Madison Clinic
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Primary Prevention of Opportunistic Infections

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Condition Indication Recommendation
Pneumocystis jarovecii pneumonia (PCP) CD4 <200 or oropharyngeal candidiasis First choice: TMP-SMX 1 DS or SS po q.d. or DS q MWF
Alternatives:
Dapsone 100 mg po q.d.
Aerosolized pentamidine 300 mg qmo.
Atovaquone 1500 mg po q.d.
Mycobacterium
Tuberculosis

1) PPD reaction >= 5mm or
2) Prior PPD + without TX or
3) Quantiferon
4) Close contact with infectious
TB case
4) Hx untreated or inadequately treated healed TB (i.e. old fibrotic lesions on chest imaging with appropriate epidemiology)

IMPORTANT TO RULE OUT ACTIVE TB! [LINK]

INH-sensitive TB:
INH 300mg/d po +pyridoxine 50mg/d x 9mo.
INH-resistant TB:
RIF 600mg/d po. x 4mo.
Multidrug (INH and Rifampin) resistant TB:
Consult Health Department
Toxoplasma gondii Toxo IgG negative Counsel on prevention, repeat at CD4 <100
Toxo IgG + andCD4 <100 First choice: TMP-SMX 1 DS q.d.
Alternative:
Dapsone 50 g po q.d +
Pyrimethamine 50 mg po q.wk +
Leucovorin 25 mg po q.wk
Mycobacterium
Avium complex
CD4 <50 Azithromycin 1200 mg po q wk
or
Clarithromycin 500 mg po bid
Cytomegalovirus Negative anti-CMV Transfuse only negative anti-CMV blood
Positive anti-CMV andCD4<50 Annual fundoscopic exam

* For PCP, may discontinue primary or secondary prophylaxis if CD4 count>200 for 3 months

* For toxoplasmosis, may discontinue primary prophylaxis when CD4>200 for >3 months. Less data on discontinuation of secondary prophylaxis, but when initial treatment for toxoplasmosis is completed and CD4>200 for >6 month it appears safe to discontinue secondary prophylaxis (some advocate MRI prior to discontinuation of secondary prophylaxis).

* For MAC may discontinue primary prophylaxis when CD4>100 for >3 months. Less data on discontinuation of chronic maintenance therapy, but if patient has received >12 months of treatment for MAC, remains asymptomatic, and has had a >6 months of a CD4 count >100, it appears safe to discontinue therapy. (Some experts recommend checking MAC blood cultures prior to discontinuation; some report increase chance of relapse in osteomyelitis secondary to MAC)

For more details on prevention and treatment of opportunistic infections see the link to the Department of Health and Human Services on this webpage or go directly to:

Prevention and Treatment of Opportunistic Infections Guidelines

 

 

 

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