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.
Last Updated: November 6, 2013; Last Reviewed: November 6, 2013
|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
|Indication||First Choice||Alternative||Comments/Special Issues|
||Primary Prophylaxis indicated for selected HIV-infected adults but not children.
Criteria for Discontinuing Primary Prophylaxis:
|Itraconazole oral solution 5–10 mg/kg body weight (maximum 200 mg) per dose by mouth daily||Fluconazole 3–6 mg/kg body weight (maximum 200 mg) by mouth once daily||Secondary Prophylaxis Indicated:
If All of the Following Criteria Are Fulfilled:
|Treatment||Acute Primary Pulmonary Histoplasmosis:
Mild Disseminated Disease:
Moderately Severe to Severe Disseminated Disease
Acute Therapy (Minimum 2-Week Induction, Longer if Clinical Improvement is Delayed, Followed by Consolidation Therapy):
Acute Therapy (4–6 Weeks, Followed by Consolidation Therapy):
|Acute Primary Pulmonary Histoplasmosis:
Mild Disseminated Disease:
Moderately Severe to Severe Disseminated Disease:
|Use same initial itraconazole dosing for capsules as for solution. Itraconazole solution is preferred to the capsule formulation because it is better absorbed; solution can achieve serum concentrations 30% higher than those achieved with the capsules.
Urine antigen concentration should be assessed at diagnosis. If >39 ng/mL, serum concentrations should be followed. When serum levels become undetectable, urine concentrations should be monitored monthly during treatment and followed thereafter to identify relapse.
Serum concentrations of itraconazole should be monitored and achieve a level of 1 μg/mL at steady-state. Levels exceeding 10 µg/mL should be followed by dose reduction.
High relapse rate with CNS infection occurs in adults and longer therapy may be required; treatment in children is anecdotal and expert consultation should be considered.
Chronic suppressive therapy (secondary prophylaxis) with itraconazole is recommended in adults and children following initial therapy.
Amphotericin B deoxycholate is better tolerated in children than in adults. Liposomal amphotericin B is preferred for treatment of parenchymal cerebral lesions.
|Key to Acronyms: cART = combination antiretroviral therapy; CD4 = CD4 T lymphocyte; CNS = central nervous system; IV = intravenous