Opportunistic Infections

Question 1

Immunocompromised states:

Answer 1

-Diseases that destroy key immune responses (mainly HIV CD4 <200 aka AIDS)
-Systemic steroids for 14+ days at prednisone equivalent 20+ mg/day or 2+ mg/kg/day
-Asplenia (sickle cell or splenectomy)
-Immunosuppressants for AI or post-txp
-Cancer chemotherapy (especially with neutropenia ANC <500)

Question 2

Candida infections of mouth/throat

Answer 2

aka thrush

PPX: not recommended in these cases even though more common in immunocompromised pts

FOR TX IN HIV: systemic tx is preferred (rather than localized)

Question 3

TXP Patients

Answer 3

CMV (BLK VS)
-PPX with Letermovir (for kidney or BMT)
-PPX with Valganciclovir (for any SOT)

PJP or PCP
-PPX similar to HIV pts

Question 4

PJP/PCP PPX Options in Sulfa Allergy

Answer 4

-Atovaquone
-Dapsone
-Pentamidine

Question 5

PJP/PCP PPX Options in G6PD Deficiency

Answer 5

-Atovaquone
-Pentamidine

Question 6

Leucovorin

Answer 6

Added to all pyrimethamine containing regimens as rescue therapy to reduce the risk of pyrimethamine-induced myelosuppression

Question 7

HIV: PJP/PCP PPX Initiation/Options/DC

Answer 7

INITIATION
CD4 < 200 or AIDS-defining illness

DOC
-Bactrim DS or SS daily

ALT
-Bactrim DS 3x/week
-Dapsone
-Dapsone + Pyrimethamine + Leucovorin
-Atovaquone
-Atovaquone + Pyrimethamine + Leucovorin
-Inhaled pentamidine

DISCONTINUE
-CD4 > 200 for 3+ months and remains on ART

Question 8

HIV: Toxoplasma PPX Initiation/Options/DC

Answer 8

INITIATION
-IgG positive and CD4 < 100

DOC
-Bactrim DS daily

ALT
-Bactrim SS daily or DS 3x/week
-Dapsone + Pyrimethamine + Leucovorin
-Atovaquone
-Atovaquone + Pyrimethamine + Leucovorin

DISCONTINUE
-CD4 > 200 for 3+ months and remains on ART

Question 9

HIV: Mycobacterium avium complex (MAC) PPX Initiation/Options/DC

Answer 9

INITIATION
-Not rec if ART started immediately
-Initiate if not taking ART, CD4 < 50, and no active MAC infection

DOC
-Azithromycin 1200 mg weekly

ALT
-Azithromycin 600 mg twice weekly
-Clarithromycin 500 mg BID

DISCONTINUE
-Taking fully suppressive ART

Question 10

Candidiasis (oropharyngeal/
esophageal)

Answer 10

Thrush, white film in mouth/throat

DOC
-Fluconazole

ALT (PIC candy NO VICE)
-ORO: Itraconazole*, posaconazole, topicals (clotrimazole, nystatin)
-ESO: Voriconazole, Isavuconazonium, an Echinocandin (Caspofungin)

Secondary PPX
-Not usually recommended

Question 11

Cryptococcal meningitis

Answer 11

DOC (the FAL of crypto you get an FFF AF)
-Amphotericin B (liposomal preferred) + flucytosine

ALT
-Fluconazole + flucytosine
-Amphotericin B + fluconazole

Secondary PPX
-Fluconazole (low dose)

Question 12

Cytomegalovirus (CMV)

Answer 12

DOC
-Valganciclovir
-Ganciclovir

ALT
*If toxicities to ganciclovir or resistant strains:
-Foscarnet
-Cidofovir

PPX
-None
-HIV: continue ART and keep CD4 > 100

Question 13

Mycobacterium avium complex (MAC)

Answer 13

DOC (ACE LARMS)
-Clarithromycin or azithromycin + ethambutol

ALT
-Add a 3-4th agent using rifabutin, amikacin, streptomycin, moxifloxacin or levofloxacin

Secondary PPX
-Same as tx regimen

Question 14

Pneumocystis jirovecil
pneumonia (PJP or PCP)

Answer 14

DOC (BS PCP)
-Bactrim (high dose) +/- prednisone or methylprednisolone for 21d

ALT
-Pentamidine IV
-Clindamycin + primaquine

Secondary
-Same as primary PPX

Question 15

Toxoplasmosis

Answer 15

Risks (TOXIC PLS CLpyrB)
-Exposure to parasite via ingestion of undercooked/raw meat or raw shellfish
-Contact with cat feces/litter

DOC
-Pyrimethamine + leucovorin + sulfadiazine

ALT
-Clindamycin + pyrimethamine + leucovorin or Bactrim

Secondary PPX
-Same at tx with reduced doses