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Early Release
TABLE 2. Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections in adults
and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Preferred treatment for moderate to severe Alternative therapy for moderate to severe Indications for corticosteroids (AI)
PaO2 <70 mmHg at room air or alveolar-  imethoprim-sulfamethoxazole (TMP-SMX): over ≥60 minutes (AI), certain specialists
day IV administered q6h or q8h (AI), may
switch to PO after clinical improvement (AI)
of toxicities (BI); or
as possible and within 72 hours of PCP
therapy) (AI):
 uration of therapy: 21 days (AII)
 imaquine 15–30 mg (base) PO daily to q8h (AI)
Days 11–21 20 mg PO dailyIV methylprednisolone can be administered Preferred treatment for mild to moderate PCP Alternative therapy for mild-to-moderate administered PO in 3 divided doses (AI); or
Benefits of corticosteroid if started after 72 hours of treatment is unknown, but a major- mg/kg/day PO (3 divided dose) (BI); or
ity of clinicians will use it in patients with  imaquine 15–30 mg (base) PO daily moderate to severe PCP (BIII)
 uration of therapy: 21 days (AII)
plus clindamycin 300–450 mg PO q6h to
q8h (BI); or
 ovaquone 750 mg PO bid with food (BI)
tested for G6PD deficiency before use of primaquine daily (AI); or
daily (AI)
daily (BI); or
Dapsone 50 mg PO dail
pyrimethamine 50 mg PO weekly plus
leucovorin 25 mg PO weekly (BI); or
Dapsone 200 mg PO plus p
75 mg PO plus leucovorin 25 mg PO
weekly (BI); or
Aer
month via Respirgard II™ nebulizer (BI);
or
At
 ovaquone 1,500 mg PO daily (BI); or
25 mg + leucovorin 10 mg PO daily (CIII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
 imethamine 200 mg PO x 1, then 50 mg • Pyrimethamine (leucovorin)* plus clin- (<60 kg) to 75 mg (≥60 kg) PO daily plus damycin 600 mg IV or PO q6h (AI); or
clinically indicated only for treatment of sulfadiazine 1,000 mg (<60 kg) to 1,500 mg mass effect attributed to focal lesions or (≥60 kg) PO q6h plus leucovorin 10–25 mg associated edema (BIII); discontinue as
PO daily (can increase 50 mg) (AI)
SMX) IV or PO bid (BI); or
Anticonvulsants should be administered to eeks (BII); longer duration if
patients with a history of seizures (AIII) and
clinical or radiologic disease is extensive or pyrimethamine (leucovorin)* (BII); or
continued through the acute treatment; but • Atovaquone 1,500 mg PO bid with food should not be used prophylactically (DIII)
(or nutritional supplement) plus sulfadiaz-
ine 1,000–1,500 mg PO q6h (BII); or
• Atovaquone 1,500 mg PO bid with food (BII); or
Azithromycin 900–1200 mg PO daily (BII)
 imethamine 25–50 mg PO daily plus sul- fadiazine 2,000–4,000 mg PO daily (in two • Clindamycin 600 mg PO every 8 hours to four divided doses) plus leucovorin 10–25 mg PO daily (AI)
plus leucovorin 10–25 PO daily (BI)
[should add additional agent to prevent
PCP (AII)]; or
• Atovaquone 750 mg PO every 6–12 hours +/- [(pyrimethamine 25 mg PO daily plus
leucovorin 10 mg PO daily) or sulfadiaz-
ine 2,000–4,000 mg PO] daily (BII)
Alternative therapy for cryptosporidiosis Use of antimotility agents such as loper-  ial of nitazoxanide 500–1,000 mg PO amide or tincture of opium might palliate restoration (AII)
bid with food for 14 days (CIII) + opti-
symptoms (BIII)
omatic treatment of diarrhea (AIII)
mized ART, symptomatic treatment and rehydration & electrolyte replacement  ressive oral or IV rehydration & replacement of electrolyte loss (AIII)
* Pyrimethamine and leucovorin doses – same as in “Preferred therapy” for toxoplasmosis Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Initiate or optimize ART; immune restoration to Severe dehydration, malnutrition, and wast- CD4+ count >100 cells/µL is associated with ing should be managed by fluid support and resolution of symptoms of enteric microsporidi- nutritional supplement (AIII)
osis (AII)
Antimotility agents can be used for diarrhea
control if required (BIII)
Preferred therapy for gastrointestinal infections Alternative therapy for gastrointestinal  azoxanide 1,000 mg bid with food for U.S.) (BII)
60 days – effects might be minimal for patients with low CD4+ count (CIII)
might also be effective (not available in U.S.)
