Transcript Treating Opportunistic Infections Among HIV

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents
Bacterial Enteric Disease 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become out of date quickly.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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Bacterial Enteric Disease:
Epidemiology
 Higher incidence of gram-negative enteric
infections among HIV-infected patients
 Risk greatest if CD4 <200 cells/µL or AIDS
 Risk decreased with ART
 Most commonly cultured bacteria:
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Salmonella
Shigella
Campylobacter
E coli
Clostridium difficile
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Bacterial Enteric Disease:
Epidemiology (2)
 Source usually ingestion of contaminated food or
water
 Other risks:
 Oral-fecal exposure through sexual activity (especially
Shigella and Campylobacter)
 HIV-related alterations in mucosal immunity or intestinal
integrity, gastric acid-blocking medications
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Bacterial Enteric Disease:
Clinical Manifestations
 Three major clinical syndromes
 Self-limited gastroenteritis
 Diarrheal disease +/- fever, bloody diarrhea,
weight loss, possible bacteremia
 Bacteremia associated with extraintestinal
involvement, with or without GI illness
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Bacterial Enteric Disease:
Clinical Manifestations (2)
 Severe diarrhea: ≥6 loose stools per day,
with our without other signs/symptoms
 In HIV infection:
 Greater risk of more serious illness with
greater immunosuppression
 Relapses may occur after treatment
 Recurrent Salmonella bacteremia is an
AIDS-defining illness
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Bacterial Enteric Disease: Diagnosis
 History: exposures; medication review; diarrhea
frequency, volume, presence of blood;
associated signs/symptoms (eg, fever)
 Physical exam including temperature,
assessment of hydration and nutritional status
 Stool and blood cultures
 Obtain blood cultures in patients with diarrhea and
fever
 Routine stool culture may not identify non-jejuni noncoli Campylobacter species; request special testing
for these if initial evaluation is unrevealing
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Bacterial Enteric Disease: Diagnosis (2)
 C difficile toxin or PCR
 If recent or current antibiotic exposure, cancer
chemotherapy, recent hospitalization, residence in
long-term care facility, CD4 <200 cells/µL, acidsuppressive medications, moderate-severe
community-acquired diarrhea
 Endoscopy
 If stool studies and blood culture are nondiagnostic, or
if treatment for an established diagnosis fails
 May diagnose nonbacterial causes (eg, parasites,
CMV, MAC, noninfectious causes)
 Consider STDs (eg, rectal infections caused by
lymphogranuloma venereum or N gonorrhoeae)
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Bacterial Enteric Disease:
Preventing Exposure
Advice to patients:
 Handwashing:
 After potential contact with feces, pets or other animals,
gardening/ contact with soil; before preparing food,
eating; before and after sex
 For prevention of enteric infection, soap and water
preferred over alcohol-based cleansers (these do not
kill C difficile spores, are partly active against norovirus
and Cryptosporidium)
 Sex:
 Avoid unprotected sexual practices that might result
in oral exposure to feces
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Bacterial Enteric Disease:
Preventing Disease
 Antimicrobial prophylaxis usually not
recommended, including for travellers
 Risk of adverse reactions, resistant organisms,
C difficile infection
 Can be considered in rare cases, depending on
level of immunosuppression and the region and
duration of travel
 Fluoroquinolone (FQ) or rifaximin
 TMP-SMX may give limited protection (eg, if
pregnant or already taking for PCP prophylaxis)
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Bacterial Enteric Disease:
Treatment
 Treatments usually the same as in HIVuninfected patients
 Give oral or IV rehydration if indicated
 Advise bland diet and avoidance of fat, dairy, and
complex carbohydrates
 Effectiveness and safety of probiotics or
antimotility agents not adequately studied in HIVinfected patients
 Avoid antimotility agents if concern about
inflammatory diarrhea
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Bacterial Enteric Disease: Treatment (2)
Empiric Therapy
 CD4 count and clinical status guide initiation and
duration of empiric antibiotics, eg:
 CD4 count >500 cells/µL with mild symptoms: only
rehydration may be needed
 CD4 count 200-500 cells/µL and symptoms that
compromise quality of life: consider short course of
antibiotics
 CD4 count <200 cells/µL with severe diarrhea, bloody
stool, or fevers/chills: diagnostic evaluation and
antibiotics
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Bacterial Enteric Disease: Treatment (3)
Empiric Therapy (cont.)
 Preferred: ciprofloxacin 500-750 mg PO (or 400
mg IV) Q12H
 Alternative: ceftriaxone 1 g IV Q24H or
cefotaxime 1 g IV Q8H
 Adjust therapy based on study results
 Traveler’s diarrhea: consider possibility of
antibiotic resistance
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Bacterial Enteric Disease: Treatment (4)
Salmonella spp.
 In HIV infection, treatment recommended, because of
high risk of bacteremia and mortality in HIV-infected
patients
 Preferred:
 Ciprofloxacin 500-750 mg PO (or 400 mg IV) Q12H
 Alternative:
 Levofloxacin 750 mg PO or IV Q24H, moxifloxacin 400 mg PO
or IV Q24H
 TMP-SMX PO or IV, if susceptible
 Ceftriaxone (IV) or cefotaxime (IV), if susceptible
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Bacterial Enteric Disease: Treatment (5)
Salmonella spp. (cont.)
