CURRENT ISSUES 5 Preventing opportunistic infections in patients with HIV New standards of care for the prevention of opportunistic infections in patients with IllY infection are suggested by the US Public Health Service (USPHS) and tht:" Jnfectlous Disea"es Society of America (IDSA) in their recently published guidelines*, reports lAMA. l The 1997 USPHSIIDSA guidelines, which are endorsed by several American organisations in addition to the USPHS and IDSA, reflect the considerable amount of new information that has become available since the publication of the first version of these guidelines in 1995. 2 New standards of care Prophylaxis against disseminated Mycobacterium avium complex (MAC) disease, which was considered optional in the 1995 guidelines, is now recommended as the standard of care for patients with CD4+ cell counts of < 50/mm 3 ; the drug of choice is either clarithromycin or azithromycin. l Furthermore, vaccination against Streptococcus pneumoniae is recommended as the standard of care for patients with CD4+ cell counts of 2oo/mm 3 , but should be offered to all patients with HIV infection. Other recommendations contained in the guidelines include: • chemoprophylaxis against toxoplasmic encephalitis for patients who are positive for anti- Toxop/asma IgG antibodies and have CD4+ cell counts of < 100/mm 3 ; cotrimoxazole [trimethoprimsulfamelhoxazole] is the drug of choice • a tuberculin skin test (TST) for all HIV-infected patients with no history of a positive TST • chemoprophylaxis for 1 year after active tuberculosis (Ta) has been ruled out in patients with a positive TST of 5mm induration and in those exposed to a person with active TB; isoniazid is the drug of choice unless the patient has been exposed to drug-resistant TB Cotrimoxazole prophylaxis against Pneumocystis carinii pneumonia (PCP) remains the standard of care for HIV-infected patients with CD4+ cell counts of < 2oo/mm 3 or a history of oral candidiasis or unexplained fever of 2 weeks' duration. While prophylaxis against first episodes of cytomegalovirus (CMV) and fungal disease remains optional, lifetime prophylaxis is required to prevent recurrent PCP, toxoplasmic encephalitis, disseminated MAC, CMV or deep fungal infection. Unresolved issues It remains unclear whether chemoprophylaxis can be discontinued when a patient's CD4 count rises above a given threshoid in response to antireiruvinll iht;rapy. Efforts are needed to improve the efficacy of chemoprophylactic regimens, and to reduce the occurrence of adverse reactions, drug interactions and drug resistance, reports lAMA. The cost of chemoprophylactic regimens also needs to be reduced, since some, such as oral ganciclovir (> $US 17 OOO/year), are prohibitively expensive. * The 1997 • USPHsnDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human 1173-5503I9710123-00OSi$Ol.00 C Adi.lnternetlonel Limited 1997. All right. re..rved Immunodeficiency Virus' were published in Morbidity and Mortality Weekly Report 46 (RR-12): 1-46. 1997. 1. Kaplan IE, et al. Preventing opportunistic infections in persons infected WIth HJV: i997 guideline". Juurnal uf Ule American Medical Association 278: 337-338. 23-30 Jul 19972. l:SPHSIIDSA Prevention of Opportunistic Infections Working Group. USPHSIIDSA guidelines for the prevention of opponunistic infections in persons infected with human immunodeficiency virus: a summary. Annals of Internal Medicine 124: 349-368. 1 Feb 1996 PhannacoEconomics & Outcomes News 2 Aug 1997 No. 123

Preventing opportunistic infections in patients with HIV

Download PDF Report

Upload
carlene
View
214
Download
1

Embed Size (px)

Citation preview

CURRENT ISSUES5

Preventing opportunistic infectionsin patients with HIV

New standards of care for the prevention of opportunistic infections in patients with IllY infection aresuggested by the US Public Health Service (USPHS)and tht:" Jnfectlous Disea"es Society of America (IDSA)in their recently published guidelines*, reports lAMA. l

The 1997 USPHSIIDSA guidelines, which are endorsedby several American organisations in addition to theUSPHS and IDSA, reflect the considerable amount ofnew information that has become available since thepublication of the first version of these guidelines in1995.2

New standards of careProphylaxis against disseminated Mycobacterium

avium complex (MAC) disease, which was consideredoptional in the 1995 guidelines, is now recommendedas the standard of care for patients with CD4+ cellcounts of < 50/mm3; the drug of choice is eitherclarithromycin or azithromycin. l Furthermore, vaccination against Streptococcus pneumoniae is recommended as the standard of care for patients with CD4+cell counts of ~ 2oo/mm3

, but should be offered to allpatients with HIV infection.

Other recommendations contained in the guidelinesinclude:• chemoprophylaxis against toxoplasmic encephalitis for patients

who are positive for anti-Toxop/asma IgG antibodies and haveCD4+ cell counts of < 100/mm3; cotrimoxazole [trimethoprimsulfamelhoxazole] is the drug of choice

• a tuberculin skin test (TST) for all HIV-infected patients with nohistory of a positive TST

• chemoprophylaxis for 1year after active tuberculosis (Ta) hasbeen ruled out in patients with a positive TST of ~ 5mminduration and in those exposed to a person with active TB;isoniazid is the drug of choice unless the patient has beenexposed to drug-resistant TB

Cotrimoxazole prophylaxis against Pneumocystiscarinii pneumonia (PCP) remains the standard of carefor HIV-infected patients with CD4+ cell counts of< 2oo/mm3 or a history oforal candidiasis or unexplainedfever of ~ 2 weeks' duration. While prophylaxisagainst first episodes of cytomegalovirus (CMV) andfungal disease remains optional, lifetime prophylaxisis required to prevent recurrent PCP, toxoplasmicencephalitis, disseminated MAC, CMV or deep fungalinfection.

Unresolved issuesIt remains unclear whether chemoprophylaxis can be

discontinued when a patient's CD4 count rises abovea given threshoid in response to antireiruvinll iht;rapy.Efforts are needed to improve the efficacy of chemoprophylactic regimens, and to reduce the occurrence ofadverse reactions, drug interactions and drug resistance,reports lAMA. The cost of chemoprophylactic regimensalso needs to be reduced, since some, such as oralganciclovir (> $US 17 OOO/year), are prohibitivelyexpensive.* The 1997 •USPHsnDSA Guidelines for the Prevention of

Opportunistic Infections in Persons Infected with Human

1173-5503I9710123-00OSi$Ol.00C Adi.lnternetlonel Limited 1997. All right. re..rved

Immunodeficiency Virus' were published in Morbidity andMortality Weekly Report 46 (RR-12): 1-46. 1997.

1. Kaplan IE, et al. Preventing opportunistic infections in persons infectedWIth HJV: i997 guideline". Juurnal uf Ule American Medical Association278: 337-338. 23-30 Jul 19972. l:SPHSIIDSA Prevention of OpportunisticInfections Working Group. USPHSIIDSA guidelines for the prevention ofopponunistic infections in persons infected with human immunodeficiencyvirus: a summary. Annals of Internal Medicine 124: 349-368. 1 Feb 1996

PhannacoEconomics & Outcomes News 2 Aug 1997 No. 123