(BIII)
Preferred therapy for disseminated (not ocular) Alternative therapy for disseminated disease and intestinal infection attributed to microspo- ridia other than E. bienuesi and Vittaforma ole 400 mg PO bid (AII), continue
Trachipleistophora or Anncaliia (CIII)
until CD4+ count >200 cells/µL for >6
months after initiation of ART (BIII)
(Fumidil B) 3 mg/mL in saline (fumagillin
70 µg/mL) eye drops - 2 drops every 2 hours
for 4 days, then 2 drops qid (investigational
use only in U.S.) (BII) plus albendazole 400
mg PO bid for management of systemic
infection (BIII)
Tr
 eatment should be continued indefinitely to prevent recurrence or relapse (BIII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Mycobacterium tuberculosis Empiric treatment should be initiated and Directly observed therapy (DOT) is recom- continued in HIV-infected persons in whom TB is suspected until all diagnostic work-up is treatment for active TB (AII)
complete (AII)
Initial phase of TB treatment may also be administered 5 days weekly (40 doses) Treatment of drug-susceptible active TB
Treatment for drug-resistant active TB
(AII), or tiw (24 doses) (BII) by DOT
For CNS disease, corticosteroid should be (refer to Table 3 for dosing recommendations) initiated as early as possible and continued Initial phase (2 months) (AI)
for 6–8 weeks (AII)
Isoniazid (INH)† + [rifampin (RIF) or rifabutin RIF is not recommended for patients receiv- (RFB)] + pyrazinamide (PZA) + ethambutol ing HIV protease inhibitors (PI) because of (EMB); if drug susceptibility report shows its induction of PI metabolism (EII)
sensitivity to INH & RIF and PZA, then EMB erably with PZA during at least the first 2 RFB is a less potent CYP 3A4 inducer than months) (BII)
RIF and is preferred in patients receiving treatment is completed (AI)
Rifapentine administered once weekly can y or tiw (AIII) or biw
disease (CIII)
result in development of resistance in HIV- (if CD4+ count >100/µL) (CIII)
infected patients and is not recommended 2 months, followed by 10–16 additional months with INH + EMB + fluoroqui- considered in patients receiving rifamycin Pulmonary TB – 6 months (AI)
nolone (BIII)
Pulmonary TB w/ cavitary lung lesions & (+) Paradoxical reaction that is not severe may culture after 2 months of TB treatment (AII) –
be treated with nonsteroidal anti-inflamma- patients with rifamycin resistance & Extrapulmonary TB w/ CNS, bone, or joint severe disease (CIII)
anti-TB or anti-HIV therapy (BIII)
infections – 9 to 12 months (AII);
Multidrug resistant (MDR, i.e., INH & RIF Extrapulmonary TB in other sites – 6 to 9 resistant) or extensively drug resistant consider prednisone or methylprednisolone months (AII)
(XDR, i.e., resistance to INH & RIF, fluoro- 1 mg/kg of body weight, gradually reduced quinolone & at least 1 injectable agent) TB after 1–2 weeks (BIII)
on resistance pattern and with close con-
sultation with experienced specialist (AIII)
† All patients receiving INH should receive pyridoxine 25–50 mg PO daily (BIII)
Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Alternative therapy for disseminated MAC Testing of susceptibility to clarithromycin (e.g., when drug interactions or intolerance and azithromycin is recommended (BIII)
ithromycin 500 mg PO bid (AI) + etham-
In ART-naïve patients, may consider with- butol 15 mg/kg PO daily (AI)
holding initiation of ART until after 2 weeks Addition of rifabutin may also be considered: 15 mg/kg PO daily (AII)
 abutin 300 mg PO daily (dosage adjusted Addition of a third or fourth drug should tions, reduce pill burden, and potentially be considered for patients with advanced lower occurrence of IRIS (CIII)
interactions) (CI)
immunosuppression (CD4+ count <50 cells/ µL), high mycobacterial loads (>2 log CFU/ mL of blood), or in the absence of effective attributed to ART-associated IRIS (CIII)
ART (CIII)
If immune reconstitution inflammatory syndrome (IRIS) symptoms persist, short term (4–8 weeks) of systemic corticosteroid (equivalent to 20–40 mg of prednisone) can be used (CIII)
Chronic maintenance therapy (secondary prophylaxis) Duration: Lifelong therapy (AII), unless in
patients with sustained immune recovery on
ART (BII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Preferred empiric outpatient therapy (oral) Alternative empiric outpatient therapy (oral)  beta-lactam plus a macrolide (azithromycin a-lactam plus doxycycline (CIII)
