Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

Disseminated Mycobacterium avium Complex Disease

Last Updated: May 7, 2013; Last Reviewed: June 14, 2017

Recommendations for Preventing and Treating Disseminated Mycobacterium avium Complex (MAC) Disease
Preventing 1st Episode of Disseminated MAC Disease (Primary Prophylaxis)

Indications for Initiating Primary Prophylaxis:
  • CD4 count <50 cells/mm3 after ruling out disseminated MAC disease based on clinical assessment (which may include mycobacterial blood culture for some patients) (AI)
Preferred Therapy:
  • Azithromycin 1200 mg PO once weekly (AI), or
  • Clarithromycin 500 mg PO BID (AI), or
  • Azithromycin 600 mg PO twice weekly (BIII)
Alternative Therapy:
  • Rifabutin 300 mg PO daily (BI) (dosage adjusted may be necessary based on drug-drug interactions, please refer to Table 5 for dosing recommendation when used with ARV drugs).
Note: Active TB should be ruled out before starting rifabutin.

Indication for Discontinuing Primary Prophylaxis:
  • CD4 count >100 cells/mm3 for ≥3 months in response to ART (AI)
Indication for Restarting Primary Prophylaxis:
  • CD4 count <50 cells/mm3 (AIII)
Treating Disseminated MAC Disease

Preferred Therapy:
At least 2 drugs as initial therapy to prevent or delay emergence of resistance (AI)
  • Clarithromycin 500 mg PO twice daily (AI) + ethambutol 15 mg/kg PO daily (AI), or 
  • Azithromycin 500–600 mg (AII) + ethambutol 15 mg/kg PO daily (AI) when drug interactions or intolerance precludes the use of clarithromycin
Note: Testing of susceptibility to clarithromycin or azithromycin is recommended.

Alternative Therapy:
Addition of a third or fourth drug should be considered for patients with advanced immunosuppression (CD4 count <50 cells/mm3), high mycobacterial loads (>2 log CFU/mL of blood), or in the absence of effective ART (CIII).

The 3rd or 4th drug options may include:
  • Rifabutin 300 mg PO daily (CI) (dosage adjusted may be necessary based on drug-drug interactions), or
  • An aminoglycoside (CIII) such as amikacin 10–15 mg/kg IV daily or streptomycin 1 gm IV or IM daily, or
  • A fluoroquinolone (CIII) such as levofloxacin 500 mg PO daily or moxifloxacin 400 mg PO daily
Chronic Maintenance Therapy (Secondary Prophylaxis)
  • Same as treatment regimens
Criteria for Discontinuing Chronic Maintenance Therapy (AII):
  • Completed at least 12 months therapy, and 
  • No signs and symptoms of MAC disease, and
  • Have sustained (>6 months) CD4+ count >100 cells/mm3 in response to ART
Indication for Restarting Secondary Prophylaxis:
  • CD4 <100 cells/mm3 (AIII)
Other Considerations:
  • NSAIDs may be used for patients who experience moderate to severe symptoms attributed to IRIS (CIII).
  • If IRIS symptoms persist, a short term (4–8 weeks) of systemic corticosteroid (equivalent to 20–40 mg of prednisone) can be used (CII).
Key to Acronyms: MAC = Mycobacterium avium Complex; CD4 = CD4 T lymphocyte; PO = orally; BID = twice daily; ARV = antiretroviral; TB = tuberculosis; CFU = colony-forming units; ART = antiretroviral therapy; IV = intravenous; IM = intramuscular; IRIS = immune reconstitution inflammatory syndrome; NSAIDs = non-steroidal anti-inflammatory drugs

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