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.

Isosporiasis (Cystoisosporiasis)

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

Panel's Recommendations for Isosporiasis
Panel's Recommendations
  • Antiretroviral treatment of HIV-infected children to reverse or prevent severe immunodeficiency may reduce the incidence or prevent recurrence of isosporiasis (CIII).
  • Careful hand washing and thorough washing of fruits and vegetables are recommended to prevent exposure (AIII).
  • Travelers to endemic areas should avoid untreated water for drinking, brushing teeth, and in ice, as well as unpeeled fruits and vegetables, all of which can be contaminated (BIII).
  • Trimethoprim-sulfamethoxazole (TMP-SMX) is recommended for treatment of isosporiasis in HIV-infected children (AI*).
  • In those with severe immunosuppression, treatment should be followed by secondary prophylaxis with TMP-SMX until severe immunosuppression resolves (AII*).
  • As with all causes of diarrhea, supportive care, including replenishment of fluids and electrolytes, is essential (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 Preventing and Treating Isosporiasis (Cystoisosporiasis)
Indication First Choice Alternative Comments/Special Issues
Primary Prophylaxis
There are no U.S. recommendations for primary prophylaxis of isosporiasis.
N/A
Initiation of cART to avoid advanced immunodeficiency may reduce incidence; TMP-SMX prophylaxis may reduce incidence.
Secondary Prophylaxis
If Severe Immunosuppression:
  • Administer TMP-SMX 2.5 mg/kg body weight of TMP component twice daily by mouth 3 times per week
Pyrimethamine 1 mg/kg body weight (maximum 25 mg) plus folinic acid, 10–25 mg by mouth once daily. 

Second-Line Alternative:
  • Ciprofloxacin, 10–20 mg/kg body weight given twice daily by mouth 3 times per week
Consider discontinuing secondary prophylaxis in a patient receiving cART after sustained improvement from severe immunosuppression (from CDC immunologic category 3 to CD4 values that fall within category 1 or 2) for longer than 6 months.

In adults, the dose of pyrimethamine for secondary prophylaxis (25 mg daily) is lower than the dose for treatment (50–75 mg daily), but no similar data exist for children. Thus, the recommended dosing for secondary prophylaxis in children is 1 mg/kg per dose (maximum 25 mg) once daily.

Ciprofloxacin is generally not a drug of first choice in children due to increased incidence of adverse events, including events related to joints and/or surrounding tissues.
Treatment TMP-SMX 5 mg/kg body weight of TMP component given twice daily by mouth for 10 days Pyrimethamine 1 mg/kg body weight plus folinic acid 10-25 mg by mouth once daily for 14 days

Second-Line Alternatives:
  • Ciprofloxacin 10–20 mg/kg body weight/day twice daily by mouth for 7 days
  • Nitazoxanide (see doses below) for 3 consecutive days
    • Children 1–3 years: 100 mg by mouth every 12 hours
    • Children 4–11 years: 200 mg by mouth every 12 hours
    • Adolescents ≥12 years and adults: 500 mg by mouth every 12 hours
If symptoms worsen or persist, the TMP-SMX dose may be increased to 5 mg/kg/day given 3–4 times daily by mouth for 10 days or the duration of treatment may be lengthened. Duration of treatment with pyrimethamine has not been well established.

Ciprofloxacin is generally not a drug of first choice in children due to increased incidence of adverse events, including events related to joints and/or surrounding tissues.
Key to Acronyms: CD4 = CD4 T lymphocyte; CDC = Centers for Disease Control and Prevention; cART = combination antiretroviral therapy; TMP-SMX = trimethoprim-sulfamethoxazole; cART = combination antiretroviral therapy; TMP-SMX = trimethoprim-sulfamethoxazole

Download Guidelines