prophylaxis should not receive macrolide or clarithromycin) (AII)
For penicillin-allergic patients or those with monotherapy for empiric treatment of bacte- Preferred beta-lactams: high-dose amoxicillin  espiratory fluoroquinolone (levofloxacin Fluoroquinolones should be used with cau- Alternative beta-lactams: cefpodoxime or tion in patients where TB is suspected but is cin) (AII)
not being treatedEmpiric therapy with a macrolide alone is not routinely recommended, because of Preferred empiric therapy for non-ICU inpatient increasing pneumococcal resistance (DIII)
a-lactam (IV) plus a macrolide (AII)
Once the pathogen has been identified by Preferred beta-lactams: cefotaxime, a-lactam (IV) plus doxycycline (CIII)
a reliable microbiologic method, antibiotics For penicillin-allergic patients or those with should be directed at the pathogen (BIII)
For patients begun on IV antibiotic therapy, switching to PO should be considered when floxacin 750 mg or moxifloxacin) (AII)
patient is clinically improved and able to tolerate oral medicationsChemoprophylaxis may be considered for patients with frequent recurrences of seri- a-lactam (IV) plus azithromycin IV (AII)
For penicillin-allergic patients or those with ous bacterial respiratory infections (CIII)
or an IV respiratory fluoroquinolone (levo- Clinicians should be cautious of using anti- floxacin 750 mg or moxifloxacin) (AII)
biotics to prevent recurrences, because of Preferred beta-lactams: cefotaxime, fluoroquinolone (BIII)
the potential for developing drug resistance Preferred empiric Pseudomonas therapy (if Alternative empiric Pseudomonas therapy beta-lactam plus either ciprofloxacin or azithromycin (BIII)
levofloxacin 750 mg/day (BIII)
Preferred beta-lactams: piperacillin- nolone* (BIII)
For penicillin-allergic patients or those with beta-lactam use in prior 3 months Preferred empiric methicillin-resistant Staphylococcus aureus (if risks present) or linezolid alone to above (BIII)
Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Most specialists recommend treatment for all The role of long-term secondary prophylaxis HIV-infected patients with salmonellosis due for patients with recurrent bacteremia is not to the high risk of bacteremia in these patients well established. Must weigh the benefit against the risks of long-term antibiotic exposure Preferred therapy for Salmonella gastroenteritis Alternative therapy for Salmonella gas- troenteritis with or without symptomatic  ofloxacin 500–750 mg PO bid (or 400 mg IV bid) (AIII)
 vofloxacin 750 mg or moxifloxacin (BIII)
Duration for mild gastroenteritis with or without -SMX PO or IV (BIII) – if susceptible
µL: 7–14 days (BIII)
ceftriaxone (IV) or cefotaxime (IV) (BIII) – if
µL: 2–6 weeks (CIII)
 ecurrent symptomatic septicemia – may need 6 months or more (CIII)
Preferred therapy for Shigella infection Alternative therapy depending on antibiotic Therapy is indicated both to shorten the oquinolone IV or PO (AIII)
duration of illness and to prevent spread of infection (AIII)
for gastroenteritis: 3–7 days (AIII)
Shigella infections acquired outside of (BIII); or
14 days (BIII)
United States have high rates of TMP-SMX 250 mg PO daily for 4 days (BIII)
Antimicrobial therapy should be modified based on susceptibility reports  ofloxacin 500 mg PO bid (BIII); or
omycin 500 mg PO daily (BIII)
Consider addition of an aminoglycoside in
bacteremic patients (CIII)
o-moderate disease: 7 days (BIII)
eremia: at least 2 weeks (BIII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Preferred therapy for bacillary angiomatosis, Alternative therapy for bacillary angiomato- Severe Jarisch-Herxheimer-like reaction can peliosis hepatis, bacteremia, and osteomyelitis sis infections, peliosis hepatis, bacteremia,  ythromycin 500 mg PO or IV qid (AII); or
 xycycline 100 mg PO or IV q12h (AII)
omycin 500 mg PO daily (BIII)
Duration of therapy: at least 3 months (AII)
ithromycin 500 mg PO bid (BIII)
rifampin 300 mg PO or IV q12h (AIII)
Duration of therapy: 4 months (AII)
 ith a macrolide or doxycycline for patients with relapse or reinfection as long as the
CD4+ count remains <200 cells/µL (AIII)
Preferred therapy early stage (primary, second- Alternative therapy early stage (primary, The efficacy of non-penicillin alternatives secondary, and early latent syphilis) (BIII)
