Microsoft word - treatment and prophylaxis of opportunistic infections in hiv 2012[1].doc

TREATMENT AND PROPHYLAXIS OF OPPORTUNISTIC INFECTIONS IN HIV All doses stated should be reviewed for each individual patient and adjusted if they have renal or liver impairment. Primary care may be requested to prescribe medicines for prophylaxis or maintenance. Unless otherwise requested in hospital discharge or clinic letters monitoring is undertaken by secondary care. Check G6PD prior to prescribing dapsone or primaquine but do not delay treatment. If Presence of food (particularly high fat) Check G6PD prior to prescribing dapsone or primaquine but do not delay treatment. If If O2 saturations <92% or PaO2 ≤9.3kpa on room air start steroids at the same time as Prednisolone oral 40mg bd for 5 days, 40mg od for 5 days then 20mg daily for 11 days Pneumothorax is a common complication of severe disease and carries a poor prognosis. CXR required if deterioration and/or chest Discontinue prophylaxis when CD4 count >200 For >3months. A test dose of Ambisome should be given at *Oral flucytosine is not licensed in the UK but start of course – 1mg over 10 mins then patient observed foe 30 mins for signs of allergic CSF manometry should be performed on all neurological deterioration occur. Serial lumbar punctures or neurosurgical procedures are indicated for individuals with an opening pressure >250mmH2O. Corticosteroids and acetazolamide have not been shown to be of 1st line combination therapy has more rapid CSF sterilisation and decreased incidence of relapse Monitor flucytosine trough levels pre 5th dose. Aim for 35-50mg/L and definitely not >80mg/L. For azole anti-fungals consider interactions with • there is no other evidence of dissemination • radiological infiltrates are focal and • there is no hypoxia Fluconazole PO 400mg OD for 10 weeks then 200mg OD thereafter is an alternative strategy. If need IV therapy use 2nd line option. IV With sulfadiazine a fluid output of >1200ml/day should be maintained to prevent crystalluria. If this does occur stop treatment and alkalise Lack of response to 2 weeks of treatment, clinical deterioration of features that are not typical should lead to consideration of a brain bioavailability so the oral route is preferred. Corticosteroids are only indicated in patients with signs and symptoms of raised ICP when dexamethasoone 4mg QDS gradually reducing Monitor FBC, U&Es, LFTs for all anti-CMV Valganciclovir should be taken with food. Valganciclovir/ganciclovir are considered humans. Avoid direct contact of broken or central line or must be diluted in pharmacy aseptic department to be given reduce rates of electrolyte disturbances. maintain a high level of hygiene to avoid Cidofovir requires to be administered with For all azole antifungals check for interactions bioavailability and it may also have some local effect. The liquid should be taken 1 hour For all azole antifungals check for interactions bioavailability and it may also have some local effect so is the preferred formulation. The liquid should be taken 1 hour before food or CSM warning: itraconazole is contra-indicated in patients with evidence of or history of Patients should have a full ophthalmological examination prior to starting ethambutol. Rifabutin should be added if CD4<25 or markedly symptomatic DMAC features and/or laboratory parameters or if effective HAART requires adjustment for HAART interactions. Amikacin serum level monitoring is required. If treatment is to exceed 10 days an audiogram therapy. Therapy should be stopped if tinnitus Nitazoxanide efficacy is limited in severely Albendazole has poor oral bioavailability so should be taken with fatty food to maximise Adapted from BHIVA 2011 Treatment of OI Guidelines/Electronic Medicines Compendium Prepared by: K Hill, HIV/Antimicrobial Pharmacist MANAGEMENT OF STIs IN HIV POSITIVE PATIENTS The treatment of the majority of sexually transmitted infections is the same as in the uninfected population. Please refer to current NHS Tayside GUM protocols. The exceptions include genital herpes, syphilis and genital warts.
Genital Herpes 1
Primary genital herpes in those who are immunocompromised may last longer and be more severe than in HIV negative patients. Symptoms generally include:
Painful ulceration (which may be anywhere in the anogenital region) It can be associated with systemic complications including pneumonia and fulminant hepatitis. Investigations A HSV PCR swab should be taken from the base of an ulcer. Consider VZV (shingles) as part of the differential diagnosis and request VZV PCR if clinically indicated. The sample and virology form should be labelled with a red dot and the form marked as a high-risk patient.
Treatment of primary herpes
Treatment should be initiated promptly with Aciclovir 400mg x 5/day for 7-10 days.
If the patient is not able to tolerate oral therapy an inpatient admission should be sought and treatment commenced with acyclovir 5-10mg/kg body weight every 8 hours. Recurrent Herpes Patients with HIV are likely to have more frequent recurrences especially if they have significant immunosuppression (CD4<200). It is important to establish those with immunosuppression on antiretroviral therapy, as this should improve the frequency of their outbreaks. Episodic therapy for recurrences
Treatment may be provided in the form of Aciclovir 200mg x5/day for 5-10 days.
If this were too high a pill burden for some patients an alternative would be Valaciclovir 1g BD x 5-10 days. Suppressive therapy for frequent recurrences Suppressive therapy is usually reserved for those patients who have greater than six outbreaks of genital herpes per year. Treatment is in the form of Aciclovir 400mg BD, which is usually provided for one year. The first one-month of a prescription is provided from the hospital and the following 11 months should be accessed from their GP. A letter should be sent to the GP with the patient’s consent. Treatment would be stopped at that time and the patient should expect to have an initial rebound attack. The frequency of recurrences would be assessed following this. If the frequency of outbreaks is still high beyond this point, treatment can be resumed with a trial of stopping again after 12 months. If a patient were on antiretroviral therapy it would be important to ensure that viral suppression is achieved and maintained. Drug resistant herpes If a patient continues to have outbreaks whilst on recommended antiviral therapy the possibility of a drug resistant virus must be considered. A diagnosis is made by isolating HSV from genital lesions whilst the patient is taking suppressive treatment. A trial of systemic therapy should be considered with either: Foscarnet 40 mg/kg I.V. every 8 – 12 hours Cidofovir 5 mg/kg body weight. IV infusion over 1 hour diluted with Normal Saline once per week for 2 consecutive weeks. Administered with oral Probenecid. Genital Warts 1
Human papilloma virus infection is more commonly associated with anogenital warts and either CIN or AIN in those who are immunocompromised.
CIN Women are recommended to undergo annual cervical screening. Patients who receive a report of mild dyskaryosis should be referred to colposcopy. Please refer to the HIV smear protocol. AIN Men especially MSM who have anogenital warts should have proctoscopy performed. The presence of any atypical lesions should ensure a prompt referral for biopsy of the affected area. MSM should be offered an anal examination annually. Anogenital warts Warts can be more problematic in those living with HIV infection especially in those with low CD4 counts. First line therapy should be with Imiquimod 5% Cream (Aldara) in those who are immunocompromised. Instructions of use should be provided and supported with a drug
information leaflet. Imiquimod cream can be used for up to 16 weeks. If there were poor treatment response it would be important to establish the patient on antiretroviral
therapy, as a rise in their CD4 count may be helpful in eradicating persistent HPV infection.
Syphilis 2

