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

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.

Mycobacterium avium Complex Disease

Last Updated: February 15, 2019; Last Reviewed: June 26, 2019

Recommendations for Preventing and Treating Disseminated Mycobacterium avium Complex (MAC) Disease
Preventing First Episode of Disseminated MAC Disease (Primary Prophylaxis)
  • Primary prophylaxis is not recommended for adults and adolescents who immediately initiate ART (AII).
Indications for Initiating Primary Prophylaxis:
  • Not on fully suppressive ART, and
  • CD4 count <50 cells/mm3 after ruling out disseminated MAC disease based on clinical assessment (which may include mycobacterial blood culture for some people with HIV) (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) (dose adjustment 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:
  • Initiation of effective ART (AI)
Indication for Restarting Primary Prophylaxis:
  • CD4 count <50 cells/mm3 (only if not on fully suppressive ART) (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) plus ethambutol 15 mg/kg PO daily (AI), or
    • Azithromycin 500–600 mg (AII) plus 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:
  • Some experts would recommend addition of a third or fourth drug for people with HIV with high mycobacterial loads (i.e., >2 log CFU/mL of blood), or in the absence of effective ART (CIII).

The Third or Fourth Drug Options May Include:

  • Rifabutin 300 mg PO daily (CI) (dose adjustment may be necessary based on drug-drug interactions), or
  • A fluoroquinolone (CIII) (e.g., levofloxacin 500 mg PO daily or moxifloxacin 400 mg PO daily), or
  • An injectable aminoglycoside (CIII) (e.g., amikacin 10–15 mg/kg IV daily or streptomycin 1 gm IV or IM 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 people with HIV who experience moderate to severe symptoms attributed to IRIS (CIII).
  • If IRIS symptoms persist, a short-term course (4 weeks–8 weeks) of systemic corticosteroid (equivalent to prednisone 20–40 mg) can be used (CII).

Key to Acronyms: ART = antiretroviral therapy; ARV = antiretroviral; BID = twice daily; CD4 = CD4 T lymphocyte; CFU = colony-forming units; IM = intramuscular; IRIS = immune reconstitution inflammatory syndrome; IV = intravenous; MAC = Mycobacterium avium complex; NSAIDs = non-steroidal anti-inflammatory drugs; PO = orally; TB = tuberculosis

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