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47 Cards in this Set
- Front
- Back
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What are 4 OIs that have no effective therapy? What do they require? When? When should it be initiated for TB? |
4 opportunistic infections that have no effective therapy: 1. cryptosporidiosis, 2. microsporidiosis 3. promyelocytic leukemia 4. Kaposi sarcoma These infections require ART initiation w/ in two weeks For TB; initiate ART when CD4 < 50 |
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How does PCP present? When does PCP risk increase? Prophylaxis? |
PCP (pneumocystitis jirovecii pnumonia) i. presents w/ fever, SOB, nonproductive cough ii. elevated lactate dehydrogenase iii. diffuse pulmonary infiltrates iv. hypoxemia **at risk for PCP if CD4 < 200 For prophylaxis DOC - Bactrim DS or SS once daily Alternative - Bactrim DS MWT (3x wk) |
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DOC for PCP be treatment? |
DOC: treat for 21 days Moderate to severe PCP a. IV Bactrim 15-20 mg/kg/day every 6-8 hrs for 21 days Mild to Moderate b. Bactrim DS 2 tabs tid |
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What are some alternative PCP treatments? |
All used for 21 days a. clindamycin and primaquine b. pentamidine c. trimethoprime and dapsone d. atovaquone |
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What drug can be used as adjuvant treatment w/ corticosteroids? |
corticosteroids for pts w/ sever PCP (A-a gradient of 35 or more; or PO2 of 70 or less); start w/in 72 hours decreases mortality |
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When can PCP prophylaxis be stopped? |
When CD4 count is > 200 for 3 consecutive months |
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How are candida infections diagnosed? |
S/S of infections -creamy white, curd like patches on tongue or other oral mucosal surfaces -pain, decreased food/fluid intake Fungal culture, potassium hydroxide smear Endoscopic evaluation |
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What drugs can be used to treat oral candidiasis? Treatment duration? |
Treatment duration 3-14 days duration, but it relapses w/in 30 days -indicated for mucous membrane and cutaneous Candida infections 1. Nystatin -for initial episode in pts w/ CD4 > 50 cells/mm3 2. clotrimazole (alternative to nystatin) -for initial episode in pts w/ CD4 > 50 -indicated for oropharyngeal and esophageal candidiasis 3. fluconazole 4. intraconazole |
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When are pts at the highest risk for cryptococcosis infections? |
CD4 less than 50 cells/mm3
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What are S/S of cryptococcosis infections? How is cryptococcosis infection diagnosed? |
a. almost always meningitis b. usually present for weeks or months (average 31 days) c. insidious onset i. low grade fever ii. headaches iii. altered sensorium, irritability, somnolence, clumsiness, impaired memory and judgement, behavior changes iv. seizures may occur late in course Diagnosis i. positive CSF ii. CSF india ink iii. CSF cryptococcal antigen titer |
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What is the preferred agent for cryptococcosis treatment? |
Lipid amphotericin 3-4 mg/kg/day plus flucytosine 25 mg/kg q6hr for at least 2 wks followed by fluconazole 400 mg/day for at least 8 wks |
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What is secondary prophylaxis for cryptococcosis treatment? |
fluconazole 200 mg/day may consider d/c afer a minimum of 1 yr chronic maintenance therapy if CD4 is > 100 cells/mm3 x 3 mos after initiation of potent combo ART reinitiate if CD4 ever drops below 100 cells/mm3 |
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What should be used as primary prophylaxis for cyrptococcosis? |
Primary prophylaxis not recommened |
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At what CD4 cell count does M. avium complex (MAC) risk increase? |
CD4 < 50 cells/mm3 |
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What is the preferred regimen for treating MAC? |
macrolide plus ethambutol for 12 months clarithromycin 500 mg BID; or azithromycin (if can't take clarith) plus ethambutol 15 mg/kg/day |
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What are some other MAC treatments? |
rifabutin fluoroquinolones: levoflox, moxiflox aminoglycoside such as amikacin or streptomycin |
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When can chronic maintenance or secondary prophylaxis cease for MAC? |
after 12 months of therapy if CD4 > 100 cells/mm3 for 6 months or longer because of potent combination ART and if pt is asymptomatic restart if CD4 drops below 100 cells/mm3 |
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When should primary prophylaxis for MAC begin? What agents should be used? |
Primary prophylaxis for MAC should begin if CD4 < 50 cells/mm3 Agents: clarithromycin 500 mg bid (preferred) azithromycin 1200 mg weekly azithromycin 600 mg BID rifabutin 300 mg/day -do not give alone to pts w/ TB -can cause rash, GI disturbances, neutropenia, body fluid discolorations |
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How is cytomegalovirus (CMV) diagnosied? |
serology virus isolation -tissue culture can take up to 6 wks |
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What are GI manifestations of CMV? |
colitis esophagitis and gastritis (uncommon) hepatitis w/ histologic evidence but minimal clinical importance |
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What pulmonary infections can CMV manifest?' When should you initiate treatment? |
pneumonia however, CMV is commonly in bronchial secretions and it is of of questionable importance initiate treatment if: documented tissue infection CMV is only pathogen deteriorating illness |
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What is the most important clinical manifestation of CMV? Why? |
retinitis generally occurs in pts w/ CD4 < 100 begins unilaterally and spreads bilaterally Early complaints are "floaters" pain behind eye In general this is progressive and does not spontaneously resolve ***can lead to blindness in weeks 26% progression even w/ treatment; retinal detachment very common |
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How is CMV treated? Why is this drug a good choice? |
Ganciclovir and valganciclovir ganciclovir and valganciclovir must be triphosphorylated; the rate limiting step in this process is the first phosphorylation. CMV induces the production of the enzyme necessary for the monophophorylation of ganciclovir but not acyclovir |
