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.

Talaromycosis (Formerly Penicilliosis)

Last Updated: November 21, 2019; Last Reviewed: November 21, 2019

Recommendations for Preventing and Treating Talaromycosis
Preventing First Episode of Talaromycosis (Primary Prophylaxis)
Indication for Primary Prophylaxis:
  • Persons with a CD4 count <100 cells/mm3, who are unable to have ART, or have treatment failure without access to effective ART options and who either:
    • Reside in the highly endemic regions in northern Thailand, throughout Vietnam, and southern China (particularly in highland regions during the rainy humid months) (BI), or
    • Are from countries outside of the endemic region and must travel to the region (BIII).
Primary Prophylaxis
For Individuals Residing in Endemic Areas:
  • Preferred Therapy: Itraconazole 200 mg PO once daily (BI)
  • Alternative Therapy: Fluconazole 400 mg PO once weekly (BII)
For Individuals Traveling to Endemic Areas:
  • Preferred Therapy: Begin itraconazole 200 mg PO once daily 3 days before travel and continue for 1 week after leaving the endemic area (BIII).
  • Alternative Therapy: Begin fluconazole 400 mg 3 days before travel, then continue 400 mg once weekly while in the area, and take final dose after leaving the endemic area (BIII).
Indication for Discontinuing Primary Prophylaxis for Persons who Reside in Endemic Areas:
  • CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII)
  • Viral load suppression for ≥6 months on ART (BIII)
Indication for Restarting Primary Prophylaxis:
  • CD4 count decreases to <100 cells/mm3 (BIII) and patient still resides in or travels to high-risk areas. Primary prophylaxis for travelers may begin three days prior to travel to allow serum drug level to reach steady state and may continue for one week after travel (BIII).
Treating Acute Infection in Severely Ill Patients
Preferred Therapy:
  • Induction therapy with liposomal amphotericin B 3 to 5 mg/kg/day IV for 2 weeks, followed by consolidation therapy with itraconazole 200 mg PO twice daily for 10 weeks (AI), followed by maintenance therapy or secondary prophylaxis with itraconazole 200 mg PO daily (AII)
Alternative Therapy:
  • In settings where liposomal amphotericin B is not available, induction therapy with deoxycholate amphotericin B 0.7 mg/kg/day IV for 2 weeks, followed by consolidation therapy with itraconazole 200 mg PO twice daily for 10 weeks (AI), followed by maintenance therapy or secondary prophylaxis with itraconazole 200 mg PO daily (AII)
  • In settings where amphotericin B is not available, induction therapy with voriconazole 6 mg/kg IV every 12 hours for 1 day (loading dose) and then voriconazole 4 mg/kg IV every 12 hours for 2 weeks, or oral voriconazole 600 mg every 12 hours on day 1 (loading dose) and then voriconazole 400 mg PO every 12 hours for 2 weeks; followed by consolidation therapy with voriconazole 200 mg PO twice daily or itraconazole 200 mg PO twice daily for a maximum of 10 weeks (BII); followed by maintenance therapy or secondary prophylaxis with itraconazole 200 mg PO daily (AII)
  • Itraconazole is not recommended as induction therapy for talaromycosis (AI).
Criteria for Discontinuing Chronic Maintenance Therapy:
  • CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII)
  • Virologic suppression for ≥6 months on ART (BIII)
Criteria for Restarting Chronic Maintenance Therapy:
  • CD4 count decreases to <100 cells/mm3 (AIII)
Other Considerations
  • ART can be initiated as early as one week after the initiation of treatment for talaromycosis with amphotericin B induction therapy to improve outcomes (BII).
  • Given erratic absorption of itraconazole, extensive interindividual variability and non-linear PKs of voriconazole, and the potential for drug interactions with ARV drugs, itraconazole and voriconazole concentrations should be monitored, and serum trough concentration should be >0.5 µg/mL for itraconazole and >1 µg/mL for voriconazole (BIII). Both itraconazole and voriconazole can have significant drug-drug interactions with various ARV drugs; dosage adjustment may be necessary, and TDM to guide therapy can be considered (see the Drug-Drug Interactions tables in the Adult and Adolescent Antiretroviral Guidelines for further recommendations).
Key: ART = antiretroviral therapy; ARV = antiretroviral; CD4 = CD4 T lymphocyte; IV = intravenous; PK = pharmacokinetic; PO = orally; TDM = therapeutic drug monitoring

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