Transcript Campylobacter

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
November 2014
www.aidsetc.org
About This Presentation
These slides were developed using recommendations
published in May 2013 and updated in November 2014.
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field of HIV care, this information could become out of
date quickly.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
2
November 2014
www.aidsetc.org
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:
 Salmonella
 Shigella
 Campylobacter
 E coli
 Clostridium difficile
3
November 2014
www.aidsetc.org
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
4
November 2014
www.aidsetc.org
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
5
November 2014
www.aidsetc.org
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 AIDSdefining illness
6
November 2014
www.aidsetc.org
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
7
November 2014
www.aidsetc.org
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)
8
November 2014
www.aidsetc.org
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
9
November 2014
www.aidsetc.org
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)
10
November 2014
www.aidsetc.org
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
11
November 2014
www.aidsetc.org
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
12
November 2014
www.aidsetc.org
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
13
November 2014
www.aidsetc.org
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
14
November 2014
www.aidsetc.org
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)
15
November 2014
www.aidsetc.org
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):




16
Levofloxacin 750 mg PO or IV Q24H
Moxifloxacin 400 mg PO or IV Q24H
TMP-SMX 106/800 mg PO or IV Q12H
Azithromycin 500 mg PO QD for 5 days (not
recommended if bacteremia)
November 2014
www.aidsetc.org
Bacterial Enteric Disease: Treatment (7)
Shigella spp. (cont.)
 High rate of TMP-SMX resistance in infections
acquired outside the U.S.; reports of azithromycin
resistance in HIV-infected MSM
 Duration of therapy
 Gastroenteritis: 7-10 days (5 days for
azithromycin)
 Bacteremia: ≥14 days
 Recurrent infection: up to 6 weeks
17
November 2014
www.aidsetc.org
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
18
November 2014
www.aidsetc.org
Bacterial Enteric Disease: Treatment (9)
Campylobacter spp. (cont.)
 Bacteremia: ciprofloxacin 500-750 mg PO or 400
mg IV Q12H + aminoglycoside
 Duration of therapy
 Gastroenteritis: 7-10 days (5 days for azithromycin)
 Bacteremia: >14 days
 Recurrent bacteremic disease: 2-6 weeks
19
November 2014
www.aidsetc.org
Bacterial Enteric Disease: Treatment (10)
C difficile
 Treatment as in HIV-uninfected patients
20
November 2014
www.aidsetc.org
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)
21
November 2014
www.aidsetc.org
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
22
November 2014
www.aidsetc.org
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
23
November 2014
www.aidsetc.org
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
24
November 2014
www.aidsetc.org
Bacterial Enteric Disease:
Preventing Recurrence (2)
 Shigella
 Chronic suppressive therapy not recommended for firsttime infections
 Recurrent infections: extend antibiotic treatment for up to
6 weeks
 ART expected to decrease recurrence
 Campylobacter
 Chronic suppressive therapy not recommended for firsttime infections
 Recurrent infections: extend antibiotic treatment for 2-6
weeks
 ART expected to decrease recurrence
25
November 2014
www.aidsetc.org
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
26
November 2014
www.aidsetc.org
Websites to Access the Guidelines
 http://www.aidsetc.org
 http://aidsinfo.nih.gov
27
November 2014
www.aidsetc.org
About This Slide Set
 This presentation was prepared by Susa Coffey,
MD, for the AETC National Resource Center in
June 2013 and updated in November 2014
 See the AETC NRC website for the most current
version of this presentation:
http://www.aidsetc.org
28
November 2014
www.aidsetc.org