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Updated Opportunistic Infections Guidelines

for Health Care Providers

Updated Opportunistic Infections Guidelines

Introduction

New guidelines for OI prevention and treatment include major updates to all sections of the document.

There are numerous changes in the recommendations for prevention, diagnosis, and management. Among the highlights are the following.

Treatment

  • CMV retinitis

    Intravitreal injections of ganciclovir or foscarnet, in combination with systemic therapy, are recommended for initial treatment of sight-threatening lesions. Ganciclovir ocular implants are no longer available.

  • Cryptococcal meningitis

    For initial treatment, lipid formulations of amphotericin B are preferred to amphotericin B deoxycholate, based on lower rates of renal toxicity and equivalent efficacy.

    Discontinuation of maintenance therapy is recommended if the CD4 count is =100 cells/無 (rather than =200 cells/無) for =3 months, for persons who have completed initial treatment and at least 1 year of maintenance therapy and who fulfill other criteria, including having HIV RNA suppression on ART.

  • Disseminated MAC

    Azithromycin is now included among "preferred" components of treatment regimens.

  • Hepatitis B

    ART is recommended for all HIV/HBV-coinfected patients, regardless of CD4 count or HBV treatment status. The ART regimen should include 2 ARVs with activity against both HIV and HBV, (ie, tenofovir + either emtricitabine or lamivudine), if possible. If tenofovir cannot be used, entecavir can be added to a fully suppressive ART regimen to treat HBV. These recommendations are consistent with those in the DHHS adult ARV treatment guidelines.

  • Hepatitis C

    The HCV protease inhibitors boceprevir and telaprevir are recommended, in combination with pegylated interferon + ribavirin, for use in coinfected patients with HCV genotype 1, if there are no significant interactions between the ARV agents and the HCV PI.

    For persons with minimal liver disease, deferring therapy can be considered, especially given the rapid developments in HCV therapy and anticipated availability of new drugs.

    The guidelines state that HCV PIs "should not be routinely used" in treatment of acute HCV in HIV-coinfected patients.

  • Varicella zoster

    Herpes zoster: acyclovir has been downgraded to an "alternative" therapy; valacyclovir and famciclovir are "preferred."

    Progressive outer retinal necrosis or acute retinal necrosis: Intravitreal injections of ganciclovir or foscarnet are recommended, in combination with systemic therapy; ganciclovir ocular implants are no longer available.

Vaccinations

  • Streptococcus pneumoniae

    Recommendations for use of the 23-valent pneumococcal polysaccharide vaccine (PPV23) have been revised and recommendations for the 13-valent pneumococcal conjugate vaccine (PCV13) have been added:

    For individuals who have not received any pneumococcal vaccination:
    Preferred Vaccination
    • 1 dose of PCV13, followed by:
    • For patients with CD4 count of =200 cells/無: PPV23 should be given at least 8 weeks after receiving PCV13; or
    • For patients with CD4 count of <200 cells/無: PPV23 can be offered at least 8 weeks after receiving PCV13 or can be postponed until increase of CD4 count to >200 cells/無 on ART
    Alternative Vaccination
    • 1 dose of PPV23
    For individuals who have previously received PPV23:
    • 1 dose of PCV13 should be given at least 1 year after last receipt of PPV23
    Revaccination of PPV:
    • A dose of PPV23 is recommended for individuals 19-64 years of age if at least 5 years have elapsed since previous dose of PPV23
    • Another dose should be given for individuals aged 65 or older, if at least 5 years have elapsed since previous dose of PPV23
  • Human papillomavirus

    Vaccination is recommended for HIV-infected young men and young women aged 13-26:

    For females:
    • HPV recombinant vaccine quadrivalent (types 6, 11, 16, 18) 0.5 mL IM at 0, 1-2, and 6 months, or
    • HPV recombinant vaccine bivalent (types 16, 18) 0.5 mL IM at 0, 1-2, and 6 months
    For males:
    • HPV recombinant vaccine bivalent (types 16, 18) 0.5 mL IM at 0, 1-2, and 6 months

Inevitably, given the length of time it takes to develop guidelines and the lag time before publication, some areas of the guidelines' recommendations lag behind current practice. Consultation with experts is recommended.

Reference