skip navigation

Skip Nav

HIV/AIDS News

USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus

Date: July 14, 1995
Source: Centers for Disease Control and Prevention (CDC)

Members of the USPHS/IDSA Prevention of Opportunistic Infections Working Group
The working group was chaired by Jonathan E. Kaplan, Centers for Disease Control and Prevention, Atlanta; Henry Masur, National Institutes of Health, Bethesda, MD; and King K. Holmes, University of Washington, Seattle.
USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus: A Summary
PREFACE
In the United States, opportunistic infections reduce the quality and duration of life for approximately 1 million persons who have HIV infection (1), especially for the estimated 250,000 persons who are severely immunosuppressed, as measured by a CD4+ T-lymphocyte count below 200 cells/uL (2; CDC, unpublished data). In the late 1980s and early 1990s, efforts to prevent opportunistic infections focused first on chemoprophylaxis against Pneumocystis carinii pneumonia (PCP) (3,4), and then on chemoprophylaxis against disseminated Mycobacterium avium complex (MAC) disease (5).
During the past decade, clinicians and researchers have learned that, in addition to P. carinii and MAC, other pathogens can cause disease in patients with HIV infection. Knowledge regarding the reduction of risk of exposure to, and thus acquisition of, opportunistic pathogens also has increased. During this decade, the number of chemoprophylactic regimens available for preventing disease also has increased. Information about preventing exposure and preventing disease is often published in journals that are not regularly reviewed by health-care providers; some of it has not yet been published.
In 1994, the U.S Public Health Service (USPHS) -- primarily through the efforts of CDC and the National Institutes of Health (NIH) and the Infectious Diseases Society of America (IDSA) -- recognized the importance of preventing opportunistic infections and the need to consolidate information for health-care providers. In response, these organizations initiated an effort to develop comprehensive recommendations for the prevention of opportunistic infections in HIV-infected persons. Draft recommendations were reviewed by consultants from CDC, NIH, and IDSA, as well as by members of other Federal and non-Federal agencies, community organizations, physicians caring for HIV-infected persons, and HIV-infected persons themselves. These recommendations were discussed at a 2-day meeting convened by CDC, NIH, and IDSA in Atlanta in September 1994. Comments were solicited from the public, and final recommendations were approved by USPHS and IDSA. These recommendations were also endorsed by the American Academy of Pediatrics, the Infectious Diseases Society of Obstetrics and Gynecology, and the Society of Healthcare Epidemiologists of America. The recommendations are designed for the use of health-care providers, but they also can provide useful information for HIV-infected patients.
The full text of the USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus is being published in a supplement to Clinical Infectious Diseases (6-8). This report excerpts the disease-specific recommendations that form the basis for the guidelines. These recommendations address 17 opportunistic infections or groups of opportunistic infections by providing guidelines on a) preventing exposure to the opportunistic pathogens, b) preventing the first episode of disease (by chemoprophylaxis or vaccination), and c) preventing disease recurrence (by long-term maintenance drug therapy). This report also includes the drug regimens used to prevent opportunistic infections in HIV-infected adults and adolescents and infants and children.
Several factors were considered in developing these recommendations, including a) the level of immunosuppression at which opportunistic disease is most likely to occur; b) the incidence of disease; c) the severity of disease in terms of morbidity, cost of care (including hospitalization), and mortality; d) the feasibility, efficacy, and cost of the prevention measure; e) the impact of the prevention measure on the quality of life; and f) (for chemoprophylaxis recommendations) drug toxicities, drug interactions, and the potential for the development of drug resistance.
Recommendations are rated according to the strength of the recommendation for or against use (letters A-E) and the quality of the evidence supporting the recommendation (Roman numerals I-III) (6) (Tables 1,2). When applying the letter ratings A-E to recommendations involving chemoprophylaxis, the strength of evidence and magnitude of clinical benefit were balanced against the toxicity, drug interactions, and cost of the chemoprophylactic regimen and the feasibility of alternative approaches such as early diagnosis and treatment of the opportunistic infection. Recommendations designated "A" are supported by evidence that is both statistically and clinically persuasive, are strongly recommended, should always be offered, and are considered standard care. Those designated "B" are recommended for consideration; such measures should generally be offered but should involve some discussion of the pros and cons between the provider and the patient. Measures designated "C" are considered optional, either because evidence of benefit is insufficient or because any proven benefit is minimal from the clinical standpoint and may not outweigh either the toxicity, drug interactions, or cost of the chemoprophylaxis or the feasibility of alternative approaches. Measures designated "D" should generally not be offered; those designated "E" are contraindicated. The Roman numeral ratings I-III refer to the quality of evidence that forms the basis for the recommendations regarding the use of a product or measure for preventing opportunistic infections in HIV-infected persons.
Applying this rating system to recommendations regarding prevention of exposure was complicated by the lack of information regarding the effectiveness of various counseling messages. Therefore, few "prevention of exposure" recommendations are rated "A"; many are considered optional (rating "C"). However, use of the rating system should facilitate understanding of the relative importance of the various prevention recommendations.
The prevention recommendations presented here differ from those previously published because they include strategies for preventing many opportunistic infections not previously discussed, particularly those associated with prevention of exposure. They also modify earlier recommendations. For example, for PCP prophylaxis for sulfa-intolerant patients, either dapsone or dapsone plus pyrimethamine are now recommended in preference to aerosolized pentamidine. For prophylaxis against initial episodes of disseminated MAC disease, the threshold of treatment has been lowered from 100 to 75 CD4+ T-lymphocytes/uL. Chemoprophylaxis against toxoplasmic encephalitis is now recommended.
In this report, the disease-specific recommendations are not listed in priority order. Health-care providers who manage and treat HIV-infected patients should consult the overview of the USPHS/IDSA guidelines, which addresses both the initial and follow-up evaluations of the HIV-infected patient (7). In addition to opportunistic infections addressed in the disease-specific recommendations, the overview of the guidelines briefly addresses other infections that occur with increased frequency in HIV-infected persons (e.g., syphilis, hepatitis B, and other sexually transmitted diseases). Sections on preventing opportunistic infections in children and in pregnant women are included. In this report, only the tables concerning drugs and doses in adults and children (Tables 3a, 3b and 4a, 4b) and the summary of prevention of exposure recommendations (Table 5) have been excerpted from the overview. The approach to preventing opportunistic infections and other infections commonly encountered in HIV-infected persons, as described in the overview, should be integrated with other aspects of HIV care, as described elsewhere (9).
