Question | Discussion | References | CME Credit

Updated November 12, 2010

Case 3: Prophylaxis for Mycobacterium avium complex

Author: Robert D. Harrington, MD

A 42-year-old-man with advanced HIV disease presents to the clinic for follow-up care. He has experienced major problems with adherence and is failing a salvage therapy consisting of zidovudine–lamivudine–abacavir (Trizivir) plus lopinavir–ritonavir(Kaletra). He intermittently takes trimethoprim–sulfamethoxazole (Bactrim, Septra) for Pneumocystis prophylaxis. In the past 2 months, he has lost 12 pounds and complains of frequent 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 against disseminated Mycobacterium avium complex (MAC) disease?

A The patient's CD4 count is less than 50 cells/mm3 so he should immediately start clarithromycin (Biaxin) plus rifabutin (Mycobutin) for prophylaxis against disseminated MAC.
B The patient's CD4 count is less than 50 cells/mm3 and this warrants monthly sputum and stool surveillance cultures for MAC infection. Prophylaxis against disseminated MAC should occur only if the patient has a stool or urine culture positive for MAC.
C Recent guidelines recommend initiating prophylaxis against disseminated MAC 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 and night sweats suggest he may possibly have disseminated MAC. Before prophylaxis against disseminated MAC is started, disseminated MAC infection should be ruled out.