Antimicrobial prophylaxis

Antimicrobial Prophylaxis per CD4 Counts – Rachael Pellegrino

CD4

counts

Opportunistic Infection

Indication for Prophylaxis

Medication

Special Notes

<200

cells/mm3

Pneumocystis Pneumonia (PJP)

CD4 < 200, or

CD4 < 14%, or

CD4 200-250 w/ delayed init. ART & poor f/u

TMP-SMX: 1 DS daily (qd), or

TMP-SMX: 1SS qd

TMP-SMX: 1 DS TIW

If intolerant of TMP-SMX:

dapsone*, or

pentamidine, or

atovaquone

<200

cells/mm3

Toxoplasma gondii encephalitis

Toxoplasma IgG + and CD4 < 100

TMP-SMX 1 DS tab daily

Alternative regimens:

Dapsone, or

Atovaquone

(all regimens effect. for PJP )

<200

cells/mm3

Mycobacterium avium- intracellulare (MAC, MAI)

Only if not on fully suppressive ART and active disseminated MAC is ruled out

- Azithromycin 1200 mg weekly, or

-Clarithromycin 500 mg BID, or

- Rifabutin 300 mg daily

NOT indicated for those initiating ART

 

 

Infection

Screening Indication

Intervention

Hepatitis A Virus (HAV)

Non-immune w/ risk for HAV infection (MSM, IVDU) or chronic liver disease

HAV vaccine

Hepatitis B Virus (HBV)

Pts w/o chronic HBV or non-immune

HBV vaccine. Ideally admin. before CD4 < 350

Human Papilloma virus (HPV)

Age 13-45

HPV vaccine series

Influenza A and B Virus

All patients

Yearly inactivated influenza vaccine

Latent Mycobacterium tuberculosis infection (LTBI)

-Pts with positive screening test for LTBI w/ no evidence of active disease.

-Pts w/ known exposure

(INH 300mg + pyridoxine 25-50mg) PO daily for 9 months

Streptococcus pneumoniae

All patients

PCV13 and PPV23 (order and timing depends on previous vaccination history and CD4)

Syphilis

All pts exposed to sex partner with syphilis diagnosis

Screening for syphilis and gonorrhea/chlamydia with treatment if indicated.

Varicella Zoster Virus (VZV)

Pre-exposure: CD4>200, no previous vaccine.Shingrix (recombinant vaccine) is not live virus, only Zostavax (live virus) is contraindicated for CD4 <200).

Post-exposure: Close contact, particularly if CD4 <200

Pre-exposure: Consider vaccination

Post-exposure: Varicella-zoster immune globulin