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 Enteric Infections

Last Updated: August 10, 2017; Last Reviewed: August 10, 2017

Recommendations for Preventing and Treating Bacterial Enteric Infections
Preventing Bacterial Enteric Illness
  • Antimicrobial prophylaxis to prevent bacterial enteric illness usually is not recommended, including for travelers (AIII).
  • In rare cases, such as for immunosuppressed travelers, depending on their level of immunosuppression, the region of travel, and the trip’s duration, antimicrobial prophylaxis with fluoroquinolones or rifaximin can be considered (CIII).
  • For pregnant women and patients already on trimethoprim-sulfamethoxazole (TMP-SMX) for prophylaxis against Pneumocystis pneumonia TMP-SMX may offer limited protection against travelers’ diarrhea as an alternative to fluoroquinolone or rifaximin (BIII).
General Considerations when Managing Patients with Bacterial Enteric Infections
  • Oral or IV rehydration therapy (if indicated) should be given to patients with diarrhea (AIII)
  • Antimotility agents should be avoided if there is concern about inflammatory diarrhea, including Clostridium difficile infection (CDI) (BIII).
  • Diagnostic fecal specimens should be obtained prior to initiation of empiric antimicrobial therapy.
  • If stool sample is obtained, antibiotic susceptibilities should be performed to confirm and inform antibiotic choice given increased reports of antibiotic resistance. 
  • Risk of a bacterial enteric infection increases as CD4 count declines, with the greatest risk in patients with CD4 counts <200 cells/mm3. Risk of bacteremia also increases with decreasing CD4 count. If no clinical response after 3 to 4 days, consider follow-up stool culture with antibiotic susceptibility testing and other methods to detect enteric pathogens (e.g., toxin assays, molecular methods), alternative diagnosis, antibiotic resistance, or drug-drug interactions. 
  • Effective ART may reduce the frequency, severity, and recurrence of bacterial enteric infections.

Empiric Treatment of Bacterial Enteric Infections (Pending Diagnostic Studies)

For patients with advanced HIV (CD4 count <200 cells/mm3 or concomitant AIDS-defining illnesses) and clinically severe diarrhea (≥6 liquid stools/day or bloody stool and/or accompanying fever or chills).

Preferred Therapy

  • Ciprofloxacin 500–750 mg PO (or 400 mg IV) q12h (AIII)

Alternative Therapy

  • Ceftriaxone IV 1 g q24h (BIII), or
  • Cefotaxime IV 1g q8h (BIII) 

Note: IV antibiotic therapy with hospitalization should be considered in patients with marked nausea, vomiting, diarrhea, electrolyte abnormalities, acidosis, blood pressure instability, and/or when clinical judgment indicates severity of disease.

For patients with persistent diarrhea (>14 days) but no other severe clinical signs (e.g., dehydration, blood in stool), antibiotic therapy can be withheld until a diagnosis is confirmed.

Diarrhea is a common illness of international travelers. Antimicrobial resistance among enteric bacterial pathogens outside the United States is common. Clinicians should consider the possibility of resistant infections when prescribing empiric antibiotic therapy for HIV-infected travelers while traveling or upon return to the United States, particularly among travelers to South and Southeast Asia.

Treating Salmonellosis

All HIV-infected patients with salmonellosis should receive antibiotic treatment due to the increased risk of bacteremia (by 20 to 100-fold) and mortality (by as much as 7-fold) compared with HIV-negative individuals (AIII).

Preferred Therapy for Salmonella Gastroenteritis With or Without Bacteremia:

  • Ciprofloxacin 500–750 mg PO (or 400 mg IV) q12h (AIII)

 Alternative Therapy:

  • Levofloxacin 750 mg (PO or IV) q24h (BIII), or 
  • Moxifloxacin 400 mg (PO or IV) q24h (BIII)

If susceptible, alternatives to fluoroquinolone may include 1 of the following:

  • Trimethoprim 160 mg/sulfamethoxazole 800 mg (PO or IV) q12h (BIII), or
  • Ceftriaxone IV 1g q24h (BIII), or
  • Cefotaxime IV 1g q8h (BIII) 

Duration of Therapy for Gastroenteritis Without Bacteremia

  • If CD4 count >200 cells/mm3: 7–14 days (BIII)
  • If CD4 count <200 cells/mm3 particularly if primary illness was severe: 2–6 weeks (BIII)

Duration of Therapy for Gastroenteritis With Bacteremia

  • If CD4 count >200 cells/mm3: 14 days; longer duration if bacteremia persists or if the infection is complicated (e.g., metastatic foci of infection are present) (BIII)
  • If CD4 count <200 cells/mm3: 2–6 weeks (BIII) 

Secondary Prophylaxis

The role of long-term, secondary prophylaxis for patients with recurrent bacteremia or gastroenteritis is not well established. Clinicians must weigh the benefit against the risks of long-term antibiotic exposure (BIII). Antibiotic choices for secondary prophylaxis are the same as for primary treatment and are dependent on the sensitivity of the Salmonella isolate.

