02. Common Opportunistic Infections

8/2/2019 02. Common Opportunistic Infections

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Wanla Kulwichit, MDInfectious Diseases

Chulalongkorn University

SEARCH Regional HIV/AIDS TrainingSEARCH Regional HIV/AIDS Training

88thth January to 9January to 9thth February, 2007February, 2007

Supported by

A Training GrantFrom

Opportunistic Infections in HIV-infectedPatientsAn Overview


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TB & HIV


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MDRMDR--TB more than nonTB more than non--HIV?HIV?Same Rx or longer?Same Rx or longer?

RifampinRifampin V.S.V.S. antiretroviralsantiretrovirals

When to startWhen to start antiretroviralsantiretrovirals??

Beware of immune recovery!Beware of immune recovery!


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Primary MDR-TB: HIV - nonHIV


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Primary MDR-TB: HIV - nonHIV

Int J Tuberc Lung Dis2000; 4: 537-43


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Primary MDR higher among

HIV (8.5%) than nonHIV(4.4%) P= 0.022

Int J Tuberc Lung Dis2001; 5: 32-9


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Same or longer?

N Engl J Med1995; 332: 779-84


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Optimal duration of

treatment is uncertain

CDC NIH IDSA Statement

MMWRDecember 17, 2004


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Optimal duration of

therapy for HIV-1-related TB disease

remains controversial




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Prolonged therapyrecommended for

patients with delayedCLINICAL or

BACTERIOLOGIC

responseCDC NIH IDSA Statement



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SYMPTOMATIC or

POSITIVE CULTUREat or after 2 months of

therapy




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Rifampicin and HAART:

problems with PI and NNRTI


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Rifam-nevirapine:CONTRAINDICATED!

MMWR1998; 47 (RR-20)


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Nevirapine andrifampin

MMWR2000; 49: 185-9

Data are insufficient to assess

whether dose adjustments arenecessary


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Nevirapine and rifampin(contd)

MMWR2000; 49: 185-9

Rifampin and nevirapine should

be used only if clearly indicatedand with careful monitoring


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Co-administration of rifampin

and nevirapine in HIV-infectedpatients with tuberculosis

AIDS2003,

17:637642


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-36 pts, 4 lost to follow-up-all pts cured of TB-74% undetectable viral loads-median CD4 increase116/cu.mm.

AIDS2003,

17:637642


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Nevirapine high therapeuticindex

With dose of 400 mg/day, steady state Cmin

4.5 + 1.9 microgram/ml IC50 for the drug = 0.00250.025microgram/ml

J Infect Dis 1995, 171:537545


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What do experts say?

Annu Rev Med2004; 55: 283-301


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Updated Guidelines for the Use of

Rifamycins for the Treatment ofTuberculosis Among HIV-Infected PatientsTaking Protease Inhibitors or Nonnucleoside

Reverse Transcriptase Inhibitors

http://www.cdc.gov/nchstp/tb/tb_hiv_drugs/toc.htm


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What do experts say?

(contd)

THE LANCET Vol 363 April 17,2004


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What does a pseudo-

expert need to say?

THE LANCET Vol 364 July 24, 2004

Wh t d d


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What does a pseudo-

expert need to say?(contd)



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What does the expert

counter-say? (contd)



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Immune ReconstitutionInflammatory Syndrome (IRIS)

Immune reconstitutionsyndrome

Immune restitution syndromeImmune recovery syndrome

Paradoxical response

C 1 t t t


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Case 1: pretreatment

Am J Roentgenol2000; 174: 43-9


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Case 1: worsening


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Case 1: worsening,

postHAART




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C 2 i tHAART


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Case 2: worsening postHAART


C fi ll i d


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Case 2: finally improved



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P d i l i f TB


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Paradoxical worsening of TB

postHAART: PPD conversion

Am J Resp Crit Care Med1998;158: 157-61

Incidence of IRIS HIV


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Incidence of IRIS: HIV-

nonHIV; HAART-nonHAART

Am J Resp Crit Care Med1998; 158: 157-61


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IRIS: any pretreatment clinical clue?

Am J Resp Crit Care Med1998; 158: 157-61

More extrapulm diseases and


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More extrapulm diseases and

lower CD4 in IRIS

Chest2001; 120: 193-7


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Delayed HAART until

after 2 months of TBtreatment, regardless of

CD4 count

Am J Respir Crit Care Med2001; 164: 7-12BMJ2002; 324: 802-3


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Starting HAART early: CD4

100

AIDS2002; 16: 75-83


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Waiting for controlled studies(until then) decision should be

individualized

CDC NIH IDSA StatementMMWRDecember 17, 2004

When to start ART?


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Avoid simultaneous prescription



When to start ART?(contd)mostmost HCPsHCPs wait at least 4wait at least 4--8 weeks8 weeks

Algorithm: focal brain lesions


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go t oca b a es o s

Amer i canAmer i canAcademyAcademy

o fo f

Neu ro logyNeu ro logy

1 9 9 71 9 9 7

Algorithm: focal brain lesions


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g

Amer i canAmer i canAcademyAcademy

o fo f

Neu ro logyNeu ro logy

1 9 9 71 9 9 7


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Algorithm:Toxoplasmic

encephalitis

Montoya&Remington

2000

M b t i i l


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Mycobacterium aviumcomplex

Infections at low CD4 count

(likely < 50 ; very likely < 75) No need for clarithromycin susceptibility

testing for primary treatment

(Official Statement of American ThoracicSociety - Am J Respir Crit Care Med

Vol. 156. pp. S1S25, 1997)

M b t i i l


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Mycobacterium aviumcomplex:disseminated disease

ART initiated simultaneously or within 1-2

weeks of MAC Rx

US CDC MMW R Dec 17 , 20 04


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Cryptococcal meningitis

Cryptococcal Ag titers partially correlatedwith treatment response in HIV-infected

patients

Clin I nfect Dis1994 May;18(5):789-792.

Cryptococcal meningitis (specific)


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Cryptococcal meningitis (specific)

treatment problem for Thailand 5-flucytosine not available

Monotherapy with high-dose AmphotericinB - ?adequate

AmB + 400 mg/d fluconazole not sig.different from AmB alone

AmB + 800-1,200 mg/d fluconazole V.S.

AmB alone still ongoing (multicenter trials)

02. Common Opportunistic Infections

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