Transcript Guidelines for Prevention and Treatment of Opportunistic Infections

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected
Adults and Adolescents
Cryptosporidiosis Slide Set
Prepared by the AETC National Resource Center
based on recommendations from the CDC,
National Institutes of Health, and HIV Medicine
Association/Infectious Diseases Society of America
About This Presentation
These slides were developed using recommendations
published in May 2013. The intended audience is
clinicians involved in the care of patients with HIV.
Users are cautioned that, because of the rapidly
changing field of HIV care, this information could
become out of date quickly. Finally, it is intended that
these slides be used as prepared, without changes in
either content or attribution. Users are asked to honor
this intent.
-AETC National Resource Center
http://www.aidsetc.org
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Cryptosporidiosis: Epidemiology
 Caused by Cryptosporidium species
 Protozoan parasites
 Infect small intestine mucosa; in
immunosuppressed patients, also infect
large intestine and other sites
 Advanced immunosuppression (eg, CD4
<100 cells/µL) associated with prolonged,
severe, or extraintestinal disease
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Cryptosporidiosis: Epidemiology (2)
 Infection results from ingestion of oocysts
excreted in feces of infected humans or
animals
 Water supplies and recreational water
sources (oocysts may withstand standard
chlorination)
 Person-to-person transmission common, via
oral-anal contact, from infected children to
adults (eg, during diapering), or care of
patients with diarrhea
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Cryptosporidiosis: Epidemiology (3)
 Common cause of chronic diarrhea in AIDS
patients in developing countries
 In developed countries with low rates of
envrionmental contamination and
widespread use of effective ART, <1 case
per 1,000 person-years in AIDS patients
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Cryptosporidiosis: Clinical Manifestations
 Acute or subacute onset of profuse watery,
nonbloody diarrhea, often with nausea, vomiting,
and abdominal cramping
 Fever in 1/3 of patients
 Can be very severe, especially with immune
suppression
 Malabsorption is common; dehydration,
electrolyte abnormalities, malnutrition may result
 Biliary tract and pancreatic duct may be infected,
causing scleroding cholangitis and pancreatitis
 Pulmonary infection is possible
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Cryptosporidiosis: Diagnosis
 Microscopic identification of oocysts in
stool or tissue
 DFA very sensitive, specific, is current gold
standard for stool specimens
 Acid-fast staining often used
 PCR extremely sensitive
 ELISA or immunochromatographic tests
 Small intestine biopsy with identification of
Cryptosporidium organisms
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Cryptosporidiosis: Diagnosis (2)
 Single specimen usually sufficient in
profuse diarrhea
 Repeat stool sampling is recommended in
mild disease
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Cryptosporidiosis: Prevention
Preventing exposure
 Avoid exposure to infected contacts
 Contact with diarrhea
 Potential oral exposure to feces during sex
 Direct contact with farm animals, stool from
pets
 Scrupulous handwashing after potential
contact with feces (eg, after diapering), after
handling pets or other animals, gardening,
before preparing food or eating, before and
after sex
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Cryptosporidiosis: Prevention (2)
 Avoid exposure to contaminated water,
food
 Do not drink or swallow water from
recreational sources (lakes, streams, pools)
 Ice, fountain beverages, water fountains may
be contaminated
 Avoid raw oysters
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Cryptosporidiosis: Prevention (3)
 Boil tap water for ≥1 minute during
outbreaks or when community advisory is
issued
 Submicron water filters or bottled water may
reduce risk
 For non-outbreak settings, data are
inadequate to recommend that all persons
with low CD4 counts avoid drinking tap
water
 Consider drinking only filtered water
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Cryptosporidiosis: Prevention (4)
Preventing disease
 Primary prophylaxis:
 Appropriate initiation of ART before severe
immunosuppression should prevent disease
 Rifabutin and possibly clarithromycin are
protective, but data insufficient to recommend
as chemoprophylaxis
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Cryptosporidiosis: Treatment
 Preferred strategies
 ART with immune restoration (to CD4 count
>100 cells/µL)
 Usually results in complete resolution; should be
offered as part of initial management of
cryptosporidiosis
 Symptomatic treatment: antidiarrheals
 Tincture of opium may be more effective than
loperamide
 Octreotide usually not recommended (no more
effective than other antidiarrheals)
 Supportive care: aggressive hydration,
electrolyte repletion, nutritional support (IV
therapies may be needed)
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Cryptosporidiosis: Treatment (2)
 Alternative strategies
 No consistently effective antimicrobial therapy
in absence of ART
 Consider nitazoxanide or other antiparasitic
drugs in conjunction with ART, not instead of
ART
 Nitazoxanide 500-1,000 mg PO BID for 14 days +
ART and other measures above
 Some studies show clinical improvement with nitazoxanide
 Paromomycin 500 mg PO QID for 14-21 days + ART
and other measures above
 Limited data; may improve clinical response in conjunction
with ART
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Cryptosporidiosis: Starting ART
 ART should be offered as part of initial
management of this infection
 PIs inhibit Cryptosporidium in animal models –
some experts prefer PI-based ART
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Cryptosporidiosis: Monitoring and
Adverse Events
 Monitor closely for volume depletion, electrolyte
loss, weight loss, and malnutrition
 TPN may be indicated
 IRIS not reported
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Cryptosporidiosis: Treatment Failure
 Supportive treatment
 Optimization of ART
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Cryptosporidiosis: Prevention of Recurrence
 No effective prevention, other than
immune restoration with ART
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Cryptosporidiosis: Considerations in
Pregnancy
 Rehydration and ART initiation as with
nonpregnant adults
 Nitazoxanide not teratogenic in animals, but no
data in pregnant humans
 Use after 1st trimester in severely symptomatic women
 Paromomycin: limited information on
teratogenicity; minimal systemic absorption with
PO administration
 Use after 1st trimester in severely symptomatic
women
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Cryptosporidiosis: Considerations in
Pregnancy (2)
 Loperamide: possible risk of hypospadias with
1st-trimester exposure
 Avoid during 1st trimester, unless benefits expected to
outweigh risks
 Preferred antimotility agent during late pregnancy
 Tincture of opium not recommended during late
pregnancy
 Opiate exposure during late pregnancy associated with
neonatal respiratory depression; chronic exposure may
result in neonatal withdrawal
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Websites to Access the Guidelines
 http://www.aidsetc.org
 http://aidsinfo.nih.gov
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About This Slide Set
 This presentation was prepared by
Susa Coffey, MD, and Oliver Bacon,
MD, for the AETC National Resource
Center in May 2013
 See the AETC NRC website for the
most current version of this
presentation:
http://www.aidsetc.org
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