Suppression of HIV replication with ART is expected to decrease the risk of recurrent illnesses.

Clinicians should be aware that recurrence may represent development of antimicrobial resistance during therapy. 

Some Experts Recommend Secondary Prophylaxis for

  • Patients with recurrent bacteremia, or 
  • Patients with recurrent gastroenteritis (with or without bacteremia) with CD4 count <200 cells/mm3 and severe diarrhea (CIII)

When to Stop Secondary Prophylaxis:

  •  After resolution of Salmonella infection and response to ART with sustained viral suppression and CD4 count >200 cells/mm3 (CII)

Treating Shigellosis

Therapy is indicated to shorten the duration of illness and to possibly prevent spread to others (AIII). However, given increasing antimicrobial resistance and limited data demonstrating that antibiotic therapy limits transmission, antibiotic treatment may be withheld in HIV-infected patients with CD4 >500 cells/mm3 whose diarrhea resolves prior to culture confirmation of Shigella infection (CIII).

Preferred Therapy

  • Ciprofloxacin 500–750 mg PO (or 400 mg IV) q12h if MIC<0.12 ug/ml (see Note) (AIII)

 Alternative Therapy (Depending on Susceptibility Results):

  • Levofloxacin 750 mg (PO or IV) q24h (BIII), or 
  • Moxifloxacin (PO or IV) 400 mg q24h (BIII) or
  • Trimethoprim 160 mg/sulfamethoxazole 800 mg PO or IV q12h (BIII) or
  • Azithromycin 500 mg PO daily for 5 days (BIII) (Note: Azithromycin is not recommended for Shigella bacteremia [AIII])

Duration of Therapy:

  • Gastroenteritis: 7–10 days (AIII) (except azithromycin, treat for 5 days)
  • Bacteremia: ≥14 days (BIII)
  • Recurrent infections: up to 6 weeks (BIII) 

Chronic Maintenance or Suppressive Therapy:

  • Not recommended for first-time Shigella infections (BIII)
Note: Increased resistance of Shigella to fluoroquinolones is occurring in the United States. Avoid treating Shigella with fluoroquinolones if ciprofloxacin MIC is ≥0.12 ug/ml even if the laboratory identifies the isolate as sensitive. Many Shigella strains resistant to fluoroquinolones exhibit resistance to other commonly used antibiotics. Thus, antibiotic sensitivity testing of Shigella isolates from HIV-infected individuals should be performed routinely.
Treating Campylobacteriosis
  • Optimal treatment is poorly defined.
  • There is an increasing rate of fluoroquinolone resistance in the United States (22% resistance in 2013 among C. jejuni isolates). 
  • Antimicrobial therapy should be modified based on susceptibility reports. 

Mild Disease if CD4 Count >500 cells/mm3:

  • If diarrhea resolves prior to culture confirmation of Campylobacter infection, antibiotic treatment can be withheld (CIII). If symptoms persist, consider antibiotic therapy (CIII).

Mild to Moderate Disease

Preferred Therapy:

  • Ciprofloxacin 500–750 mg PO (or 400 mg IV) q12h (BIII)—if susceptible, or
  • Azithromycin 500 mg PO daily for 5 days (BIII) (Not recommended for bacteremia [AIII])

Alternative Therapy (Depending on Susceptibility Results):

  • Levofloxacin 750 mg PO or IV q24h (BIII), or 
  • Moxifloxacin 400 mg PO or IV q24h (BIII)

Bacteremia

  • Ciprofloxacin 500–750 mg PO (or 400 mg IV) q12h (BIII) plus an aminoglycoside (BIII) in bacteremic patients to limit the emergence of antibiotic resistance 

Duration of Therapy:

  • Gastroenteritis: 7–10 days (BIII) [5 days if azithromycin is used]
  • Bacteremia: >14 days (BIII)
  • Recurrent bacteremic disease: 2–6 weeks (BIII)

Chronic Maintenance or Suppressive Therapy:

  • Not recommended for first-time Campylobacter infections (BIII)
Treating Clostridium difficile Infection (CDI)

Preferred Therapy:
  • Vancomycin 125 mg (PO) 4 times per day for 10–14 days (AI)
  • For severe, life-threatening CDI, see text and references for additional information.

Alternative Therapy for Mild CDI:

  • For mild, outpatient disease: metronidazole 500 mg (PO) 3 times per day for 10–14 days (CII)

Recurrent CDI:

  • Treatment is the same as in patients without HIV infection. Fecal microbiota therapy (FMT) may be successful and safe to treat recurrent CDI in HIV-infected patients (CIII). See text and references for additional information.
Key to Acronyms: CD4 = CD4 T lymphocyte cell; IV = intravenously; PO = orally; q(n)h = every “n” hours.

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