Reprints of this article and of individual components of the USPHS/IDSA guidelines can be obtained from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003. Telephone: (800) 458-5231.
Disease-Specific Recommendations*
PNEUMOCYSTIS CARINII PNEUMONIA
Prevention of Exposure
(1) Although some authorities recommend that HIV-infected persons at risk for P. carinii pneumonia (PCP) not share a hospital room with a patient with PCP, data are insufficient to support this recommendation as standard practice (CIII).
Prevention of Disease
(2) Adults and adolescents with HIV infection (including those who are pregnant) should receive chemoprophylaxis against PCP if they have a CD4+ lymphocyte count of less than 200/gmL (AI), unexplained fever (greater than 100 F) for greater than or equal to 2 weeks (AII), or a history of oropharyngeal candidiasis (AII).
Trimethoprim-sulfamethoxazole (TMP-SMZ) is the preferred prophylactic agent (AI). TMP-SMZ may confer cross-protection against toxoplasmosis (AII) and many bacterial infections (AII). For patients with an adverse reaction that is not life-threatening, treatment with TMP-SMZ should be continued if clinically feasible; for those who have discontinued such therapy, its reinstitution should be strongly considered (AII). Whether it is best to reintroduce the drug at the original dose or at a lower and gradually increasing dose or to try a desensitization regimen is unknown.
If TMP-SMZ cannot be tolerated, alternative prophylactic regimens include dapsone (AI), dapsone plus pyrimethamine plus leucovorin (AI), and aerosolized pentamidine administered by the Respirgard II nebulizer (Marquest, Englewood, CO) (AI). Regimens including dapsone plus pyrimethamine are also protective against toxoplasmosis (AI) but not against most bacterial infections. Because data on their efficacy for PCP prophylaxis are insufficient, the following regimens generally cannot be recommended for this purpose: aerosolized pentamidine administered by other nebulization devices currently available in the United States, intermittently administered parenteral pentamidine, oral pyrimethamine/sulfadoxine, oral clindamycin plus primaquine, oral atovaquone, and intravenous trimetrexate. However, the use of these agents may be considered in unusual situations in which the recommended agents cannot be administered (CIII).
Prevention of Recurrence
(3) Adults and adolescents with a history of PCP should receive chemoprophylaxis with the regimens indicated above to prevent recurrence (AI).
Notes
Pediatric Notes
(4) Children born to HIV-infected mothers should receive prophylaxis with TMP-SMZ beginning at 4-6 weeks of age (11) (AII). Prophylaxis should be discontinued for children who are subsequently found not to be infected with HIV. HIV-infected children and children whose infection status remains unknown should continue to receive prophylaxis for the first year of life. The need for subsequent prophylaxis should be determined on the basis of age-specific CD4+ lymphocyte count thresholds (11,12) (AII).
(5) Children with a history of PCP should receive chemoprophylaxis as indicated above to prevent recurrence (AI).
Note Regarding Pregnancy
(6) Chemoprophylaxis for PCP should be administered to pregnant women as to other adults and adolescents (AIII), although some providers, because of a general concern about administering drugs during the first trimester of pregnancy, may choose not to initiate such therapy until after the first trimester. Because of the increase in blood plasma volume and the reduced concentrations of drugs during pregnancy, the double-strength (DS) dose of TMP-SMZ (one DS tablet daily) should be used.
TOXOPLASMIC ENCEPHALITIS
Prevention of Exposure
(1) HIV-infected persons should be tested for IgG antibody to Toxoplasma soon after the diagnosis of HIV infection to detect latent infection with Toxoplasma gondii (BIII).
(2) All HIV-infected persons, but particularly those who lack IgG antibody to Toxoplasma, should be counseled about the various sources of toxoplasmic infection. They should be advised not to eat raw or undercooked meat, particularly undercooked pork, lamb, or venison (BIII). Specifically, meat should be cooked to an internal temperature of 150 F; meat cooked until no longer pink inside generally has an internal temperature of 165 F and therefore satisfies this requirement. HIV-infected persons should wash their hands after contact with raw meat and after gardening or other contact with soil; in addition, they should wash fruits and vegetables well before eating them raw (BIII). If the patient owns a cat, the litter box should be changed daily, preferably by an HIV-negative, nonpregnant person; alternatively, the patient should wash the hands thoroughly after changing the litter box (BIII). Patients should be encouraged to keep their cats inside and not to adopt or handle stray cats (BIII). Cats should be fed only canned or dried commercial food or well-cooked table food, not raw or undercooked meats (BIII). Patients need not be advised to part with their cats or to have their cats tested for toxoplasmosis (EII).
Prevention of Disease
(3) Toxoplasma-seropositive patients with a CD4+ lymphocyte count of less than 100/gmL should receive prophylaxis against toxoplasmic encephalitis (TE) (AII). The doses of TMP-SMZ recommended for PCP prophylaxis appear to be effective against TE as well (AII). If patients cannot tolerate TMP-SMZ, the regimens including dapsone plus pyrimethamine that are recommended for PCP prophylaxis provide protection against TE (AI). Prophylactic monotherapy with dapsone, pyrimethamine, azithromycin, clarithromycin, or atovaquone cannot be recommended on the basis of current data (DII). Aerosolized pentamidine does not afford protection against TE (EI).
(4) Toxoplasma-seronegative persons who are not taking a PCP prophylactic regimen known to be active against TE should be retested for IgG antibody to Toxoplasma when their CD4+ lymphocyte count falls below 100/gmL to determine whether they have seroconverted and are therefore at risk for TE (CIII). Patients who have seroconverted should receive prophylaxis for TE as described above (AII).
Prevention of Recurrence
(5) Patients who have had TE should receive lifelong suppressive therapy with drugs active against Toxoplasma to prevent relapse (AI). The combination of pyrimethamine plus sulfadiazine and leucovorin is highly effective for this purpose (AII). A commonly used regimen for patients who cannot tolerate sulfa drugs is pyrimethamine plus clindamycin (AII); however, only the combination of pyrimethamine plus sulfadiazine appears to provide protection against PCP as well (AII).
Notes
Pediatric Note
(6) Current data are insufficient for the formulation of specific guidelines for children. The provider should consider the recommendations for adults; children greater than 12 months of age who are seropositive for IgG antibody to Toxoplasma, have a CD4+ lymphocyte count of less than 100/uL, and are not already taking medication effective against Toxoplasma may be considered as candidates for chemoprophylaxis (CIII). Some providers would consider opting for chemoprophylaxis for very young children with higher CD4+ lymphocyte counts consistent with severe immunosuppression (12) and with evidence of toxoplasmic infection.
