Pulmonary OIs

Question 1

MAC prophylaxis What & When

Answer 1

Azithromycin 1250mg once a week OR Clari 500mg BD

CD4 <50 not on ART. Stop prophylaxis once SVR achieved.

NOTE - no need for primary prophylaxis even if CD4<50 but planning to start ART in 2 weeks.

Question 2

MAC treatment & when to stop

Answer 2

Macrolide + ethambutil + rifampicin

12 months minimum. Can be stopped if there is:

• clinical improvement
• culture conversions
• on ART with undetectable VL
• CD4 > 100 for at least 6 MONTHS

Question 3

M kansasii treatment

Answer 3

Rif + ethambutol + INH

Minimum 12 months after culture conversion

Question 4

PJP treatment

Answer 4

First line - high dose Septrin for 21 days even if develops infection whilst on prophylaxis dose

Adjunctive steroids if moderate to severe:

PaO2 < 9.3 KPa
SaO2 < 92% at rest or falling > 3% on exercise

Treatment failure: 4 days of therapy and no improvement:

Second line - Oral primaquine + oral/IV clindamycin

Or pentamidine

Second line for mild:
Oral clinda+ primaquine OR
Oral atovaquone OR
Oral trim + dapsone

Question 5

PJP prophylaxis

Answer 5

Primary:

CD4 < 200
CD4% < 14% of total lymphocytes

If CD4 between 200-250 and ART delayed/ 3 monthly monitoring not possible

Regimens:
960 OD or
480 OD or
960 three times a week

If develops toxicity - stop and reintroduce slowly as desensitisation.

Second line:
Nebulised pentamidine
Dapsone (plus pyrimethamine for Toxo cover)
Atovaquone

Stopping primary prophylaxis:
CD4>200 for 3 months
CD4 100-200 but undetectable for 3-6 months

Stopping secondary prophylaxis:
Until immune reconstitution after starting ART

Question 6

Cryptococcal disease Tx

Answer 6

Pulmonary alone with no hypoxia or CNS disease - first line fluconazole 400mg OD

Any dissemination or hypoxia - Ambisome as per CNS treatment

Question 7

Cryptococcal prophylaxis

Answer 7

Secondary prophylaxis - discontinue after 1 year if CD4 > 100 and undetectable for > 3 months

Question 8

Aspergillosis prophylaxis & Tx

Answer 8

Prophylaxis NOT recommended

Primary therapy - Voriconazole

Question 9

PJP grading

Answer 9

Mild to moderate -
> 9.3 KPa on ABG on RA
>92% sats at rest or falling < 3% on exertion
CXR: Normal or minor interstitial shadowing

Major:
Anything more than above