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Case 3: Prophylaxis for Mycobacterium avium complex

Author: Robert D. Harrington, MD

Case last updated: June 30, 2004

A 42-year-old-man with late stage HIV is failing salvage therapy consisting of zidovudine plus lamivudine plus abacavir (Trizivir) and lopinavir-ritonavir (Kaletra). He is currently taking trimethoprim-sulfamethoxazole (Bactrim, Septra) for Pneumocystis prophylaxis. He has lost 12 pounds during the last two months and is having night sweats. His hematocrit has decreased from 36 to 27 and his absolute CD4 count has decreased from 49 to 19 cells/mm3.

Which of the following is TRUE regarding prophylaxis for Mycobacterium avium complex (MAC) disease?

A The patient's CD4 count is less than 50 cells/mm3 so he should immediately receive prophylaxis for MAC. Recent studies have shown that prophylaxis with rifabutin (Mycobutin) plus clarithromycin (Biaxin) is clearly more effective than clarithromycin alone.
B The patient's CD4 count is less than 50 cells/mm3 and this warrants monthly sputum and stool surveillance cultures for MAC. Prophylaxis for MAC should only occur if the patient has a positive stool or urine culture.
C Recent guidelines now recommend initiating MAC prophylaxis in a patient with a CD4 cell count less than 100 cells/mm3 if they have concomitant oral candidiasis.
D The patient's symptoms of weight loss, night sweats suggest he may possibly have disseminated MAC. Before MAC prophylaxis is started, disseminated MAC infection should be ruled out.
E The patient is taking trimethoprim-sulfamethoxazole and that will provide adequate prophylaxis against MAC.