Transcript Adult OI Guidelines

Guidelines for Prevention and Treatment of Opportunistic
Infections in HIV-Infected Adults and Adolescents
Cryptosporidiosis Slide Set
Prepared by the AETC National Coordinating 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field of HIV care, this information could become out of date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
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Epidemiology
Clinical Manifestations
Diagnosis
Prevention
Treatment
Considerations in Pregnancy
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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 1sttrimester 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 Coordinating
Resource Center in May 2013
 See the AETC NCRC website for the most current
version of this presentation: http://www.aidsetc.org
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