 Optimal duration of therapy not defined
 Gastroenteritis without bacteremia
 CD4 count ≥200 cells/µL: 7-14 days
 CD4 count <200 cells/µL: 2-6 weeks
 Gastroenteritis with bacteremia
 CD4 count ≥200 cells/µL:14 days, longer if
persistent bacteremia or complicated infection
 CD4 count <200 cells/µL: 2-6 weeks
 If bacteremia, monitor closely for recurrence
(eg, bacteremia or localized infection)
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Bacterial Enteric Disease: Treatment (6)
Shigella spp.
 Treatment recommended, to shorten duration and
possibly prevent transmission
 Preferred:
 Ciprofloxacin 500-750 mg PO or 400 mg IV Q12H
 Alternative (depending on susceptibilities):
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Levofloxacin 750 mg PO or IV Q24H
Moxifloxacin 400 mg PO or IV Q24H
TMP-SMX 106/800 mg PO or IV Q12H for 3-7 days
Azithromycin 500 mg PO QD for 5 days (not recommended if
bacteremia)
 High rate of TMP-SMX resistance in infections acquired
outside the United States
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Bacterial Enteric Disease: Treatment (7)
Shigella spp. (cont.)
 Duration of therapy
 Gastroenteritis: 7-10 days (5 days for
azithromycin)
 Bacteremia: ≥14 days
 Recurrent infection: up to 6 weeks
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Bacterial Enteric Disease: Treatment (8)
Campylobacter spp.
 Optimal treatment in HIV poorly defined
 Culture and susceptibility recommended (increasing
resistance to FQ)
 Mild disease and CD4 >200 copies/µL: may withhold
antibiotics unless symptoms persist beyond several days
 Mild-moderate disease
 Preferred
 Ciprofloxacin 500-750 mg PO or 400 mg IV Q12H
 Azithromycin 500 mg PO QD for 5 days (avoid if bacteremia)
 Alternative (depending on susceptibilities):
 Levofloxacin 750 mg PO or IV Q24H
 Moxifloxacin 400 mg PO or IV Q24H
 Bacteremia: ciprofloxacin 500-750 mg PO or 400 mg
IV Q12H + aminoglycoside
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Bacterial Enteric Disease: Treatment (9)
Campylobacter spp. (cont.)
 Duration of therapy
 Gastroenteritis: 7-10 days (5 days for
azithromycin)
 Bacteremia: >14 days
 Recurrent bacteremic disease: 2-6 weeks
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Bacterial Enteric Disease: Treatment (10)
C difficile
 Treatment as in HIV-uninfected patients
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Bacterial Enteric Disease:
Initiating ART
 ART expected to decrease risk of recurrent
Salmonella, Shigella, and Campylobacter
infections
 Follow standard guidelines
 Consider patient’s ability to ingest and absorb
ARV medications
 Consider prompt ART initiation if Salmonella
bacteremia, regardless of CD4 count (should not
be delayed)
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Bacterial Enteric Disease:
Monitoring and Adverse Effects
 Monitor closely for treatment response
 Follow-up stool culture not required if clinical
symptoms and diarrhea resolve
 May be required if public health considerations
and state law dictate
 IRIS has not been described
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Bacterial Enteric Disease:
Treatment Failure
 Consider follow-up stool culture if lack of response
to appropriate antibiotic therapy
 Look for other enteric pathogens including C difficile;
antibiotic resistance
 Consider malabsorption of antibiotics: use IV
antibiotics if patient is clinically unstable
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Bacterial Enteric Disease:
Preventing Recurrence
 Salmonella
 Secondary prophylaxis should be considered for
patients with recurrent Salmonella bacteremia; also
might be considered for those with recurrent
gastroenteritis (with or without bacteremia) and in
those with CD4 count <200 cells/µL and severe
diarrhea
 This approach is not well established; weigh benefits
and risks
 Consider stopping secondary prophylaxis if Salmonella
infection is resolved, patient is on ART with virologic
suppression and CD4 count >200 cells/µL
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Bacterial Enteric Disease:
Preventing Recurrence (2)
 Shigella
 Chronic suppressive therapy not recommended for
first-time infections
 Recurrent infections: extend antibiotic treatment for up
to 6 weeks
 ART expected to decrease recurrence
 Campylobacter
 Chronic suppressive therapy not recommended for
first-time infections
 Recurrent infections: extend antibiotic treatment for 2-6
weeks
 ART expected to decrease recurrence
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Bacterial Enteric Disease:
Considerations in Pregnancy
 Diagnosis as with nonpregnant women
 Management as with nonpregnant adults, except:
 Expanded-spectrum cephalosporins or azithromycin should be
first-line therapy for bacterial enteric infections (depending on
organism and susceptibility testing)
 FQs can be used if indicated by susceptibility testing or failure of
first-line therapy (arthropathy in animals; no increased risk of
arthropathy or birth defects in humans after in utero exposure)
 Avoid TMP-SMX in 1st trimester (increased risk of birth defects)
 Sulfa therapy near delivery may increase risk to newborn of
hyperbilirubinemia and kernicterus
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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
June 2013
 See the AETC NRC website for the most current
version of this presentation:
http://www.aidsetc.org
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