Benzathine penicillin G 2.4 million units IM patients and should be undertaken only with for 1 dose (AII)
 xycycline 100 mg PO bid for 14 days close clinical and serologic monitoring (BIII)
(BIII); or
 eftriaxone 1 g IM or IV daily for 8–10 probenecid is not recommended for patients days (BIII); or
with history of sulfa allergy (DIII)
omycin 2 g PO for 1 dose (CII)
The Jarisch-Herxheimer reaction is an acute febrile reaction accompanied by headache Preferred therapy late-latent disease (>1year or Alternative therapy late-latent disease (with- and myalgias that might occur within the of unknown duration, CSF examination ruled first 24 hours after therapy for syphilis Benzathine penicillin G 2.4 million units IM  xycycline 100 mg PO bid for 28 days weekly for 3 doses (AIII)
Preferred therapy late-stage (tertiary – cardio-vascular or gummatous disease)  ule out neurosyphilis before therapy with 3 doses of benzathine penicillin and obtain
infectious diseases consultation to guide
management (AIII)
Preferred therapy neurosyphilis (including otic  ocaine penicillin 2.4 million units IM lion units per day, administered as 3–4 mil- 10–14 days (BII) +/- benzathine penicillin
lion units IV q4h or by continuous IV infusion G 2.4 million units IM weekly for 3 doses for 10–14 days (AII) +/- benzathine penicillin
after completion of above (CIII); or
G 2.4 million units IM weekly for 3 doses after completion of IV therapy (CIII)
ferred approach (BIII); if not feasible,
C
 eftriaxone 2 grams IM or IV daily for 10–14 days (CIII)
Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Preferred therapy oropharyngeal candidiasis: Alternative therapy oropharyngeal candidi- Chronic or prolonged use of azoles might asis: initial episodes (7–14 day treatment) ole 100 mg PO daily (AI); or
Higher relapse rate of esophageal candidia- lotrimazole troches 10 mg PO 5 times daily daily (BI); or
sis with echinocandins than with fluconazole (BII); or
 statin suspension 4–6 mL qid or 1–2 bid x 1, then 400 mg daily (BI)
flavored pastilles 4–5 times daily (BII)
started on voriconazole or posaconazole for
secondary prophylaxis until ART produces
immune reconstitution (CI)
Preferred therapy esophageal candidiasis Alternative therapy esophageal candidiasis  iconazole 200 mg PO or IV bid (BI)
Suppressive therapy is usually not recom- mended (DIII) unless patients have frequent
IV daily (AI)
ole 400 mg PO bid (BI)
or severe recurrences. If decision is to use  aconazole oral solution 200 mg PO daily 50 mg IV daily (BI)
ole 100 mg PO tiw (BI)
IV daily (BI)
aconazole oral solution 200 mg PO daily IV daily (BI)
ole 100–200 mg PO daily (BI)
Preferred therapy uncomplicated vulvovaginal ole 400 mg PO bid (BII)
 al fluconazole 150 mg for 1 dose (AII)
daily for 3-7 days (BII)
miconazole, tioconazole, or terconazole) for  y topical azole (CII)
3–7 days (AII)
Preferred therapy fluconazole-refractory Alternative therapy fluconazole-refractory aconazole oral solution ≥200 mg PO daily (AII)
ole oral solution 400 mg PO bid (AII)
IV daily (BII)
Lipid f
mg/kg IV daily (BII)
Anidulafungin 1
IV daily (BII)
Caspofungin 50 mg IV dail
50 mg IV daily (CII)
 iconazole 200 mg PO or IV bid (CIII)
Fluconazole-refractory oropharyngeal candidiasis (not esophageal) mL (not available in U.S.) – 1 mL PO qid
(CIII)
Preferred therapy complicated (severe or recur-rent) vulvovaginal candidiasis ole 150 mg q72h x 2-3 doses (AII)
al >7 days (AII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Addition of flucytosine to amphotericin B has been associated with more rapid sterilization daily plus flucytosine 100 mg/kg PO daily in mulation, dose as preferred therapy) plus of CSF and decreased risk for subsequent 4 divided doses for at least 2 weeks (AI); or
fluconazole 400 mg PO or IV daily (BII)
Patients receiving flucytosine should have kg IV daily (consider for persons who have blood levels monitored; peak level 2 hours renal dysfunction on therapy or have high alone (BII)
after dose should not exceed 75 µg/mL. likelihood of renal failure) plus flucytosine Dosage should be adjusted in patients with 100 mg/kg PO daily in 4 divided doses for at plus flucytosine 100 mg/kg PO daily in 4 least 2 weeks (AII)
divided doses for 4–6 weeks (CII) – for
is performed (AII). Repeated LPs or CSF
shunting are essential to effectively manage
increased intracranial pressure (BIII).