Notes Regarding Pregnancy
(7) Because of the low incidence of TE during pregnancy and the possible risk associated with pyrimethamine treatment, chemoprophylaxis with pyrimethamine-containing regimens can reasonably be deferred until after pregnancy for women who are seropositive for IgG antibody to Toxoplasma (CIII). TMP-SMZ can be administered as described for prophylaxis of PCP. For prophylaxis of recurrent TE, pyrimethamine should be used with caution (CIII).
(8) In rare cases, HIV-infected pregnant women with serological evidence of remote toxoplasmic infection have transmitted Toxoplasma to the fetus in utero. Pregnant HIV-infected women who have evidence of primary toxoplasmic infection or active toxoplasmosis (including TE) should be evaluated during pregnancy in consultation with appropriate specialists (CIII). Infants born to women with serological evidence of infections with HIV and Toxoplasma should be evaluated for congenital toxoplasmosis (CIII).
CRYPTOSPORIDIOSIS
Prevention of Exposure
(1) HIV-infected persons should be educated and counseled about the many ways that Cryptosporidium can be transmitted. Modes of transmission include contact with infected adults and diaper-age children, contact with infected animals, consumption of contaminated drinking water, and contact with contaminated water during recreational activities (BIII).
(2) HIV-infected persons should avoid contact with human and animal feces. They should be advised to wash their hands after contact with human feces (e.g., during diaper changing), after handling of pets, and after gardening or other contact with soil. HIV-infected persons should avoid sexual practices such as oral-anal intercourse that may result in oral exposure to feces (BIII).
(3) HIV-infected persons should be advised that newborn and very young pets may pose a small risk of cryptosporidial infection, but they should not be advised to destroy or give away healthy pets. Persons contemplating the acquisition of a new pet should avoid bringing any animal with diarrhea into their households, should avoid purchasing a dog or cat less than 6 months of age, and should not adopt stray pets. HIV-infected persons who wish to assume the small risk of acquiring a puppy or kitten less than 6 months of age should request that their veterinarian examine the animal's stool for Cryptosporidium before they have contact with the animal (BIII).
(4) HIV-infected persons should avoid exposure to calves and lambs and to premises where these animals are raised (BII).
(5) HIV-infected persons should not drink water directly from lakes or rivers. Because water can be accidentally ingested, patients should be advised that swimming in lakes, rivers, or public swimming pools may put them at increased risk for infection (BII).
(6) Several outbreaks of cryptosporidiosis have been linked to municipal water supplies. During outbreaks or in other situations in which a community "boil-water" advisory is issued, boiling of water for 1 minute will eliminate the risk of cryptosporidiosis (AI). Use of submicron personal-use water filters* (i.e., home/office types) and/or bottled water** (2) may reduce the risk (CIII). The magnitude of the risk of acquiring cryptosporidiosis from drinking water in a nonoutbreak setting is uncertain, and current data are inadequate to recommend that all HIV-infected persons boil or avoid drinking tap water in nonoutbreak settings. However, HIV-infected persons who wish to take independent action to reduce the risk of waterborne cryptosporidiosis may choose to take precautions similar to those recommended during outbreaks. Such decisions should be made in conjunction with health care providers. Persons who opt for a personal-use filter or bottled water should be aware of the complexities involved in selecting appropriate products, the lack of enforceable standards for the destruction or removal of oocysts, the cost of the products, and the logistic difficulty of using these products consistently.
Prevention of Disease
(7) No effective chemoprophylactic agents are available for cryptosporidiosis.
Prevention of Recurrence
(8) No drug regimens are known to be effective in preventing the recurrence of cryptosporidiosis.
Note
Pediatric Note
(9) At present, no data indicate that formula-preparation practices for infants should be altered in an effort to prevent cryptosporidiosis (CIII).
MICROSPORIDIOSIS
Prevention of Exposure
(1) Other than general attention to hand washing and other personal hygiene measures, no precautions to reduce exposure can be recommended at this time. Prevention of Disease
(2) No chemoprophylactic regimens are known to be effective in preventing microsporidiosis.
Prevention of Recurrence
(3) No chemotherapeutic regimens are known to be effective in preventing the recurrence of microsporidiosis.
TUBERCULOSIS
Prevention of Exposure
(1) HIV-infected persons should be advised that certain activities and occupations may increase the likelihood of exposure to tuberculosis (BIII). These include volunteer work or employment in health care facilities, correctional institutions, and shelters for the homeless as well as in other settings identified as high risk by local health authorities. Decisions about whether to continue with activities in these settings should be made in conjunction with the health care provider and should take into account such factors as the patient's specific duties in the workplace, the prevalence of tuberculosis in the community, and the degree to which precautions are taken to prevent the transmission of tuberculosis in the workplace (BIII). Whether or not the patient continues with such activities may affect the frequency with which screening for tuberculosis needs to be conducted.
Prevention of Disease
(2) When HIV infection is first recognized, the patient should be screened by the Mantoux method with intermediate-strength (5-TU) PPD (AI). Routine evaluation for anergy is controversial; some experts recommend anergy testing for persons in settings where there is an increased risk of infection with Mycobacterium tuberculosis (i.e., in areas where the prevalence of such infection is greater than 10%) (CIII).
(3) All HIV-infected persons with a positive result in the tuberculin skin test (TST; greater than or equal to 5 mm of induration) should undergo chest radiography and clinical evaluation for the exclusion of active tuberculosis. HIV-infected individuals who have symptoms suggestive of tuberculosis should undergo chest radiography and clinical evaluation regardless of their TST status (AII).
(4) All HIV-infected persons with a positive TST result who have no evidence of active tuberculosis and no history of treatment or prophylaxis for tuberculosis should receive 12 months of preventive chemotherapy with isoniazid (AI). Since HIV-infected persons are at risk for peripheral neuropathy, those receiving isoniazid should also receive pyridoxine (BIII). The decision to use alternative antimycobacterial agents for chemoprophylaxis should be based on the relative risk of exposure to resistant organisms and may require consultation with public health authorities (AII). The need for direct observation as a means of documenting compliance with chemoprophylaxis should be considered on an individual basis (BIII).
(5) HIV-infected individuals who are close contacts of persons with infectious tuberculosis (i.e., acid-fast bacillary smear-positive pulmonary disease) should receive preventive therapy -- regardless of TST results or prior courses of chemoprophylaxis -- after active tuberculosis has been excluded (AII). Such persons should be tested with 5-TU PPD. If the TST result is initially negative, the individual should be evaluated again 3 months after the discontinuation of contact with the infectious source, and the information obtained should be considered in the course of decisions about whether chemoprophylaxis should continue (BIII).
