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.

Bacterial Respiratory Disease

Last Updated: May 7, 2013; Last Reviewed: July 25, 2017

Recommendations for Preventing and Treating Bacterial Respiratory Diseases
Preventing Streptococcus pneumoniae Infections

Indications for Pneumococcal Vaccination:
  • All HIV-infected persons regardless of CD4 count
Vaccination Recommendations:
For Individuals Who Have Not Received Any Pneumococcal Vaccination:
Preferred Vaccination:
  • One dose of PCV13 (AI), followed by:
  • For patients with CD4+ count ≥200 cells/µL: PPV23 should be given at least 8 weeks after receiving PCV13 (AII); or
  • For patients with CD4 count <200 cells/µL: PPV23 can be offered at least 8 weeks after receiving PCV13 (CIII) or can await increase of CD4 count to >200 cells/µL on ART (BIII)
Alternative Vaccination:
  • One dose of PPV23 (BII)
For Individuals Who Have Previously Received PPV23:
  • One dose of PCV13 should be given at least 1 year after the last receipt of PPV23 (AII)
Re-vaccination of PPV
  • A dose of PPV23 is recommended for individuals 19–64 years old if ≥5 years have elapsed since the first dose of PPV (BIII)
  • Another dose should be given for individuals 65 years or older, if at least 5 years have elapsed since previous PPV23 dose (BIII)
Vaccine Dosing:
  • PCV13 - 0.5 mL IM
  • PPV23 - 0.5 mL IM
Preventing Influenza and Bacterial Pneumonia as a Complication of Influenza

Indication for Influenza Vaccination:
  • All HIV-infected persons during influenza season (AIII)
Vaccination:
  • Inactivated influenza vaccine per recommendation of the season (AIII)
Note: Live attenuated influenza vaccine is contraindicated in HIV-infected persons (AIII)
Treating Community-Acquired Bacterial Pneumonia

Note: Empiric antimicrobial therapy should be initiated promptly for patients presenting with clinical and radiographic evidence consistent with bacterial pneumonia. The recommendations listed below are suggested empiric therapy. The regimen should be modified as needed once microbiologic and drug susceptibility results are available.

Empiric Outpatient Therapy (Oral)
Preferred Therapy:
  • An oral beta-lactam + a macrolide (azithromycin or clarithromycin) (AII), or
    • Preferred beta-lactams: high-dose amoxicillin or amoxicillin/clavulanate
    • Alternative beta-lactams: cefpodoxime or cefuroxime
  • A fluoroquinolonea (AII), especially for patients with penicillin allergies
    • Levofloxacina 750 mg PO once daily (AII), or
    • Moxifloxacina 400 mg PO once daily (AII)
Alternative Therapy:
  • A beta-lactam (AII) + doxycycline (CIII)
Duration of Therapy:
  • For most patients: 7–10 days; a minimum of 5 days. The patient should be afebrile for 48–72 hours, and should be clinically stable before discontinuation of therapy
Empiric Therapy for Non-ICU Hospitalized Patients
Preferred Therapy:
  • An IV beta-lactam + a macrolide (azithromycin or clarithromycin) (AII), or
    • Preferred beta-lactams: ceftriaxone, cefotaxime, or ampicillin-sulbactam
  • An IV fluoroquinolonea (AII), especially for patients with penicillin allergies
    • Levofloxacina 750 mg IV once daily (AII)or
    • Moxifloxacina 400 mg IV once daily (AII)
Alternative Therapy:
  • An IV beta-lactam (AII) + doxycycline (CIII)
  • IV penicillin may be used for confirmed pneumococcal pneumonia (BIII)
Empiric Therapy for ICU Patients
Preferred Therapy:
  • An IV beta-lactam + IV azithromycin (AII), or
  • An IV beta-lactam + (levofloxacina IV 750 mg once daily or moxifloxacina 400mg IV daily) (AII)
    • Preferred beta-lactams: ceftriaxone, cefotaxime, or ampicillin-sulbactam
Alternative Therapy:
For Penicillin-Allergic Patients:
  • Aztreonam (IV) + an IV respiratory fluoroquinolone (moxifloxacin 400 mg per day or levofloxacin 750 mg per day) (BIII)
Empiric Therapy for Patients at Risk of Pseudomonas Pneumonia
Preferred Therapy:
  • An IV antipneumococcal, antipseudomonal beta-lactam + (ciprofloxacin IV [400 mg q8–12h] or levofloxacin IV 750 mg/day) (BIII)
    • Preferred beta-lactams: piperacillin-tazobactam, cefepime, imipenem, or meropenem
Alternative Therapy:
  • An IV antipneumococcal, antipseudomonal beta-lactam + an IV aminoglycoside + IV azithromycin (BIII), or
  • An IV antipneumococcal, antipseudomonal beta-lactam + an IV aminoglycoside + an IV antipneumococcal fluoroquinolone (moxifloxacin [400 mg/day] or levofloxacin [750 mg/day]) (BIII)
For Penicillin-Allergic Patients
  • Replace the beta-lactam with aztreonam (BIII)
Empiric Therapy for Patients at Risk of Staphylococcus aureus Pneumonia:
  • Vancomycin IV or linezolid (IV or PO) should be added to the baseline regimen (BIII).
  • Although not routinely recommended, the addition of clindamycin to vancomycin (but not to linezolid) may be considered for severe necrotizing pneumonia to minimize bacterial toxin production (CIII).
Other Considerations
  • Empiric therapy with a macrolide alone is not routinely recommended because of increasing pneumococcal resistance (BIII).
  • Patients receiving a macrolide for MAC prophylaxis should not receive macrolide monotherapy for empiric treatment of bacterial pneumonia.
  • Once the pathogen has been identified by reliable microbiologic methods, antibiotics should be modified to treat the pathogen (BIII).
  • For patients begun on IV antibiotic therapy, switching to PO should be considered when patient is clinically improved and able to tolerate oral medications.
  • Antibiotics chemoprophylaxis is generally not recommended because of the potential for development of drug resistance microorganisms and drug toxicities.
a Respiratory fluoroquinolones such as levofloxacin or moxifloxacin are also active against Mycobacterium tuberculosis. In patients with undiagnosed TB, fluoroquinolones may alter response to therapy, delay TB diagnosis, and increase the risk of drug resistance. These drugs should be used with caution in patients in whom TB is suspected but who are not receiving a standard 4-drug TB regimen.

Key to Acronyms: PCV13 = 13-Valent Pneumococcal Conjugate Vaccine; CD4 = CD4 T lymphocyte cell; PPV 23 = 23-Valent Pneumococcal Polysaccharide Vaccine; ART = antiretroviral therapy; IM = intramuscularly; PO = Orally; IV = Intravenously; MAC = Mycobacterium avium complex

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