrimethamine + Sulfadiazine + Leucovorin TMP-SMX DS
104
Who should receive primary prophylaxis for toxoplasma gondii?
Patients who are Toxoplasma IgG positive and have CD4 count <100
105
What is the preferred therapy for primary prophylaxis of toxoplasma gondii?
TMP-SMX DS one tablet PO daily
106
When can we discontinue primary prophylaxis for toxoplasma gondii?
When CD4 count is > 200 for > 3 months Or If CD4 is 100-200 and HIV RNA is not detectable for at least 3-6 months
107
Who should receive secondary prophylaxis for toxoplasma gondii?
All patients after completion of treatment
108
When can we discontinue prophylaxis for toxoplasma gondii?
When CD4 count > 200 for >6 months AND Patient has successfully completed initial therapy AND Pt is asymptomatic
109
When would we restart prophylaxis for toxoplasma gondii?
If CD4 < 200 regardless of HIV RNA level

Spring 2025 Therapeutics V (41 decks)

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