Syphilis serological screening should be performed 3 monthly in the HIV positive population. In those who decline serology or are at low risk of acquiring syphilis this should be documented clearly in their case notes along with a risk assessment and readdressed again at their next appointment. Symptoms, signs and investigations are as per the uninfected population. Patients with HIV may have more extensive genital ulceration and a higher incidence of neurological complications. All HIV positive patients with a rash should have syphilis serology undertaken. If there are any neurological symptoms or signs the patient should have a CT scan of brain performed followed by a lumbar puncture. A positive CSF VDRL in the absence of contamination with blood is diagnostic of neurosyphilis. A negative CSF TPPA excludes infection. Please follow the guidance in the standard GUM Syphilis protocol. Treatment HIV positive patients should receive the same treatment as per the uninfected population and is dependant upon the stage of disease. Benzathine Penicillin 2.4 mega units I.M. as a single dose
It is important to ensure close follow up and serological testing at the recommended intervals. Late latent/Cardiovascular or Gummatous syphilis Benzathine Penicillin 2.4 mega units I.M. on day 1, day 8 and day 15
Procaine penicillin G 2.4 mega units I.M. once daily x 17 days plus oral probenecid 500mg qds x 17 days.
Treatment with oral therapies is not recommended. Lymphogranuloma Venereum
In HIV-infected MSM presenting with symptoms of proctitis, a high index of suspicion for LGV should be held. Swabs should be undertaken at proctoscopy and include microscopy, GC culture, GC/CT NAAT and if there is any ulceration then swabs for both HSV and syphilis PCR should be taken. The NAAT form should be labelled “proctitis in HIV+ MSM. Please send for LGV serovars”. Inguinal lymph nodes can be aspirated and aspirate sent for Chlamydia PCR and LGV serovars. Empiric treatment should be commenced with doxycycline 100mg bd for 7 days. If there is significant ulceration then HSV treatment should be added as above. The patient
should be followed up with results at 7 days and if the rectal Chlamydia is positive then doxycycline should be continued for up to three weeks or until LGV has been
All patients diagnosed with LGV should have syphilis serology and hepatitis C serology undertaken. All HIV infected patients diagnosed with an acute STI should be seen by a sexual health adviser for partner notification for both the acute STI and for HIV. They should receive in depth counselling regarding safer sex advice to protect their own health and to reduce the risk of onward transmission of HIV. They should be made aware of the legal issues relating to sexual transmission of HIV and made aware of the availability of PEPSE. History should also include interventions around substance misuse and domestic violence. Condoms should be made available to all HIV-infected individuals and should be offered at every clinic visit. 1) British HIV Association, BASHH and FSRH guidelines for the management of the sexual and reproductive health of people living with HIV, 2008. HIV Medicine 2) UK National guidelines on the management of Syphilis; International Journal of STD and AIDS 2008; 19:729-40 Reviewed by Dr S Allstaff, January 2012



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