(6) TST-negative, HIV-infected persons from risk groups or geographic areas with a high prevalence of M. tuberculosis infection (greater than 10%) may be at increased risk of tuberculosis. Some experts recommend preventive therapy for anergic individuals or perhaps for all persons in this category (CIII). However, the efficacy of preventive therapy in this group has not been demonstrated, and decisions concerning the use of chemoprophylaxis in these situations must be individualized.
(7) Although the reliability of the TST may diminish as the CD4+ lymphocyte count declines, testing should be repeated at least annually for HIV-infected persons who are TST-negative on initial evaluation (BIII). In addition to documenting tuberculous infection, TST conversion in an HIV-infected person should alert health care providers to the possibility of an infectious case in the environment and lead to notification of public health officials for investigation to identify a possible source case.
(8) The administration of BCG vaccine to HIV-infected persons is contraindicated because of its potential to cause disseminated disease (EII).
Prevention of Recurrence
(9) Chronic suppressive therapy for a patient who has successfully completed a recommended regimen of treatment for tuberculosis is not necessary (EII).
Notes
Pediatric Note
(10) All infants born to HIV-infected mothers should have a TST (5-TU PPD) at 9-12 months of age (CIII). All children living in households with M. tuberculosis-infected (TST-positive) persons should be evaluated for tuberculosis (13) (CIII); those exposed to a person with active tuberculosis should receive preventive therapy after active tuberculosis has been excluded (AII).
Note Regarding Pregnancy
(11) HIV-infected pregnant women who have a positive TST result without evidence of active tuberculosis should receive standard chemoprophylaxis (AII). When possible, chest radiography should be undertaken and chemoprophylaxis should be initiated after the first trimester in order to avoid the critical period of major organogenesis. Preventive therapy with isoniazid should be accompanied by treatment with pyridoxine so that peripheral neuropathy does not develop. Alternative regimens (e.g., rifampin, rifabutin) should be used with caution during pregnancy.
DISSEMINATED INFECTION WITH MYCOBACTERIUM AVIUM COMPLEX
Prevention of Exposure
(1) Organisms of the M. avium complex (MAC) are common in environmental sources such as food and water. Current information does not support specific recommendations regarding avoidance of exposure.
Prevention of Disease
(2) Prophylaxis with rifabutin should be considered for HIV-infected adults and adolescents who have a CD4+ lymphocyte count of less than 75/uL, although some experts would wait until the count is less than 50/uL (BII). Disseminated MAC disease should be ruled out (by a negative blood culture) before prophylaxis is initiated. Because treatment with rifabutin may result in the development of resistance to rifampin in individuals with active tuberculosis, the latter condition should be excluded before rifabutin prophylaxis is begun. Drug interactions, partial efficacy, and cost are among the other issues that should be considered in decisions about whether to institute prophylaxis for MAC disease. Data on the safety and efficacy of clarithromycin, azithromycin, and combinations of clarithromycin or azithromycin with rifabutin have not yet been reviewed sufficiently to warrant recommendations concerning these regimens.
(3) Although the detection of MAC organisms in the respiratory or gastrointestinal tract may be predictive of the development of disseminated MAC infection, no data are available on the efficacy of prophylaxis with rifabutin or other drugs in patients with MAC organisms at these sites and a negative blood culture. Therefore, routine screening of respiratory or gastrointestinal specimens for MAC cannot be recommended at this time (DIII).
Prevention of Recurrence
(4) Patients who are treated for disseminated MAC infection should continue to receive full therapeutic doses for life (BIII). The use of a macrolide, usually clarithromycin, is generally recommended in conjunction with at least one other drug, such as ethambutol, clofazimine, ciprofloxacin, or rifabutin.
Notes
Pediatric Note
(5) HIV-infected children less than 12 years of age also develop disseminated MAC infections. Prophylaxis should be considered similar to that recommended for adults and adolescents (BI). For children 6-12 years of age, a CD4+ lymphocyte count of less than 75/uL is a reasonable threshold for the initiation of chemoprophylaxis. Some adjustment for age is necessary in the interpretation of CD4+ lymphocyte counts of children less than 6 years of age (12). No pediatric formulation of rifabutin is currently available, but a dosage of 5 mg/kg has been used in pharmacokinetic studies.
Note Regarding Pregnancy
(6) Information is insufficient for recommendations concerning the use of rifabutin or clarithromycin during pregnancy.
BACTERIAL RESPIRATORY INFECTIONS
Prevention of Exposure
(1) Because Streptococcus pneumoniae and Haemophilus influenzae are common in the community, there is no effective way to reduce exposure to these bacteria.
Prevention of Disease
(2) As soon as possible after HIV infection is diagnosed, adults should receive a single dose of 23-valent polysaccharide pneumococcal vaccine (BIII). This recommendation is especially pertinent in light of the increasing incidence of invasive infections with drug-resistant strains of S. pneumoniae. Although the administration of protein-polysaccharide conjugate H. influenzae type b vaccine may be considered, data are insufficient to recommend the use of this vaccine in HIV-infected adults at this time.
(3) TMP-SMZ, administered daily, may be effective in preventing serious bacterial respiratory infections (although not those caused by drug-resistant S. pneumoniae); this fact should be considered in the selection of an agent for PCP prophylaxis (AII). However, indiscriminate use of this drug (when not indicated for PCP prophylaxis or other specific reasons) may promote the development of resistant organisms.
(4) An absolute neutrophil count that is depressed because of HIV disease or drug therapy may be increased by granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF). However, data are insufficient for recommendations concerning the use of G-CSF or GM-CSF to prevent bacterial infections in HIV-infected patients with neutropenia.
Prevention of Recurrence
(5) Some clinicians may choose to offer antibiotic chemoprophylaxis to HIV-infected patients with recurrent serious bacterial respiratory infections (BIII). TMP-SMZ, administered for PCP prophylaxis, is appropriate for drug-sensitive organisms.
(6) All invasive pneumococcal isolates from HIV-infected patients should be tested for susceptibility to b-lactam antibiotics, and local patterns of resistance should be considered in the choice of regimens for empirical treatment (AII). Invasive infections due to H. influenzae should be treated with regimens effective against b-lactamase-producing strains until drug susceptibilities are known (AII).
Notes
Pediatric Notes
(7) Children with HIV infection should receive H. influenzae type b vaccine in accordance with the guidelines of the Advisory Committee for Immunization Practices (14) and the American Academy of Pediatrics (13) (AII). Children greater than 2 years of age should also receive 23-valent polysaccharide pneumococcal vaccine (BII).