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What are some adverse effects of ganciclovir and valganciclovir? |
neutropenia thrombocytopenia confusion, convulsions, dizziness, headache N/V, diarrhea, abnormal LFTs |
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What are alternative CMV treatments? Why is ganciclovir preferred? When is *** preferred? Adverse reactions? |
foscarnet foscarnet and ganciclovir are equally effective against CMV, however, foscarnet decreases mortality because of its anti-HIV effects foscarnet is preferred if ganciclovir resistent CMV w/ mutations in the UL97 region of viral genome Adverse reactions renal impairment -esp if pt is dehydrated -2-3 fold increase in SCr -usually reversible -hydration w/ 2.5 L/day will prevent decreased hemaglobin/hematocrit electrolyte abnormalities penile ulcerations |
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What is another alterative CMV treatment besides ganciclovir and foscarnet? |
cidofovir requires intracellular activation Also active against ganciclovir resistant CMV w/ mutations in UL97 region |
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When is secondary prophylaxis recommended for CMV? What about primary prophylaxis? |
Secondary proph should continue until CD4 > 100 cells/mm3 for 3-6 mos primary proph is not recommended |
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Toxoplasmosis What can be hosts for sporozoite (Toxoplasma gondii) production? |
FELINES; keep liter box changed daily |
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What are S/S of toxoplasmosis? |
fever, headache, altered mental status focal neurologic deficits seizures CSF: mild pleocytosis, increased protein, normal glucose |
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How can toxoplasmosis be diagnosed? |
Brain bx: only definitive diagnosis; not usually done Antibodies or T. gondii isolation in serum of CSF |
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Who is standard toxoplasmosis therapy? |
a. pyrimethamine 50-75 mg/day (loading dose 200 mg in two dose); plus, b. sulfadiazine 1000-1500 mg every 6 hours i. watch for bone marrow suppression, thombocytopenia, granulocytopenia, anemia ii. can add folinic acid (leucovorin) 10-25 mg/day to reduce bone marrow effects of pyrimethamine iii. treat for 6 wks or after S/S resolve |
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What are alternative toxoplasmosis treatments? |
used in combo w/ pyrimethamine/leucovorin for sulfa intolerance a. clindamycin b. atovaquone c. azithromycin |
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When should patients receive prophylaxis for toxoplasmosis? What agent should be used? |
Primary proph for pts who are tosoplasma-seropositive w/ a CD4 100 or less Bactrim DS daily; or, dapsone/pyrimethamine/leucovorin; or atovaquone w/out pyrimethamine can d/c once CD4 > 200 for 3 months |
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What can be used for secondary prophylaxis for toxoplasmosis? |
pyrimethamine plus leucovorin clindamycin atovaquone can d/c once CD4 > 200 for 6 months |
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How is tuberculosis transmitted? |
person to person: airborne droplets carrying M. tuberculosis are inhaled |
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What vaccine can interfere with the TB skin test (PPD)? |
bacille calmette-guerin |
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What is the booster effect of the TB PPD? What should be done if a person has a + PPD? |
The TB test can restimulate hypersitivity in those exposed in the past year. Those with small TB test reactions can be retested in 1 wk, if positive, result should be attributed to boosting of subclinical hypersensitivity; chemoprophylaxis not necessary. |
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If a person is PPD positive (no HIV dx) what therapy should they receive? |
a. isoniazid 300 mg/day or 900 mg weekly for 9 months b. rifampin 600 mg/day for 4 months c. rifapentine 900 mg plus isoniazid 900 mg/wk for 12 wks |
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If a pt has a positive PPD and they are HIV+ what treament should they receive? |
isoniazid 300 mg/day for 9 months *Preferred*
isoniazid 900 mg 2x week for 9 months w/ directly observed therapy (lower strength evidence) |
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With a PPD of 5 mm what groups TB positive? |
pts w/ chest radiograph consistent w/ TB HIV+ pts receiving prednisone >15 mg/day for greater than 1 month |
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With a PPD of 10 mm what groups are TB positive? |
recent immigrants from countries w/ a high prevalence of TB IV drug abusers residents and employees of prisons, jails, nursing homes, hospitals, and homeless shelters pts w/ DM, silicosis, leukemias, lymphomas, chronic renal failure children < 4 y/o |
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With a PPD of 15 mm what groups are TB positive? |
Pts w/ no identifiable risk factors |
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What drugs are first line agents for TB treatment of active infections? |
isoniazid rifampin pyrazinamide ethambutol streptomycin |
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What drugs should be used to treat a pt w/ active TB who is HIV- or HIV+? |
option 1: isoniazide, rifampin, pyrazinamide, ethambutol for 2 months, followed by isoniazid and rifampin for 4 months option 2: isoniazid, rifampin, and ethambutol for 2 months followed by isoniazid and rifampin for 7 months |
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What should be initiated in pts w/ active TB who are HIV+ and when?
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ART with in 2 wks of CD4 count decreasing to 50 cells/mm3 or less |
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What ART should not be administered w/ rifampin? What can be substituted for rifampin? |
PIs and NNRTIs (except for efavirenz or nevirapine) should not be given w/ rifampin Rifabutin can be substituted for rifampin |
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What should be used for TB w/ known resistance to isoniazide? |
rifampin, pyrazinamide, themabutol, and moxifloxacin/levofloxacin for 2 months for 2 months; followed by rifampin plus ethambutol plus moxifloxacin/levofloxacin for 7 months |