Preferred consolidation therapy (after at least 2 weeks of successful induction – defined as  aconazole 200 mg PO bid for 8 weeks significant clinical improvement & negative (BI), or until CD4+ count >200 cells/µL for
>6 months as a result of ART (BII).
ole 200 mg PO daily (AI) lifelong
or until CD4+ count ≥200 cells/µL for >6 unless immune reconstitution as a result months as a result of ART (BII)
of potent ART – for patients intolerant of
or who failed fluconazole (BI)
Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Preferred therapy for moderately severe to Alternative therapy moderately severe to Itraconazole levels should be obtained in all patients to ensure adequate absorption Induction therapy (for 2 weeks or until clinically Induction therapy (for 2 weeks or until clini- (AIII). Serum concentrations of itraconazole
+ hydroxyitraconazole should be >1 µg/mL Itraconazole oral solution is preferred over daily (AI)
IV daily (BI)
capsule by certain specialists because of  aconazole 200 mg PO tid for 3 days, then daily (CIII)
bid (AII)
infected patients with CD4+ count >300 cells/µL should be managed as non-immu- Preferred therapy for less severe disseminated nocompromised host (AIII)
diseaseInduction and maintenance therapy  aconazole 200 mg PO tid for 3 days, then 200 mg PO bid (AII)
Preferred therapy for meningitisInduction therapy (4–6 weeks) ericin B 5 mg/kg/day (AII)
 aconazole 200 mg PO bid-tid for ≥1 year and until resolution of abnormal CSF find-
ings (AII)
Preferred therapy for long term suppression
therapy
In patients with severe disseminated or CNS
infection (AII) and in patients who relapse
despite appropriate therapy (CIII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Preferred therapy for mild infections (focal pneumonia or positive coccidiodal serologic ole 400 mg PO daily (BII); or
Therapy should be continued indefinitely  aconazole 200 mg PO tid x 3 days, then for patients with diffuse pulmonary or dis- 200 mg bid (BII)
seminated diseases as relapse can occur in
25%–33% in HIV-negative patients (AIII)
Preferred therapy for severe, nonmeningeal Alternative therapy for severe nonmeningeal Therapy should be lifelong in patients with infection (diffuse pulmonary or severely ill infection (diffuse pulmonary or disseminated meningeal infections as relapse occurred in patients with extrathoracic disseminated dis- 80% of HIV-infected patients after discon-  ertain specialists add triazole to ampho- tinuation of triazole therapy (AII)
IV daily (AII)
once amphotericin B is stopped (BIII)
IV daily (AIII)
Duration of therapy: until clinical improvement, then switch to azole Preferred therapy for meningeal infections Alternative therapy for meningeal infections ole 400–800 mg PO or IV daily (AII)
 aconazole 200 mg PO tid x 3 days, then 200 mg PO bid (BII)
Intr
 athecal amphotericin B when triazole antifungals are not effective (AIII)
ole 400 mg PO daily (AII); or
 aconazole 200 mg PO bid (AII)
Potential for significant pharmacokinetic then 4 mg/kg q12h IV (BIII), followed by
1 mg/kg/day IV (AIII); or
voriconazole; it should be used cautiously voriconazole PO 200 mg q12h after clinical in these situations. Consider therapeutic 5 mg/kg/day IV (AIII)
drug monitoring and dosage adjustment if Duration of therapy: until CD4+ count >200 cells/µL and with evidence of clinical response daily (BII)
Posaconaz
ole 400 mg bid PO (BII)
Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
The choice of initial therapy for CMV retinitis For immediate sight-threatening lesions days, then 5 mg/kg IV daily (AI); or
tion and severity of the lesion(s), level of clovir 900 mg PO (bid for 14–21 days, then immunosuppression, and other factors such once daily) (AI)
days, then valganciclovir 900 mg PO daily as concomitant medications and ability to adhere to treatment (AIII)
administered immediately after diagnosis Initial therapy in patients with CMV retinitis, until ganciclovir implant can be placed (CIII)
IV q12h for 14–21 days, then 90–120 mg/ esophagitis, colitis, and pneumonitis should kg IV q24h (AI); or
include initiation or optimization of ART days, then 900 mg PO daily (BII)
In patients with CMV neurological disease, saline hydration before and after therapy localized morbidity might occur because of IRIS, a brief delay in initiation of ART until the dose followed by 1 g PO 2 hours after clinical improvement might be prudent (CIII)
the dose, and 1 g PO 8 hours after the
dose (total of 4 g) (AI) Note: This regimen
Maintenance therapy for CMV retinitis can should be avoided in patients with sulfa allergy because of cross hypersensitivity inactive disease and sustained CD4+ count (>100 cells/mm3 for ≥3–6 months); consulta-
tion with ophthalmologist is advised (BII)
Patients with CMV retinitis who discontin-
Preferred chronic maintenance therapy (sec- Alternative chronic maintenance (secondary regular eye examination, optimally every anciclovir 900 mg PO daily (AI); or