(8) To prevent serious bacterial infections in HIV-infected children with documented antibody deficiency, clinicians should use intravenous immunoglobulin (IVIG) (AI). The administration of IVIG should also be considered for HIV-infected children with recurrent serious bacterial infections (AI), but such treatment may not provide additional benefit to children receiving daily TMP-SMZ.
Note Regarding Pregnancy
(9) Pneumococcal vaccine is not contraindicated during pregnancy.
BACTERIAL ENTERIC INFECTIONS
Prevention of Exposure
Food
(1) Health care providers should advise HIV-infected persons not to eat raw or undercooked eggs (including foods that may contain raw eggs -- e.g., some preparations of hollandaise sauce, Caesar and other salad dressings, and mayonnaise); raw or undercooked poultry, meat, or seafood; or unpasteurized dairy products. Poultry and meat should be well cooked and should not be pink in the middle (internal temperature, greater than 165 F). Produce should be thoroughly washed before being eaten (BIII).
(2) Health care providers should advise HIV-infected persons to avoid cross-contamination of foods. For example, uncooked meats should not come into contact with other foods, and hands, cutting boards, counters, and knives and other utensils should be washed thoroughly after contact with uncooked foods (BIII).
(3) Health care providers should advise HIV-infected persons that, although the incidence of listeriosis is low, it is a serious disease that occurs with unusually high frequency among HIV-infected persons who are severely immunosuppressed. Such persons may choose to avoid soft cheeses because some studies have shown an association between these foods and listeriosis. These studies have also documented an association between ready-to-eat foods (e.g., hot dogs and cold cuts from delicatessen counters) and listeriosis. An immunosuppressed, HIV-infected person who wishes to reduce the risk of food-borne disease as much as possible may choose to re-heat such foods until they are steaming hot before eating them (CIII).
Pets
(4) When obtaining a new pet, HIV-infected persons should avoid young animals (less than 6 months of age), especially those with diarrhea (BIII).
(5) HIV-infected persons should avoid contact with animals that have diarrhea (BIII). HIV-infected pet owners should seek veterinary care for animals with diarrheal illness, and a fecal sample from such animals should be examined for Cryptosporidium, Salmonella, and Campylobacter.
(6) HIV-infected persons should wash their hands after handling pets (especially before eating) and should avoid contact with pets' feces (BIII).
(7) HIV-infected persons should avoid contact with reptiles (such as snakes, lizards, and turtles) because of the risk of salmonellosis (BIII).
Travel
(8) The risk of food and waterborne infections among immunosuppressed, HIV-infected persons is magnified during travel to developing countries. Those who elect to travel to such countries should avoid foods and beverages that may be contaminated, particularly raw fruits and vegetables, raw or undercooked seafood or meat, tap water, ice made with tap water, unpasteurized milk and dairy products, and items sold by street vendors (AII). Foods and beverages that are generally safe include steaming-hot foods, fruits that are peeled by the traveler, bottled (especially carbonated) beverages, hot coffee and tea, beer, wine, and water brought to a rolling boil for 1 minute (AII). Treatment of water with iodine or chlorine may not be as effective as boiling but can be used when boiling is not practical (BIII).
Prevention of Disease
(9) Prophylactic antimicrobial agents are not generally recommended for travelers (DIII). The effectiveness of these agents depends upon local antimicrobial-resistance patterns of gastrointestinal pathogens, which are seldom known. Moreover, these agents can elicit adverse reactions and can promote the emergence of resistant organisms. However, for HIV-infected travelers, antimicrobial prophylaxis may be considered, depending upon the level of immunosuppression and the region and duration of travel (CIII).
The use of fluoroquinolones -- such as ciprofloxacin (500 mg/d) -- can be considered when prophylaxis is deemed necessary (BIII). As an alternative (e.g., for children, pregnant women, and persons already taking TMP-SMZ for PCP prophylaxis), TMP-SMZ may offer some protection against traveler's diarrhea (BIII). The risk of toxicity should be considered before treatment with TMP-SMZ is initiated solely because of travel.
(10) Antimicrobial agents such as fluoroquinolones (e.g., 500 mg of ciprofloxacin b.i.d. for 3-7 days) should be given to patients before their departure, to be taken empirically should traveler's diarrhea develop (BIII). Alternative antibiotics for children and pregnant women should be discussed (CIII). Travelers should consult a physician if their diarrhea is severe and does not respond to empirical therapy, if their stools contain blood, if fever is accompanied by shaking chills, or if dehydration develops. Antiperistaltic agents such as diphenoxylate and loperamide can be used for the treatment of mild diarrhea. However, the use of these drugs should be discontinued if symptoms persist beyond 48 hours. Moreover, these agents should not be given to patients with high fever or with blood in the stool (AII).
(11) Some experts recommend that HIV-infected persons with salmonella gastroenteritis receive antimicrobial therapy to prevent extraintestinal spread. However, no controlled study has demonstrated a beneficial effect of such treatment, and some studies of immunocompetent persons have suggested that antimicrobial therapy can lengthen the shedding period. The fluoroquinolones -- primarily ciprofloxacin (750 mg b.i.d. for 14 days) -- can be used when antimicrobial therapy is opted for (CIII).
Prevention of Recurrence
(12) HIV-infected persons with salmonella septicemia require long-term therapy for the prevention of recurrence. The fluoroquinolones, primarily ciprofloxacin, are usually the drugs of choice for susceptible organisms (BII).
(13) Household contacts of HIV-infected persons with salmonellosis or shigellosis should be evaluated for asymptomatic carriage of Salmonella or Shigella so that strict hygienic measures and/or antimicrobial therapy can be instituted and recurrent transmission to the HIV-infected person can be prevented (CIII).
Notes
Pediatric Notes
(14) Like HIV-infected adults, HIV-infected children should wash their hands after handling pets (especially before eating) and should avoid contact with pets' feces. Hand washing should be supervised (BIII).
(15) HIV-exposed infants less than 3 months of age and all HIV-infected children with severe immunosuppression should receive treatment for salmonella gastroenteritis to prevent extraintestinal spread. Possible choices of antibiotics include TMP-SMZ, ampicillin, cefotaxime, ceftriaxone, or chloramphenicol; ciprofloxacin may be considered for the treatment of children greater than 6 years of age (CIII).
