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: February 8, 2019; Last Reviewed: February 8, 2019

Panel's Recommendations for Isosporiasis
Panel's Recommendations
I. In children with HIV infection, what are the best interventions (compared with no intervention) to prevent initial episodes of isosporiasis (cystoisosporiasis)?
  • Careful hand washing and thorough washing of fruits and vegetables are recommended to prevent exposure. Travelers to isosporiasis-endemic areas should avoid untreated water for drinking, brushing teeth, and in ice, as well as unpeeled fruits and vegetables (expert opinion).
II. In children with HIV infection, what are the best interventions (compared with no intervention) to treat isosporiasis (cystoisosporiasis)?
  • Trimethoprim-sulfamethoxazole (TMP-SMX) is recommended for treatment of isosporiasis in children with HIV infection (strong, high).
  • Supportive care, including replenishment of fluids and electrolytes, should be provided (expert opinion).
III. In children with HIV infection, what are the best interventions (compared with no intervention) to prevent recurrent episodes of isosporiasis (cystoisosporiasis)?
  • Antiretroviral therapy (ART) administered to children with HIV infection to reverse or prevent severe immunodeficiency may be effective in preventing recurrence of isosporiasis (weak, very low).
  • In children with severe immunosuppression, treatment of isosporiasis should be followed by secondary prophylaxis with TMP-SMX (strong, high).
IV. In children with HIV infection receiving secondary prophylaxis for isosporiasis (cystoisosporiasis), when can secondary prophylaxis be safely discontinued?
  • Clinicians may consider discontinuing secondary prophylaxis in patients without evidence of active Isospora infection who have sustained improvement in immunologic status (CDC immunologic category 1 or 2) for >6 months in response to ART (weak, very low).

Rating System

Strength of Recommendation: Strong; Weak

Quality of Evidence: High; Moderate; Low; or Very Low

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 ART to avoid severe immunodeficiency may reduce incidence; TMP-SMX prophylaxis may reduce incidence.
Secondary Prophylaxis
If Severe Immunosuppression:
  • TMP-SMX 2.5 mg/kg body weight of the TMP component (maximum 80 mg TMP) twice daily by mouth 3 times per week
Pyrimethamine 1 mg/kg body weight (maximum 25 mg) plus folinic acid 5-15 mg by mouth once daily.

Second-Line Alternative:
  • Ciprofloxacin 10–20 mg/kg body weight (maximum 500 mg) by mouth 3 times per week
Consider discontinuing secondary prophylaxis in patients without evidence of active Isospora infection who have sustained improvement in immunologic status (from CDC immunologic category 3 to CD4 values that fall within category 1 or 2) for >6 months in response to ART.

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 data exist for dosing in children. Thus, the recommended dose for secondary prophylaxis in children is pyrimethamine 1 mg/kg (maximum 25 mg) by mouth once daily.

Ciprofloxacin is not a drug of choice in children because of increased incidence of adverse events, including events related to joints and/or surrounding tissues.
Treatment TMP-SMX 5 mg/kg body weight of the TMP component (maximum 160 mg TMP) twice daily by mouth for 10 days Pyrimethamine 1 mg/kg body weight (maximum 25 mg) plus folinic acid 5-15 mg by mouth once daily for 14 days

Second-Line Alternatives:
  • Ciprofloxacin 10–20 mg/kg body weight (maximum 500 mg) by mouth twice daily for 7 days
  • Nitazoxanide (see doses below) for 3 consecutive days
Children Aged 1 Year–3 Years:
  • Nitazoxanide 100 mg by mouth every 12 hours
Children Aged 4 Years–11 Years:
  • Nitazoxanide 200 mg by mouth every 12 hours
Adolescents Aged ≥12 Years and Adults:
  • Nitazoxanide 500 mg by mouth every 12 hours
If symptoms worsen or persist, the TMP-SMX dose (5 mg/kg/dose of the TMP component) may be given more frequently (e.g., 3–4 times daily by mouth for 10 days) and/or the duration of treatment may be increased to 3-4 weeks.

The optimal duration of treatment with pyrimethamine has not been established.

Ciprofloxacin is not a drug of choice in children because of 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; ART = antiretroviral therapy; TMP-SMX = trimethoprim-sulfamethoxazole

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