Adult OI Guidelines
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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field of HIV care, this information could become out of date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
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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