3 months, for early detection of relapse or immune recovery uveitis (IRU) (AIII)
6–8 months if CD4+ count remains <100 IRU might develop in the setting of immune cells/µL) + valganciclovir 900 mg PO daily once daily (AI); or
until immune recovery (BIII)
reconstitution. Treatment of IRU: periocular corticosteroid or short courses of systemic probenecid as above (AI)
Preferred therapy for CMV esophagitis or colitis or until resolution of signs and symptoms
(BII)
Or
 al valganciclovir may be used if symptoms are not severe enough to interfere with oral
absorption (BII)
Maint
sary, but should be considered after relapses
(BII)
 eatment should be considered in patients with histologic evidence of CMV pneumonitis
and who do not respond to treatment of
other pathogens (AIII)
The r
been established (CIII)
Preferred therapy CMV neurological diseaseTreatment should be initiated promptly  ombination of ganciclovir IV + foscarnet IV to stabilize disease and maximize response,
continue until symptomatic improvement
(BII)
Maint
PO + IV foscarnet) should be continued for
life unless evidence of immune recovery is
evident (BII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Herpes simplex virus (HSV) Preferred therapy for orolabial lesions and disease PO bid, or acyclovir 400 mg PO tid (AI)
 olabial HSV: 5–10 days (AII)
al HSV: 5–14 days (AI)
Preferred therapy for severe mucocutaneous HSV infections apy acyclovir 5 mg/kg IV q8h (AII)
 ter lesions began to regress, change to PO therapy as above (AI). Continue therapy until
lesions have completely healed.
Preferred therapy for acyclovir-resistant muco- Alternative therapy for acyclovir-resistant Topical formulations of neither trifluridine mucocutaneous HSV infections (CIII)
nor cidofovir are commercially available in divided doses until clinical response (AI)
products can be prepared using trifluridine ophthalmic solution and the intravenous Duration of therapy: 21–28 days or longer  yclovir 10 mg/kg IV q8h for 21 days (AII)
Suppressive therapy (For patients with frequent
or severe recurrences of genital herpes) (AI)
yclovir 500 mg PO bid (AI)
vir 500 mg PO bid (AI)
 yclovir 400 mg PO bid (AI)
If HHV-6 has been identified as cause of dis-
ease in HIV-infected patients, use same drugs
and doses as treatment for CMV disease (CIII)
Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Varicella zoster virus (VZV) Varicella (chickenpox) Infection caused by acyclovir-resistant VZV net 90 mg/kg IV q12h (AII)
mologist with management of VZV retinitis  yclovir (20 mg/kg body weight up to a is strongly recommended (AIII)
maximum of 800 mg PO 5x daily), valacyclo- Corticosteroid therapy for herpes zoster is vir 1,000 mg PO tid, or famciclovir 500 mg not recommended (DIII)
PO tid x 5–7 days (AII)
 yclovir 10–15 mg/kg IV q8h x 7–10 days (AIII)
Ma
 y switch to oral acyclovir, famciclovir, or valacyclovir after defervescence if no
evidence of visceral involvement is evident
(AIII)
Herpes zoster (shingles)Acute localized dermatomal yclovir 1g tid or famciclovir 500 mg tid, or acyclovir 800 mg PO 5x daily x 7–10 days
(AII), longer duration should be considered if
lesions are slow to resolve
Extensive cutaneous lesion or visceral involvement  yclovir 10–15 mg/kg IV q8h until clinical improvement is evident (AII)
Switch t
mg tid or famciclovir 500 mg tid, or acyclovir
800 mg PO 5x daily) after clinical improve-
ment is evident, to complete a 10–14 day
course (AIII)
Progressive outer retinal necrosis (PORN) 90 mg/kg IV q12h, plus ganciclovir 2
mg/0.05mL intravitreal twice weekly, and/or
foscarnet 1.2 mg/0.05mL intravitreal twice
weekly (AIII)
Optimization of
ART (AIII)
 yclovir 10 mg/kg IV q8h x 10–14 days, followed by valacyclovir 1,000 mg PO tid x 6
weeks (AIII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Initiation or optimization of ART should be done for all patients with KS, PEL, or MCD primary effusion lymphoma (BII)
[PEL], multicentric
Castleman’s disease
Preferred therapy for visceral KS (BII), dis-
seminated cutaneous KS (CIII), and PEL (BIII)
apy + ART (BII)
 al valganciclovir or IV ganciclovir might be useful as adjunctive therapy in PEL (BII)
anciclovir 900 mg PO bid (BII); or
Rituximab, 375 mg/m2 given weekly x 4–8 vir 5 mg/kg IV q12h (BII)
weeks, may be an alternative to antiviral
therapy (BII)
Treatment of condyloma acuminata (genital warts) Intralesional interferon-alpha is usually not  yotherapy (liquid nitrogen or cryoprobe) recommended because of high cost, difficult to all lesions bid x 3 consecutive days, fol- – apply until each lesion is thoroughly administration, and potential for systemic lowed by 4 days of no therapy, repeat weekly side effects (DIII)
for up to 4 cycles (BIII); or
providers allow the lesion to thaw, then The rate of recurrence of genital warts is freeze a 2nd time in each session (BIII).