(16) HIV-infected children with salmonella septicemia require long-term therapy for the prevention of recurrence. TMP-SMZ is the drug of choice; ampicillin or chloramphenicol can be used if the organism is susceptible. Ciprofloxacin may be considered for the treatment of children greater than 6 years of age (CIII). (17) Antiperistaltic drugs are not recommended for children (DIII).
Notes Regarding Pregnancy
(18) Since both pregnancy and HIV infection confer a risk for listeriosis, pregnant HIV-infected women should pay particular attention to recommendations concerned with this disease (BII).
(19) Fluoroquinolones should not be used during pregnancy. TMP-SMZ may offer some protection against traveler's diarrhea.
INFECTION WITH BARTONELLA (FORMERLY ROCHALIMAEA)
Prevention of Exposure
(1) HIV-infected persons, particularly those who are severely immunosuppressed, are at unusually high risk of developing relatively severe disease due to Bartonella species. These individuals should consider the potential risks of cat ownership (CIII). Those who elect to acquire a cat should adopt or purchase an older animal (greater than 1 year of age) that is in good health (BII).
(2) Although declawing is not generally advised, HIV-infected persons should avoid rough play with cats and situations in which scratches are likely (BII). Any cat-associated wound should be washed promptly (CIII). HIV-infected persons should not allow cats to lick open cuts or wounds (BIII).
(3) Care of cats should include flea control (CIII).
(4) There is no evidence of benefit to cat or owner from routine culture or serological testing of the pet for Bartonella infection (DII).
Prevention of Disease
(5) No data currently support chemoprophylaxis for Bartonella-associated disease (CIII).
Prevention of Recurrence
(6) Relapse or reinfection with Bartonella has sometimes followed a course of primary treatment. Although no firm recommendation can be made regarding prophylaxis in this situation, long-term suppression of infection with erythromycin or doxycycline should be considered (CIII).
Note
Pediatric Note
(7) The risks of cat ownership for HIV-infected children who are severely immunocompromised should be discussed with parents/caretakers (CIII).
CANDIDIASIS
Prevention of Exposure
(1) Candida organisms are common on mucosal surfaces and skin. No measures are available to reduce exposure to these fungi.
Prevention of Disease
(2) Although data from a prospective controlled trial indicate that fluconazole can reduce the risk of mucosal (oropharyngeal, esophageal, and vaginal) candidiasis in patients with advanced HIV disease, routine primary prophylaxis is not recommended because of the effectiveness of therapy for acute disease, the low mortality associated with mucosal candidiasis, the potential for resistant Candida organisms to develop, the possibility of drug interactions, and the cost of prophylaxis (DII).
Prevention of Recurrence
(3) Many experts do not recommend chronic prophylaxis of recurrent oropharyngeal or vulvovaginal candidiasis for the same reasons that they do not recommend primary prophylaxis. However, if recurrences are frequent or severe, intermittent or chronic administration of topical nystatin, topical clotrimazole, or an oral azole (ketoconazole, fluconazole, or itraconazole) may be considered (BI). Other factors that influence choices about such therapy include the impact of the recurrences on the patient's well-being and quality of life, the need for prophylaxis for other fungal infections, cost, toxicities, and drug interactions.
(4) Adults or adolescents with a history of documented esophageal candidiasis, particularly multiple episodes, should be considered candidates for chronic suppressive therapy with fluconazole (BI).
Notes
Pediatric Notes
(5) Primary prophylaxis of candidiasis in HIV-infected infants is not indicated (DII).
(6) Suppressive therapy with systemic azoles should be considered for infants with severe recurrent mucocutaneous candidiasis (BIII) and particularly for those with esophageal candidiasis (BI).
CRYPTOCOCCOSIS
Prevention of Exposure
(1) Although HIV-infected persons cannot avoid exposure to Cryptococcus neoformans completely, avoiding sites that are likely to be heavily contaminated with C. neoformans (e.g., areas heavily contaminated with pigeon droppings) may reduce the risk of infection.
Prevention of Disease
(2) Because of the low probability that the results will affect clinical decisions, routine testing of asymptomatic persons for serum cryptococcal antigen is not recommended (DIII).
(3) Data from a prospective controlled trial indicate that fluconazole can reduce the frequency of cryptococcal disease among patients with advanced HIV disease; thus, physicians may wish to consider chemoprophylaxis for adult and adolescent patients with a CD4+ lymphocyte count of less than 50/uL (BI). However, such prophylaxis should not be offered routinely because of the relative infrequency of cryptococcal disease, the possibility of drug interactions, the potential for development of resistance, and the cost of prophylaxis (DII). The need for prophylaxis or suppressive therapy for other fungal infections (e.g., candidiasis) should be considered in the course of decisions about prophylaxis for cryptococcosis.
Prevention of Recurrence
(4) Patients who complete initial therapy for cryptococcosis should receive lifelong suppressive treatment with fluconazole (AI).
Notes
Pediatric Note
(5) There are no data on which to base specific recommendations for children, but lifelong suppressive therapy with fluconazole after an episode of cryptococcosis is appropriate (CIII).
Note Regarding Pregnancy
(6) Although treatment with fluconazole is indicated to prevent the recurrence of cryptococcosis, this drug should be used with caution in pregnant women (CIII). At high doses, fluconazole has been associated with both fetal death and increased rates of fetal abnormalities in rats.
HISTOPLASMOSIS
Prevention of Exposure
(1) Although HIV-infected persons living in or visiting histoplasmosis-endemic areas cannot completely avoid exposure to Histoplasma capsulatum, they should avoid activities known to be associated with increased risk (e.g., cleaning chicken coops, disturbing soil beneath bird-roosting sites, and exploring caves) (CIII).
Prevention of Disease
(2) Routine skin testing with histoplasmin in histoplasmosis-endemic areas is not predictive of disease and should not be performed (EII).
(3) No recommendation can be made regarding chemoprophylaxis for HIV-infected persons in histoplasmosis-endemic areas or for histoplasmin-positive persons in nonendemic areas. Prevention of Recurrence
(4) Patients who complete initial therapy should receive lifelong suppressive treatment with itraconazole (AII).
Note
Pediatric Note
(5) Because primary histoplasmosis can lead to disseminated infection in children, HIV-infected children with histoplasmosis should receive suppressive therapy for life (CIII).
COCCIDIOIDOMYCOSIS
Prevention of Exposure
(1) Although HIV-infected persons living in or visiting areas in which coccidioidomycosis is endemic cannot completely avoid exposure to Coccidioides immitis, they should, when possible, avoid activities associated with increased risk (e.g., those involving extensive exposure to disturbed soil as occurs at building excavation sites, on farms, or during dust storms) (CIII). Prevention of Disease
(2) Routine skin testing with coccidioidin (spherulin) in coccidioidomycosis-endemic areas is not predictive of disease and should not be performed (EII).
