Transcript Guidelines for Prevention and Treatment of Opportunistic

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected
Adults and Adolescents
Microsporidiosis 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become out of date quickly.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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Microsporidiosis: Epidemiology
 Protists, related to fungi
 Many species, including Enterocytozoon
bieneusi, Encephalitozoon cuniculi,
Encephalitozoon intestinalis
 Ubiquitous, may be zoonotic and/or
waterborne
 Risk greatest with CD4 count <100 cells/µL
 Incidence dramatically lower in areas with
widespread use of effective ART
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Microsporidiosis: Clinical Manifestations
 Most common: diarrheal illness
 Other manifestations: cholangitis, hepatitis,
encephalitis, ocular infection, sinusitis,
myositis, disseminated infection
 Clinical syndromes may vary by species
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Microsporidiosis: Diagnosis
 Microscopic identification of stool or tissue
samples
 Identification requires high magnification
(1,000×), selective stains to differentiate
spores from cellular debris
 Electron microscopy, PCR, Ab-specific stains can
determine species
 Evaluate 3 stool samples
 Small bowel biopsy if stool studies are
negative and suspicion is high
 Urine examination may be useful if cause is
Encephalitozoon or Trachipleistophora spp
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Microsporidiosis: Prevention
 Preventing exposure
 Handwashing; avoidance of undercooked
meat or seafood and exposure to infected
animals
 Patients with CD4 counts of <200 cells/μL
should avoid drinking untreated water
 Primary prophylaxis
 Appropriate initiation of ART before severe
immunosuppression should prevent disease
 No chemoprophylaxis known to be effective
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Microsporidiosis: Treatment
 ART with immune restoration (to CD4
count >100 cells/µL)
 Should be offered to all as part of initial
management
 If severe dehydration, malnutrition,
wasting: hydration, nutritional support (IV
therapies may be needed)
 Antimotility agents, if needed for diarrhea
control
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Microsporidiosis: Treatment (2)
 E bieneusi GI infections:
 ART and fluid support as above
 no specific antimicrobial;
 Fumagillin 60 mg PO QD or TNP-470: some evidence
of efficacy but not available in United States
 Nitazoxanide: limited data; cannot be recommended
with confidence
 Nonocular infection caused by microsporidial
other than E bieneusi and V corneae:
 Albendazole 400 mg PO BID
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Microsporidiosis: Treatment (3)
 Disseminated disease caused by
Trachipleistophora or Anncaliia
 Itraconazole 400 mg PO QD + albendazole 400 mg
PO BID
 Ocular infection: fumagillin (Fumidil B) eye
drops 70 mcg/mL + albendazole 400 mg PO
BID
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Microsporidiosis: Starting ART
 ART should be offered as part of initial
management of this infection
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Microsporidiosis: Adverse Events
 Albendazole: adverse effects are rare;
monitor hepatic enzymes
 Fumagillin
 Topical: no known substantial side effects
 Oral: thrombocytopenia
 IRIS: 1 report
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Microsporidiosis: Treatment Failure
 Supportive treatment
 Optimization of ART
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Microsporidiosis: Prevention of Recurrence
 Ocular:
 If CD4 >200 cells/µL on ART, consider
discontinuing treatment after ocular infection
resolves; restart if CD4 drops to <200 cells/µL
 Other manifestations:
 Safety of treatment discontinuation after
immune restoration with ART is not known
 Reasonable to discontinue maintenance
therapy in asymptomatic patients on ART with
increase in CD4 count to >200 cells/µL for ≥6
months (no data to support this approach)
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Microsporidiosis: Considerations in
Pregnancy
 Initiate ART to restore immune function
 Albendazole:
 Embryotoxic and teratogenic in animals
 Not recommended in 1st trimester, use during later
pregnancy only if benefits expected to outweigh risks
 Systemic fumagillin: growth retardation in rats:
should not be used with pregnant women
 Topical fumagillin appears safe
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Microsporidiosis: Considerations in
Pregnancy (2)
 Itraconazole: avoid in 1st trimester
 Loperamide: possible risk of hypospadias with
1st-trimester exposure
 Avoid in 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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