 ichloroacetic acid or bicloroacetic acid nonconsecutive nights weekly for up to 16 cauterization – 80%–90% aqueous solu- tion, apply to each lesion, repeat weekly with soap and water 6–10 hours after appli- for 3–6 weeks (BIII)
cation (BII)
 gical excision (BIII) or laser surgery
(CIII)
Podoph
sion in tincture of benzoin – apply to all
lesions, then wash off a few hours later,
repeat weekly for 3–6 weeks (CIII)
Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Treatment for patients who do not require Emtricitabine, entecavir, lamivudine, or tenofovir should not be used for the treat- ment of HBV infection in patients who are with independent activity against each virus and with the least potential of selecting not receiving combination ART (EII)
HIV resistance mutations (BIII)
Among patients coinfected with HIV, HBV,  onsider tenofovir + emtricitabine as part of  onsider early initiation of ART, especially HIV and HBV regimen (CIII)
should be the first priority. If ART is not required, an interferon-based regimen, Lamivudine or emtricitabine-naïve patients For patients with CD4+ count >350 cells/ which suppresses both HCV & HBV, should µL, HBeAg (-), HBV DNA >2,000 IU/mL be considered (CIII)
daily) or emtricitabine 200 mg PO daily] + If IFN-based treatment for HCV has failed, tenofovir (TDF) 300 mg PO daily (CIII) (+
ovir 10 mg PO daily (CIII)
treatment of chronic HBV with nucleoside or nucleotide analogs is recommended (CIII)
For patients with CD4+ count >350 cells/ Cross-resistance to emtricitabine or telbivu- Lamivudine or emtricitabine-experienced µL, HBeAg (+), HBV DNA >20,000 IU/mL patients with detectable HBV DNA (assume (>200,000 copies/mL), and elevated ALT erferon alfa-2a 180 µg SQ weekly (CIII) x 48 weeks – with careful follow-up
agents with anti-HBV activity because of the as part of an ART regimen + lamivudine or emtricitabine (CIII); or
If anti-HBV therapy is discontinued and a emtricitabine + other combination ART (BII);
flare occurs, therapy should be reinstituted, as it can be potentially life saving (BIII)
 ecavir 1 mg PO daily can be considered in patients with complete HIV suppression
(while on ART) who do not demonstrate
YMDD (M204V/I) motif mutations in HBV
DNA (CIII)
Duration of therapy: Because of the high rates
of relapse, certain specialists recommend
continuing therapy indefinitely (CIII)
Genotype 1, 4, 5, or 6 (AI)
In patients for whom ribavirin is contrain- For patients with CD4+ count <200 cells/µL, erferon alfa-2a 180 µg SQ weekly, or initiation of ART may be considered before HCV treatment (CIII)
sive to erythropoietin, renal failure, or virin PO (wt-based dosing) (AII)
erferon alfa-2a 180 µg SQ weekly concomitant use is contraindicated (EI).
(AII), or
erferon alfa-2b 1.5 µg/kg SQ weekly patients with hepatic decompensation. Liver transplantation, if feasible, should be the Genotype 2 or 3 (AI)
primary treatment option (CIII).
erferon alfa-2a 180µg SQ weekly, or Interferon is abortifacient in high doses  er transplantation if feasible (CIII)
and ribavirin is teratogenic. HCV treatment or women who are not willing to use birth control (EIII).
