Be Prepared
Indication for starting primary chemoprophylaxis for Mycobacterium avium
CD4 < 50 cells/mm3 AND not on ART therapy
*Patients who are initiated on ART therapy immediately do not need primary prophylaxis
Drug of choice for PCP pneumonia
Bactrim
PO: mild to moderate disease
IV: moderate to severe disease
Preferred steroid for cryptococcal meningitis
NONE
*No survival benefit shown between dexamethasone and placebo (patients were treated for 10 weeks)
Most common manifestation of CMV
Retinitis
Duration of treatment for PCP pneumonia
21 days
Indication and preferred agent/dosing for initiating primary chemoprophylaxis for PCP
Bactrim 1 double strength (or single strength) tablet once dailyCD4 < 200 cells/mm3
Drug of choice for Mycobacterium avium
Clarithromycin + ethambutol
Azithromycin + ethambutol
Antifungal class with no activity against cryptococcus
Echinocandins
Common pyrimethamine toxicity treated with leucovorin
bone marrow suppression
Duration of maintenance therapy for cytomegalovirus
May be stopped after initiating ART and CD4 count > 100 cells/mm3 for at least 3 to 6 months
Preferred agent for secondary chemoprophylaxis of MAC in pregnant patients
Azithromycin + ethambutol
*Clarithromycin known to cause birth defects
Treatment of choice for Toxoplasma
Pyrimethamine + Sulfadiazine + Leucovorin
Indication for adding corticosteroids in PCP pneumonia
Moderate-to-severe disease, defined by room air pO2 <70 mm Hg or Alveolar-arterial O2 gradient ≥35 mm Hg
Start within 72 hours of initiating therapy for PCP
Indication for anticonvulsant in patients with diagnosis of toxoplasma gondii
ONLY patients who have history of seizures
Should not be prophylactically prescribed
Indication for stopping chronic maintenance therapy in patients with cryptococcal meningitis
Completed induction, consolidation and 1 year of maintenance therapy
Remains asymptomatic
CD4 count ≥100 cells/µL for ≥3 months and suppressed HIV RNA in response to effective ART
Indication for chemoprophylaxis against toxoplasma gondii
Patients who are IgG seropositive AND have CD4 count < 100 cells/mm3
Preferred IV agent used to treat CMV
Ganciclovir
Foscarnet
*Cidofovir has B1 recommendation
Occasionally added on as a third agent for treatment of MAC
Rifabutin
Pre-medications for amphotericin B
NS 500 to 1000 mL (reduces nephrotoxicity)
30 minutes before infusion: acetaminophen (650 mg) and diphenhydramine (25–50 mg) or hydrocortisone (50–100 mg)
*Meperidine also used for rigors but not prophylactically
Indication for discontinuing secondary chemoprophylaxis for mycobacterium avium
Completed 12 months of treatment
No signs and symptoms of MAC
CD4 > 100 cells/mm3 for greater than or equal to 6 months AFTER ART INITIATION
Two regimens that may be used for prophylaxis for both PCP and Toxoplasma.
Bactrim
Dapsone + pyrimethamine + leucovorin
Atovaquone + leucovorin
Preferred induction, maintenance and consolidation regimens for cryptococcal meningitis
Induction: Amphotericin B + flucytosine (x atleast 2 weeks- Need negative CSF culture)
Consolidation: Fluconazole 400mg x 8 weeks
Maintenance: Fluconazole 200mg x 1 year
Associated with more frequent relapse when used for PCP pneumonia
Aerosolized pentamidine
Daily dose of clarithromycin associated with increased mortality in patients with MAC
> 1 gram/ day
ART therapy may be restarted between ______ weeks after starting anti-fungal therapy in patients with cryptococcal meningitis
2 to 10 weeks