(3) No recommendation can be made regarding routine chemoprophylaxis for HIV-infected individuals who live in coccidioidomycosis-endemic areas or for skin test-positive persons in nonendemic areas. Prevention of Recurrence
(4) Patients who complete initial therapy for coccidioidomycosis should receive lifelong systemic suppressive treatment (AII). Fluconazole is the preferred agent; alternative drugs include itraconazole, ketoconazole, and amphotericin B.
Note
Pediatric Note
(5) Although no specific data are available on coccidioidomycosis in HIV-infected children, it is reasonable to administer lifelong suppressive therapy after an acute episode of the disease (CIII).
CYTOMEGALOVIRUS DISEASE
Prevention of Exposure
(1) HIV-infected persons who belong to risk groups with relatively low rates of seropositivity for cytomegalovirus (CMV) and who anticipate possible exposure to CMV (e.g., through blood transfusion or employment in a child-care facility) should be tested for antibody to CMV (BIII). These groups include patients who have not had male homosexual contact and those who are not injection drug users.
(2) HIV-infected adolescents and adults should be advised that CMV is shed in semen, cervical secretions, and saliva and that latex condoms must always be used during sexual contact to reduce the risk of exposure to this virus and to other sexually transmitted pathogens (AII).
(3) HIV-infected adults and adolescents who are child-care providers or parents of children in child-care facilities should be informed that they -- like all children at these facilities -- are at increased risk of acquiring CMV infection (BI). Parents and other caretakers of HIV-infected children should be advised of the increased risk to children at these centers (BIII). The risk of acquiring CMV infection can be diminished by good hygienic practices, such as hand washing (AII).
(4) HIV-exposed infants and HIV-infected children, adolescents, and adults who are seronegative for CMV and require blood transfusion should receive only CMV antibody-negative or leukocyte-reduced cellular blood products in nonemergency situations (15) (BIII).
Prevention of Disease
(5) Data on the efficacy and safety of oral ganciclovir have not yet been adequately reviewed; thus no recommendation concerning this drug can be made at this time. Acyclovir is not effective in preventing CMV disease (EII). Since no chemoprophylactic agent is currently available, the most important method for preventing severe CMV disease is recognition of the early manifestations of the disease. Early recognition of CMV retinitis is most likely when the patient has been educated on this topic and undergoes regular funduscopic examinations performed by a health care provider (CIII). Patients should be made aware of the significance of increased "floaters" in the eye and should be advised to assess their visual acuity regularly by simple techniques such as reading newsprint (BIII).
Prevention of Recurrence
(6) CMV disease is not cured with courses of the currently available antiviral agents ganciclovir and foscarnet. Chronic suppressive or maintenance therapy is indicated. The presently approved regimens include parenteral or oral ganciclovir or parenteral foscarnet (AI). In spite of maintenance therapy, recurrences develop routinely and require reinstitution of high-dose induction therapy.
Note
Pediatric Note
(7) The recommendations for the prevention of CMV disease and of its recurrence apply to children as well as to adolescents and adults. However, oral ganciclovir has not been studied in children.
HERPES SIMPLEX VIRUS DISEASE
Prevention of Exposure
(1) HIV-infected persons should use latex condoms during every act of sexual intercourse to reduce the risk of exposure to herpes simplex virus (HSV) and to other sexually transmitted pathogens (AII). They should specifically avoid sexual contact when herpetic lesions (genital or orolabial) are evident (AII).
Prevention of Disease
(2) Prophylaxis of initial episodes of HSV disease is not recommended (DIII)*.
Prevention of Recurrence
(3) Because acute episodes of HSV infection can be treated successfully, chronic therapy with acyclovir is not required after lesions resolve. However, persons with frequent or severe recurrences can be given daily suppressive therapy with oral acyclovir (AI). Intravenous foscarnet can be used for the treatment of infection due to acyclovir-resistant isolates of HSV, which are routinely resistant to ganciclovir as well (AI).
Notes
Pediatric Note
(4) The recommendations for the prevention of initial disease and recurrence apply to children as well as to adolescents and adults.
Note Regarding Pregnancy
(5) The effectiveness of suppressive treatment with acyclovir in reducing the risk of perinatal HSV transmission has not been studied. Therefore, no relevant recommendation can be made.
VARICELLA-ZOSTER VIRUS INFECTION
Prevention of Exposure
(1) HIV-infected children and adults who are susceptible to varicella-zoster virus (VZV) -- i.e., those who have no history of chickenpox or are seronegative for VZV -- should avoid exposure to persons with chickenpox or shingles (AII).
Prevention of Disease
(2) For the prophylaxis of chickenpox, HIV-infected children and adults who are susceptible to VZV should be given zoster immune globulin within 96 hours after close contact with a patient with chickenpox or shingles (AI). Data are lacking on the effectiveness of acyclovir for preventing chickenpox in HIV-infected children or adults.
(3) No preventive measures are currently available for shingles.
Prevention of Recurrence
(4) Recurrence of shingles is unusual, and no drug has been proven to prevent recurrence.
Note
Note Regarding Pregnancy
(5) Zoster immune globulin is not contraindicated during pregnancy and should be given to VZV-susceptible pregnant women after exposure to VZV (AI).
HUMAN PAPILLOMAVIRUS INFECTION
Prevention of Exposure
(1) HIV-infected persons should use latex condoms during every act of sexual intercourse to reduce the risk of exposure to human papillomavirus (HPV) as well as to other sexually transmitted pathogens (AII).
Prevention of Disease
HPV-Associated Genital Epithelial Cancers in HIV-Infected Women
(2) HIV-infected women should have annual cervical Pap smears as part of their initial and routine gynecologic care. In accordance with the recommendation of the Agency for Health Care Policy and Research (9), a Pap smear should be obtained twice in the first year after diagnosis of HIV infection and, if the results are normal, annually thereafter (AII).
(3) If an HIV-infected woman has a history of abnormal Pap smears, the caregiver may choose to monitor this individual with Pap smears every 6 months (BIII).
(4) If the initial or follow-up Pap smear indicates inflammation with reactive squamous cellular changes, further management should be guided by diagnosis of the cause of the inflammation, and another Pap smear should be collected within 3 months (BIII). HIV-infected women with Pap smears showing only atypical cells of undetermined significance can be monitored with annual Pap smears (BIII).
