Transcript Treating Opportunistic Infections Among HIV

Guidelines for Prevention and Treatment of Opportunistic
Infections in HIV-Infected Adults and Adolescents
Bacterial Enteric Infections
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 and updated in May 2016. 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field of HIV care, this information could become out of date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 Infections
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Epidemiology
Clinical Manifestations
Diagnosis
Prevention
Treatment
Considerations in Pregnancy
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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 AIDSdefining 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
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Bacterial Enteric Disease: Diagnosis (2)
 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
 Antibiotic susceptibility should be performed on all stool
samples
 Increased rates of resistant and multidrug-resistant
Enterobacteriaceae, especially outside the U.S.
 Consider possible resistance when prescribing empiric
treatment for persons who develop diarrhea or systemic
infection while traveling or returning to the U.S.
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Bacterial Enteric Disease: Diagnosis (3)
 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, acid-suppressive 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 or 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; empiric
treatment with ciprofloxacin is reasonable
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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: antibiotic resistance is common
outside the U.S.
 Consider this when prescribing enteric antibiotics (esp. in
travelers to South and Southeast Asia)
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Bacterial Enteric Disease: Treatment
(4) Salmonella spp.
 In HIV infection, treatment recommended,
because of high risk of bacteremia and mortality
 Preferred:
 Ciprofloxacin 500-750 mg PO (or 400 mg IV) Q12H
 Alternative:
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Levofloxacin 750 mg PO or IV Q24H
Moxifloxacin 400 mg PO or IV Q24H
TMP-SMX 160/800 mg PO or IV Q12H, if susceptible
Ceftriaxone 1 g IV Q24H or cefotaxime 1 g IV Q8H, 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 160/800 mg PO or IV Q12H
Azithromycin 500 mg PO QD for 5 days (not recommended if
bacteremia)
 Cipro resistance reported, associated with MSM,
homelessness, international travel; azithro resistance
reported in HIV-infected MSM; high rate of TMP-SMX
resistance in infections acquired outside the U.S.
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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 is reasonable
 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
 Rates of resistance to FQs and azithromycin differ by
Campylobacter species
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Bacterial Enteric Disease: Treatment
(9) Campylobacter spp.
 Mild disease and CD4 >200 copies/µL: some
clinicians withhold antibiotics unless symptoms
persist > several days
 Mild-moderate disease (if susceptible)
 Preferred
 Ciprofloxacin 500-750 mg PO or 400 mg IV Q12H
 Azithromycin 500 mg PO QD (not recommended 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
(10) 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
(11) C difficile
 Treatment as in HIV-uninfected patients
 Vancomycin recommended over metronidazole, with
possible exception of mild C difficile infection
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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:
 Avoid coadministration of FQs with Mg- or Al-containing
antacids, or with calcium, zinc, or iron (they interfere
with FQ absorption
 Use IV antibiotics if patient is clinically unstable
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Bacterial Enteric Disease: Preventing
Recurrence
 Salmonella
 Consider secondary prophylaxis for patients with
recurrent Salmonella bacteremia; also might consider
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
 ART appears to reduce risk of recurrence
 Consider stopping secondary prophylaxis if Salmonella
infection is resolved, patient is on ART with viral
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 (associated with increased
risk of birth defects, but recent review supports use if
indicated)
 Sulfa therapy near delivery may increase risk to newborn of
hyperbilirubinemia and kernicterus
 Rifaximin can be used as with nonpregnant women
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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
and updated in May 2016
 See the AETC NRC website for the most current
version of this presentation: http://www.aidsetc.org
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