Guidelines for Prevention and Treatment of Opportunistic Infections
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Transcript Guidelines for Prevention and Treatment of Opportunistic Infections
Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected
Adults and Adolescents
Coccidioidomycosis 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become out of date quickly.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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Coccidioidomycosis: Epidemiology
Caused by Coccidioides immitis and C
posadasii
Endemic in southwest United States, parts of
Central and South America
Increased risk with extensive exposure to soil
May cause disease via reactivation of previous
infection
Disease may occur in those with no discernible
immunodeficiency
Increased risk in HIV patients with CD4 count
<250 cells/µL
Incidence and severity lower after broader
use of ART
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Coccidioidomycosis:
Clinical Manifestations
Severity associated with lower CD4
counts, lack of HIV suppression
In HIV infection, 6 common syndromes:
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Focal pneumonia
Diffuse pneumonia (presents like PCP)
Cutaneous involvement
Meningitis
Liver or lymph node involvement
Positive coccidioidal serology tests without
evidence of localized infections
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Coccidioidomycosis:
Clinical Manifestations (2)
Focal pneumonia most common if CD4
count >250 cells/µL
Other syndromes usually occur with
more advanced immunosuppression
Meningitis: headache, progressive
lethargy, fever, nausea or vomiting,
confusion
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Coccidioidomycosis: Manifestations
Chest X ray: disseminated coccidioidomycosis
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Credit: Huang L, MD; HIV InSite
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Coccidioidomycosis: Diagnosis
Culture of clinical specimens
Histopathology
Blood cultures (positive in <50%)
Coccidioidal IgM and IgG serology (EIA,
immunodiffusion, classical tube precipitin, complement
fixation): useful but poorer sensitivity in patients with
low CD4 counts
CSF analysis: typically shows lymphocytic pleocytosis,
CSF glucose <50 mg/dL, CSF protein normal or mildly
elevated; complement fixation usually positive;
culture positive in <1/3
Newer coccidioidomycosis-specific antigen assay:
detects antigen in urine and serum
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Coccidioidomycosis: Prevention
Preventing exposure
In endemic areas, impossible to avoid exposure
completely
HIV-infected persons: avoid extensive exposure
to disturbed soil in endemic areas (eg,
excavation sites, dust storms)
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Coccidioidomycosis: Prevention
Preventing disease
Primary prophylaxis not recommended
For HIV-infected persons in endemic regions:
yearly serologic testing is reasonable
If new positive IgM or IgG serologic test and CD4
count <250 cells/µL
Fluconazole 400 mg PO QD
Outside endemic regions: routine testing not
useful and should not be done
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Coccidioidomycosis: Treatment
Treatment consists of 2 phases:
induction and maintenance
Total duration of therapy ≥12 months
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Coccidioidomycosis: Treatment
Severe nonmeningeal infection: diffuse pulmonary
or severely ill with disseminated disease
Acute phase (continue until clinical improvement):
Preferred:
Amphotericin B deoxycholate 0.7-1.0 mg/kg IV QD
Lipid-formulation amphotericin B 4-6 mg/kg IV QD
Alternative: add fluconazole or itraconazole to
amphotericin B (itraconazole preferred for bone disease)
Maintenance therapy (continue indefinitely)
Fluconazole 400 mg PO QD
Itraconazole 200 mg PO BID
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Coccidioidomycosis: Treatment (2)
Mild disease: focal pneumonia
Preferred:
Fluconazole 400 mg PO QD
Itraconazole 200 mg PO BID
Alternative (limited data):
Posaconazole 200-400 mg PO BID
Voriconazole 200 mg PO BID
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Coccidioidomycosis: Treatment (3)
Meningeal infection
Consult with specialist
Acute phase
Preferred: fluconazole 400-800 mg IV or PO QD
Alternative:
Itraconazole 200 mg PO BID
Posaconazole 200-400 mg PO BID
Voriconazole 200-400 mg PO BID
Intrathecal amphotericin B if azoles not effective
Hydrocephalus may develop: may need CSF shunt
Lifelong therapy required: relapse in 80% of HIV
patients with azole therapy discontinued
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Coccidioidomycosis:
ART Initiation
Start ART as soon as possible after start of
antifungal therapy
IRIS has been reported (1 case)
Triazoles have complex, sometimes
bidirectional interactions with certain ARVs;
dosage adjustments may be needed
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Coccidioidomycosis:
Monitoring and Adverse Events
Monitor complement-fixing antibody every
12 weeks: useful in assessing response to
therapy
Increase in titer suggests recurrence or
worsening – reassess management
IRIS: 1 reported case
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Coccidioidomycosis: Treatment Failure
Failure of fluconazole or itraconazole:
Severely ill: amphotericin B (deoxycholate or
lipid formulation)
Not severely ill: consider posaconazole 200 mg
PO BID or voriconazole 200 mg PO BID
(limited data for both)
Note: significant interactions between voriconazole
and NNRTIs or ritonavir
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Coccidioidomycosis: Preventing Recurrence
Consider lifelong suppressive therapy if
CD4 count remains <250 cells/µL
Preferred:
Fluconazole 400 mg PO QD
Itraconazole 200 mg PO BID
Alternative (if patient did not initially
respond to fluconazole or itraconazole):
Posaconazole 200 mg PO BID
Voriconazole 200 mg PO BID
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Coccidioidomycosis: Preventing Recurrence (2)
Discontinuing secondary prophylaxis:
Focal pneumonia:
May discontinue after 12 months of therapy if CD4 ≥250 cells/µL
on effective ART
Monitor for recurrence (serial chest X rays and coccidioidal
serology)
Diffuse pulmonary or nonmeningeal disseminated
disease:
Relapses in >25% of cases, even in HIV-uninfected patients
Some would continue therapy indefinitely; consult with expert
Meningitis:
Relapses in 80%
Continue therapy lifelong
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Coccidioidomycosis: Considerations in
Pregnancy
More likely to disseminate if acquired
during 2nd or 3rd trimester
Amphoteracin B or its lipid formulations
are preferred initial regimen
At delivery, evaluate neonate for renal
dysfunction and hypokalemia
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Coccidioidomycosis: Considerations in
Pregnancy (2)
Azoles: avoid in 1st trimester--risk of
teratogenicity
Coccidioidal meningitis:
Only alternative to azoles is intrathecal amphotericin
B
Choice of treatment should be based on risk/benefit
considerations and in consultation with the mother
and with infectious disease and obstetric experts
Voriconazole and posaconazole: teratogenic
and embryotoxic in animals: avoid throughout
pregnancy
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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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