Transcript Guidelines for Prevention and Treatment of Opportunistic Infections

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected
Adults and Adolescents
Aspergillosis 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, owing to 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become out of date quickly.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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Aspergillosis: Epidemiology
 Caused by Aspergillus fumigatus,
occasionally by other Aspergillus species
 Invasive aspergillosis is rare in HIV-infected
persons
 Risk factors: low CD4 count (<100 cells/µL),
neutropenia, use of corticosteroids,
exposure to broad-spectrum antibiotics,
underlying lung disease
 Less common with widespread use of potent
ART
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Aspergillosis: Clinical Manifestations
 Respiratory
 Invasive pneumonia: fever, cough, dyspnea, chest
pain, hemoptysis, hypoxemia; on CXR, diffuse, focal,
or cavitary infiltrates, “halo” of low attenuation
around a pulmonary nodule (or “air crescent” on CT)
 Tracheobronchitis: fever, cough, dyspnea, stridor,
wheezing, airway obstruction; tracheal
pseudomembrane (multiple ulcerative or plaque-like
lesions) seen on bronchoscopy
 Other extrapulmonary forms include: sinusitis,
cutaneous disease, osteomyelitis
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Aspergillosis: Diagnosis
 Definitive diagnosis:
 Histopathology: tissue invasion by septate hyphae,
with positive culture for Aspergillus spp
 Probable diagnosis of invasive pulmonary
disease:
 Isolation of Aspergillus spp from respiratory
secretions or septate hyphae consistent with
Aspergillus in respiratory samples, with typical CT
findings
 ELISA test for galactomannan: sensitivity better for
BAL than for serum; high specificity; not well studied
in HIV
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Aspergillosis: Preventing Disease
 Preventing exposure:
 Aspergillus spp are ubiquitous in the
environment; exposure is not avoidable
 Avoid dusty environments to decrease
exposure to spores
 Preventing disease
 No data in HIV-infected persons; currently not
recommended
 Posaconazole effective in patients with certain
hematologic malignancies and neutropenia
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Aspergillosis: Treatment
 Not systematically evaluated in HIV-infected
patients
 Preferred:
 Voriconazole 6 mg/kg IV Q12H for 1 day, then 4
mg/kg IV Q12H until clinical improvement, then 200
mg PO Q12H
 Significant interactions with protease inhibitors and efavirenz
 Duration of therapy: not established; continue at
least until CD4 >200 cells/µL and infection
appears resolved
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Aspergillosis: Treatment (2)
 Alternative:
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Lipid formulation amphotericin B 5 mg/kg IV QD
Amphotericin B deoxycholate 1 mg/kg IV QD
Caspofungin 70 mg IV for 1 dose, then 50 mg IV QD
Micafungin 100-150 mg IV QD
Anidulafungin 200 mg IV for 1 dose, then 100 mg IV
QD
 Posaconazole 200 mg PO 4 times per day until
clinical improvement, then 400 mg PO BID
 Duration of therapy: not established; continue at
least until CD4 >200 cells/µL and infection
appears resolved
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Aspergillosis:
ART Initiation
 Start ART as soon as possible after start
of antifungal therapy
 IRIS has rarely been reported
 Triazoles have complex, sometimes
bidirectional interactions with certain
ARVs; dosage adjustments may be
needed
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Aspergillosis:
Monitoring and Adverse Events
 If new or recurrent signs and symptoms,
evaluate for relapse or recurrence
 IRIS reported rarely
 Limited data regarding monitoring of
galactomannan levels in response to therapy
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Aspergillosis: Treatment Failure
 Prognosis is poor in advanced
immunosuppression without effective ART
 No data to guide management of treatment
failure
 If voriconazole used initially, consider
change to amphotericin B, or echinocandins
in combination with voriconazole or
amphotericin B
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Aspergillosis: Preventing Recurrence
 Chronic maintenance: insufficient
data to recommend for or against
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Aspergillosis:
Considerations in Pregnancy
 Amphotericin B or its lipid formulations are
preferred initial regimen
 At delivery, evaluate neonate for renal
dysfunction and hypokalemia
 Voriconazole and posaconazole: teratogenic
and embryotoxic in animals; generally avoid
in pregnancy, especially 1st trimester
 Echinocandins: bone and visceral
abnormalities in animals; avoid in 1st
trimester
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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, 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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