Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children

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 Infections

Last Updated: November 6, 2013; Last Reviewed: November 6, 2013

Panel's Recommendations for Bacterial Infections


Panel's Recommendations

  • Status of vaccination should be reviewed at every clinical encounter and indicated vaccinations provided, according to the established recommendations for immunization of HIV-infected children (AIII). 
  • Routine use of antibiotics solely for primary prevention of serious bacterial infections is not recommended (BIII). Discontinuation of antibiotic prophylaxis is recommended for HIV-infected children receiving antibiotics for the purpose of primary or secondary prophylaxis of serious bacterial infections once they have achieved sustained (≥3 months) immune reconstitution: (CD4 T lymphocyte [CD4] cell percentage ≥25% if <6 years old; CD4 percentage ≥20% and CD4 count >350 cells/mm3 if ≥6 years old) (BII). 
  • Intravenous immune globulin is recommended to prevent serious bacterial infections in HIV-infected children who have hypogammaglobulinemia (IgG <400 mg/dL) (AI).
  • HIV-infected children whose immune systems are not seriously compromised (CDC Immunologic Category I) and who are not neutropenic can be expected to respond the same as HIV-uninfected children and should be treated with the usual antimicrobial agents recommended for the most likely bacterial organisms (AIII). 
  • Severely immunocompromised HIV-infected children with invasive or recurrent bacterial infections require expanded empiric antimicrobial treatment covering a broad range of resistant organisms (AIII). 
  • Initial empiric therapy for HIV-infected children with suspected intravascular catheter sepsis should target both gram-positive and enteric gram-negative organisms, with combinations that have activity against Pseudomonas spp. and methicillin-resistant Staphylococcus aureus (MRSA) (AIII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials in children with clinical outcomes and/or validated endpoints; I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children† with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = Expert opinion


Studies that include children or children/adolescents, but not studies limited to post-pubertal adolescents

Dosing Recommendations for Prevention and Treatment of Invasive Bacterial Infections
Indication First Choice Alternative Comments/Special Issues
Primary Prophylaxis
S. pneumoniae and other invasive bacteria
  • Pneumococcal, meningococcal, and Hib vaccines
  • IVIG 400 mg/kg body weight every 2–4 weeks 
  • TMP-SMX 75/375 mg/m2 body surface area per dose by mouth twice daily 

See Figures 1 and 2 for detailed vaccines recommendations.

Vaccines Routinely Recommended for Primary Prophylaxis. Additional Primary Prophylaxis Indicated For:
  • Hypogammaglobulinemia (that is, IgG <400 mg/dL)
Criteria for Discontinuing Primary Prophylaxis:
  • Resolution of hypogammaglobulinemia
Criteria for Restarting Primary Prophylaxis:
  • Relapse of hypogammaglobulinemia
Secondary Prophylaxis
S. pneumoniae and other invasive bacteria
  • TMP-SMX 75/375 mg/m2 body surface area per dose by mouth twice daily
  • IVIG 400 mg/kg body weight every 2–4 weeks
Secondary Prophylaxis Indicated:
  • >2 serious bacterial infections in a 1-year period in children who are unable to take cART
Criteria for Discontinuing Secondary Prophylaxis:
  • Sustained (≥ 3 months) immune reconstitution (CD4 percentage ≥25% if ≤6 years old; CD4 percentage ≥20% or CD4 count >350 cells/mm3 if >6 years old) 
Criteria For Restarting Secondary Prophylaxis:
  • >2 serious bacterial infections in a 1-year period despite cART 
Treatment
Bacterial pneumonia; S. pneumoniae; occasionally S. aureus, H. influenzae, P. aeruginosa
  • Ceftriaxone 50–100 mg/kg body weight per dose once daily, or 25–50 mg/kg body weight per dose twice daily IV or IM (max 4 g/day), or
  • Cefotaxime 40–50 mg/kg body weight per dose 4 times daily, or 50–65 mg/kg body weight 3 times daily (max 8–10 g/day) IV
  • Cefuroxime, 35–50 mg/kg body weight per dose 3 times daily (max 4–6 g/day) IV
For children who are receiving effective cART, have mild or no immunosuppression, and have mild to moderate community-acquired pneumonia, oral therapy option would be amoxicillin 45 mg/kg body weight per dose twice daily (maximum dose: 4 g per day).

Add azithromycin for hospitalized patients to treat other common community-acquired pneumonia pathogens (M. pneumoniae, C. pneumoniae).

Add clindamycin or vancomycin if methicillin-resistant S. aureus is suspected (base the choice on local susceptibility patterns).

For patients with neutropenia, chronic lung disease other than asthma (e.g., LIP, bronchiectasis) or indwelling venous catheter, consider regimen that includes activity against P. aeruginosa (such as ceftazidime or cefepime instead of ceftriaxone).

Consider PCP in patients with severe pneumonia or more advanced HIV disease.

Evaluate for tuberculosis, cryptococcosis, and endemic fungi as epidemiology suggests.
Key to Acronyms: cART = combination antiretroviral therapy; CD4 = CD4 T lymphocyte; IgG = immunoglobulin G; IM = intramuscular; IV = intravenous; IVIG = intravenous immune globulin; LIP = lymphocytic interstitial pneumonia; PCP = Pneumocystis jirovecii pneumonia; TMP-SMX = trimethoprim-sulfamethoxazole

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