(5) Controversy exists concerning the management of HIV-infected women with low-grade squamous intraepithelial lesions (SIL) evident on the cervical Pap smear; the natural history of this finding in this population has not yet been well defined. Some experts would collect another Pap smear within 3 months. If subsequent Pap smears again showed low-grade SIL, some of these authorities would refer the patient for colposcopic evaluation and biopsy (if indicated); while others would monitor compliant patients with repeat Pap smears at frequent intervals (e.g., every 3-6 months) (BIII). Other experts would refer all HIV-infected patients with low-grade SIL for colposcopy (BIII).
(6) If a Pap smear indicates high-grade SIL or squamous cell carcinoma, the woman should be referred for colposcopic examination and, if indicated, colposcopically directed biopsy (AI). HPV-Associated Anal Intraepithelial Neoplasia and Anal Cancer in HIV-Infected Men Who Have Sex with Men
(7) Although the risks for anal intraepithelial neoplasia (AIN) and anal cancer are increased among HIV-infected men who have sex with men, the role of anal cytological screening and treatment of AIN in preventing anal cancer in these men is not well defined. Therefore, no recommendations can be made for periodic anal cytological screening for the detection and treatment of AIN. Prevention of Recurrence
(8) The risks for recurrence of SIL and cervical cancer after conventional therapy are increased among HIV-infected women. The prevention of illness associated with recurrence depends on careful follow-up of patients after treatment. Patients should be monitored with frequent cytological screening and, when indicated, with colposcopic examination for recurrent lesions (AI).
Note
Pediatric Note
(9) Newborns have been known to acquire laryngeal HPV from their mothers. No recommendations can currently be made to prevent such acquisition.
References
1. CDC. Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 31 -- November 1, 1989. MMWR 1990;39:110-2,117-9.
2. CDC. Projections of the number of persons diagnosed with AIDS and the number of immunosuppressed HIV-infected persons -- United States, 1992-1994. MMWR 1992;41(No. RR-18):1-29.
3. CDC. Guidelines for prophylaxis against Pneumocystis carinii pneumonia for persons infected with human immunodeficiency virus. MMWR 1989;38(No. S-5):1-9.
4. CDC. Recommendations for prophylaxis against Pneumocystis carinii pneumonia for adults and adolescents infected with human immunodeficiency virus. MMWR 1992;41(No. RR-4):1-11.
5. Masur H. Recommendations on prophylaxis and therapy for disseminated Mycobacterium avium complex disease in patients infected with the human immunodeficiency virus. N Engl J Med 1993;329:898-904.
6. Kaplan JE, Masur H, Holmes KK, et al. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: Introduction. Clin Infect Dis 1995;21(suppl 1):1-11.
7. Kaplan JE, Masur H, Holmes KK, et al. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: an overview. Clin Infect Dis 1995;21(suppl 1):12-31.
8. USPHS/IDSA Prevention of Opportunistic Infections Working Group. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: disease-specific recommendations. Clin Infect Dis 1995;21(suppl 1):32-43.
9. El-Sadr W, Oleske JM, Agins BD, et al. Evaluation and management of early HIV infection. Clinical practice guidelines no. 7. Rockville, MD: U.S. Department of Health and Human Services, 1994; AHCPR publication No. 94-0572.
10. Gross PA, Barrett TL, Dellinger P, et al. Purpose of quality standards for infectious diseases. Clin Infect Dis 1994;18:421.
11. CDC. 1995 revised guidelines for prophylaxis against Pneumocystis carinii pneumonia for children infected with or perinatally exposed to human immunodeficiency virus. MMWR 1995;44(No. RR-4):1-11.
12. CDC. 1994 revised classification system for human immunodeficiency virus infection in children less than 13 years of age. MMWR 1994;43(No. RR-12):1-10.
13. American Academy of Pediatrics. 1994 Red Book: report of the Committee on Infectious Diseases. 23rd ed. Elk Grove Village, IL: American Academy of Pediatrics, 1994:264,279-80,375,496-7.
14. CDC. Recommendations of the Advisory Committee on Immunization Practices (ACIP): use of vaccines and immune globulins in persons with altered immunocompetence. MMWR 1993;42(No. RR-4):1-18.
15. D2.400 Standards for blood banks and transfusion services. 16th ed. Bethesda, MD: American Association of Blood Banks, 1994:12.
16. Castro, KG. Tuberculosis as an opportunistic disease in persons infected with human immunodeficiency virus. Clin Infect Dis 1995;21(suppl 1):S66-S71.
17. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. MMWR 1991;40(No. RR-13):1-25.
18. CDC. Prevention and control of influenza: part I, vaccines. MMWR 1994;43(No. RR-9):1-13.
19. CDC. Prevention and control of influenza: part 2, antiviral agents. MMWR 1994;43(No. RR-15):1-10.
20. CDC. Recommended childhood immunization schedule -- United States, January 1995. MMWR 1995;43:959-60.
21. Hall CB. The recommended childhood immunization schedule of the United States. American Academy of Pediatrics. Pediatrics 1995;95:135-7.
* These recommendations address 17 opportunistic infections or groups of opportunistic infections and cover prevention of exposure, prevention of the first episode of disease, and prevention of recurrence (including relapse and reinfection). The recommendations are not presented in order of priority; the priorities in preventing opportunistic infections in HIV-infected persons are presented in ``USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus: An Overview"" (7).
* Only filters capable of removing particles 1 um in diameter and larger should be considered. Filters that provide the greatest assurance of oocyst removal include those that operate by reverse osmosis, those labeled as "absolute" 1-um filters, and those labeled as meeting NSF (National Sanitation Foundation) standard no. 53 for "cyst removal." The "nominal" 1-um filter rating is not standardized, and many filters in this category may not be capable of removing greater than or equal to 99% of oocysts.
** Sources of bottled water (wells, springs, municipal tap-water supplies, rivers, lakes) and methods for its disinfection vary; therefore, all brands should not be presumed to be free of cryptosporidial oocysts. Water from wells and springs is much less likely to be contaminated by oocysts than water from rivers or lakes. Treatment of bottled water by distillation or reverse osmosis ensures oocyst removal. Water passed through an "absolute" 1-um filter or a filter labeled as meeting NSF standard no. 53 for "cyst removal" before bottling will provide nearly the same level of protection. Use of "nominal" 1-um filters by bottlers as the only barrier to cryptosporidia may not result in the removal of greater than or equal to 99% of oocysts.
* Controversy exists over the possible association of acyclovir therapy with prolonged survival of HIV-infected persons. Current data suggest that chronic acyclovir therapy may be considered but should not be standard practice (CIII)..

Back to Top