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.

Community-Acquired Pneumonia (CAP)

Last Updated: October 10, 2019; Last Reviewed: October 10, 2019

Recommendations for Preventing and Treating Community-Acquired Pneumonia
Preventing Streptococcus pneumoniae Infections
Indications for Pneumococcal Vaccination:
  • All persons with HIV regardless of CD4 count (AI)

Vaccination Recommendations

For Individuals Who Have Not Received Any Pneumococcal Vaccination
Preferred Vaccination:
  • One dose of PCV13 (AI), followed by:
  • CD4 count ≥200 cells/mm3: Administer PPV23 ≥8 weeks later (AI); or
  • CD4 count <200 cells/mm3: PPV23 can be offered ≥8 weeks after receipt of PCV13 (CIII) or can await until CD4 count increases to >200 cells/mm3 on ART (BIII).
For Individuals Who Have Previously Received PPV23:
  • One dose of PCV13 should be given to patients who have already received PPV23 (AII).
  • Adults (aged ≥19 years) should wait ≥1 year and adolescents (aged <19 years) should wait ≥8 weeks after their most recent dose of PPV23 before receiving a single dose of PCV13 (BIII).
Re-Vaccination of PPV23:
  • A dose of PPV23 is recommended for individuals aged 19 through 64 years if ≥5 years have elapsed since their first dose of PPV (BII).
  • A final dose of PPV23 is recommended for individuals aged ≥65 years, after ≥5 years have elapsed since their previous PPV23 dose (BII).
  • Typically, no more than 3 doses of PPV23 are given in a lifetime.
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 persons with HIV infection during influenza season (AII)
Vaccination:
  • Inactivated, standard dose or recombinant influenza vaccine per recommendation of the season (AII); or
  • High-dose inactivated influenza vaccine may be given to individuals aged ≥65 years (CIII).
Note: Live attenuated influenza vaccine is contraindicated in persons with HIV (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. Providers must also consider the risk of opportunistic lung infections (e.g., PCP, TB), which may alter the empiric therapy.


Empiric Outpatient Therapy (Oral)
Preferred Therapy:
  • An oral beta-lactam plus a macrolide (azithromycin or clarithromycin) (AI)
Preferred Beta-Lactams:
  • High-dose amoxicillin or amoxicillin/clavulanate
Alternative Beta-Lactams:
  • Cefpodoxime or cefuroxime, or
  • A respiratory fluoroquinolone (levofloxacin or moxifloxacin)a (AI), especially for patients with penicillin allergies
Alternative Therapy:
  • A beta-lactam plus doxycycline (BIII)

Empiric Therapy for Hospitalized Patients with Non-Severe CAP
Preferred Therapy:
  • An IV beta-lactam plus a macrolide (azithromycin or clarithromycin) (AI)
Preferred Beta-Lactams:
  • Ceftriaxone, cefotaxime, or ampicillin-sulbactam, or
  • An IV respiratory fluoroquinolone (levofloxacin or moxifloxacin)a (AI), especially for patients with penicillin allergies.
Alternative Therapy:
  • An IV beta-lactam plus doxycycline (BIII)
  • IV penicillin may be used for confirmed pneumococcal pneumonia (BIII)

Empiric Therapy for Patients with Severe CAP
Preferred Therapy:
  • An IV beta-lactam plus IV azithromycin (AI), or
  • An IV beta-lactam plus an IV respiratory fluoroquinolone (levofloxacin or moxifloxacin)a (AI)
Preferred Beta-Lactams:
  • Ceftriaxone, cefotaxime, or ampicillin-sulbactam
Alternative Therapy:
For Penicillin-Allergic Patients:
  • Aztreonam (IV) plus an IV respiratory fluoroquinolone (moxifloxacin or levofloxacin)a (BIII)

Empiric Therapy for Patients at Risk of Pseudomonas Pneumonia
Preferred Therapy:
  • An IV antipneumococcal, antipseudomonal beta-lactam plus (ciprofloxacin IV or levofloxacin IV 750 mg/day) (AI)
Preferred Beta-Lactams:
  • Piperacillin-tazobactam, cefepime, imipenem, or meropenem
Alternative Therapy:
  • An IV antipneumococcal, antipseudomonal beta-lactam plus an IV aminoglycoside plus IV azithromycin (BII), or
  • An IV antipneumococcal, antipseudomonal beta-lactam plus an IV aminoglycoside plus an IV antipneumococcal fluoroquinolone (moxifloxacin or levofloxacin) (BII)
For Penicillin-Allergic Patients:
  • Replace the beta-lactam with aztreonam (BII)

Empiric Therapy for Patients at Risk of MRSA Pneumonia
Preferred Therapy:
  • A nasal swab for MRSA can help inform decision of initial coverage for MRSA (see text for discussion).
  • Vancomycin IV or linezolid (IV or PO) should be added to the baseline regimen (AII).
  • 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 (CII).
Duration of Therapy:
  • For most patients, 5-7 days. The patient should be afebrile for 48–72 hours and should be clinically stable before discontinuation of therapy.
  • Longer duration of antibiotics is often required when severe CAP or bacteremia is present, and particularly if due to S. pneumoniae or complicated S. aureus infection.
Switch from IV to PO Therapy:
  • A switch should be considered for patients who have improved clinically, can swallow and tolerate oral medications, and have intact gastrointestinal function (BIII).
Other Considerations:
  • Empiric therapy with a macrolide alone is not routinely recommended because of increasing pneumococcal resistance (up to 30%) (BIII), and patients receiving a macrolide for MAC prophylaxis may have resistance due to chronic exposure (BIII).
  • Fluoroquinolones should be used with caution in patients in whom TB is suspected but who are not being treated with concurrent standard four-drug TB therapy (BIII).
  • Once the pathogen has been identified by reliable microbiologic methods, antibiotic therapy should be modified to target the pathogen (BIII).
  • If drug-resistant pathogens have not been identified by reliable microbiologic methods, antibiotic therapy can be de-escalated to cover routine causes of CAP (BIII).
  • Antibiotics chemoprophylaxis is generally not recommended because of the potential for development of drug resistance microorganisms and drug toxicities (AI).
a Respiratory fluoroquinolones (e.g., levofloxacin, 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 four-drug TB regimen.

Key: ART = antiretroviral therapy; CAP = community-acquired pneumonia; CD4 = CD4 T lymphocyte cell; IM = intramuscular; IV = intravenous; MAC = Mycobacterium avium complex; MRSA = methicillin-resistant Staphylococcus aureus; PCP = Pneumocystis pneumonia; PCV13 = 13-Valent Pneumococcal Conjugate Vaccine; PO = orally; PPV23 = 23-Valent Pneumococcal Polysaccharide Vaccine; TB = tuberculosis

Download Guidelines