eeks – genotypes 1 or 4, 5 or 6 (AI) and
genotypes 2 and 3 (BII)
At least 24 w
infection (<6 months from HCV exposure)
(BIII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Initiate antiretroviral therapy in ART-naïve patients (AII)
sion after initiation of ART. Although their Optimize ART in patients who develop PML in neurological deficits frequently persist, phase of HIV viremia on antiretroviral therapy Corticosteroids may be used in patients with
progressive clinical deficits and neuroim-
aging features suggesting inflammatory
disease (e.g., edema, swelling, and contrast
enhancement) as a result of initiating ART
(BIII)
Geographic opportunistic infections of specific consideration
Preferred therapy for chloroquine-sensitive Alternative therapy for chloroquine-sensitive infected patients are the same as HIV non- mg chloroquine base) once, then 500 mg PO (=300 mg chloroquine base) at 6, 24, and 48 tions for specific region, clinicians should  al dose = chloroquine phosphate 2,500 mg Preferred therapy for chloroquine-resistant Alternative therapy for chloroquine-resistant infections (all other malaria areas or unknown  ovaquone-proguanil (250 mg/100 mg) – 4 administered 12 hrs later, total dose = 1,250 mgQuinine sulf (infections acquired outside of southeast Asia) to 7 days (infections acquired in southeast Asia) + (doxycycline 100 mg PO q12h x 7 days or clindamycin 20 mg base/kg/day (in 3 divided doses) PO x 7 days) Intravenous artesunate is available from  tesunate 2.4 mg/kg IV bolus at 0, 12, 1–2 hours, then 0.02 mg/kg/min infusion (quinidine 6.25 mg base/kg IV over 1–2 hours, then 0.0125 mg/kg/min) for ≥24 hours Duration of therapy: 7 days for Southeast Asia and Oceania and 3 days for other areas  xycycline 100 mg PO or IV q12h x 7 days; doses) PO or 10 mg base/kg loading dose IV followed by 5 mg base/kg IV q8h; switch to PO clindamycin (dose as above) as soon as patient can take PO medication - for a total course of 7 days Early Release
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
All regions use the following regimens (except which case treat as for chloroquine-resistant P. 500 mg PO at 6, 24, and 48 hours, total dose = 2,500 mg; thenAnti-r status): primaquine 30 mg base PO daily x 14 days standard of care in the community; consid- IV for 2 weeks; followed by itraconazole 400 eration should be given to simultaneously mg PO daily for 10 weeks (AII)
initiating ART and treatment for penicilliosis
(CIII)
 aconazole 400 mg PO daily for 8 weeks Chronic maintenance therapy (secondary prophylaxis)  aconazole 200 mg PO daily (AI)
Alternative therapy for initial infection ART should be initiated or optimized (AII)
B lipid complex (AII) 2–4 mg/kg IV daily x 10
kg IV daily for total dose of 1.5–2.0 grams days; or interrupted schedule (e.g., 4 mg/kg (BII); or
effective in HIV-negative patients in India - on days 1–5, 10, 17, 24, 31, 38) to achieve may be available as an alternative in India total dose of 20–60 mg/kg (BII)
antimony) (AII) 20 mg/kg body weight IV
in the future (BI)
or IM daily for 3–4 weeks. (Contact the CDC Drug Service at 404-639-3670 or Alternative regimens for treatment failure (secondary prophylaxis) – especially in patients ericin B Lipid Complex (AII) 3–4
mg/kg every 2–4 weeks (AII)
use) (CIII)
weeks (AII)
every 4 weeks (AII)
for 10 days or interrupted schedule (e.g., 4 mg/kg on days 1–5, 10, 17, 24, 31, 38) to Other options include oral miltefosine, topi- achieve total dose of 20–60 mg/kg (BIII); or
cal paromomycin, intralesional pentavalent daily for 3–4 weeks (BIII)
Early Release
March 24, 2009
TABLE 2. (Continued) Drug therapy for treatment and chronic maintenance therapy of AIDS-associated opportunistic infections
in adults and adolescents
Preferred therapy, duration of therapy,
Opportunistic infection
chronic maintenance
Alternative therapy
Other options/issues
Chagas disease (American Preferred therapy for acute, early chronic, and Duration of therapy has not been studied in 90–120 days (CIII) (Contact the CDC
Initiation or optimization of ART in patients doses for 30–60 days (BIII) (not commercially
undergoing treatment for Chagas disease, available in the U.S., contact the CDC Drug once the patient is clinically stable (AIII)
-SMX (AI) (160 mg/800 mg) PO (or IV)
 imethamine 50–75 mg PO daily plus patients with dehydration (AIII)
qid for 10 days (AII); or
leucovorin 10–25 mg PO daily (BIII); or
 ofloxacin 500 mg PO bid x 7 days (CI)
ished patients (AIII)
7–10 days (BI)
Immune reconstitution with ART may result  y increase daily dose and/or duration (up in fewer relapses (AIII)
to 3–4 weeks) if symptoms worsen or persist
(BIII)
In patients with CD4+ count <200/µL, -SMX (160 mg/800 mg) PO tiw (AI)
(320 mg/1600 mg) tiw (BIII)
Pyr
leucovorin 5–10 mg PO daily (BIII)
Cipr
 ofloxacin 500 mg tiw (CI) – as a
ART = antiretroviral therapy; bid = twice a day; biw = twice weekly; g = gram; IM = intramuscular; IV = intravenous; µg = microgram; mg = milligram; PO = oral; qAM = every morning; qid = four times a day; q’n’h = every ‘n’ hour; qPM = every evening; SQ = subcutaneous; tid = three times daily, tiw = three times weekly

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