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
||PIs: increase quinine levels
||No available data
||Efavirenz, Nevirapine: reduces quinine levels
||Lopinavir/Ritonavir, Atazanavir/Ritonavir: reduces atovaquone and proguanil levels
||Efavirenz: reduces atovaquone and proguanil levels
||Ritonavir: reduces ritonavir levels
||Efavirenz, Nevirapine: reduces mefloquine levels
||PIs: increase lumefantrine or halofantrine levels, which can prolong QT interval
||Efavirenz, Nevirapine: increases lumefantrine or halofantrine levels, which can prolong QT interval
|Amodiaquine plus Artesunate
||Efavirenz: increases amodiaquine concentration which can increase hepatic toxicity; do not co-administer
|Chloroquine, Pyrimethamine, Sulfadoxine-Pyrimethamine
||Ritonavir: alters anti-malarial drug metabolism, may increase chloroquine levels
||Zidovudine: possibly increases risk of anemia
||Nevirapine: possibly increases adverse skin or liver adverse reactions; do not start both drugs simultaneously
||PIs: alter artemisinin metabolism
||Nevirapine: may decrease artemisinin levels
||Saquinavir: alters dapsone metabolism
|Key to Acronyms: NRTI=nucleoside reverse transcriptase inhibitor; NNRTI=non-nucleoside reverse transcriptase inhibitor; PI= protease inhibitor
* Modified from: Flateau, C., G. Le Loup, et al. Consequences of HIV infection on malaria and therapeutic implications: a systematic review. Lancet Infect Dis. 2011. 11(7);541-556.
||For Travel To Chloroquine-Sensitive Areas:
||Recommendations are the same for HIV-infected and HIV-uninfected children. Please refer to the following website for the most recent recommendations based on region and drug susceptibility: http://www.cdc.gov/malaria/
For travel to chloroquine-sensitive areas. Equally recommended options include chloroquine, atovaquone/proguanil, doxycycline (for children aged ≥8 years), and mefloquine; primaquine is recommended for areas with mainly P. vivax.
G6PD screening must be performed prior to primaquine use.
Chloroquine phosphate is the only formulation of chloroquine available in the United States; 10 mg of chloroquine phosphate = 6 mg of chloroquine base.
For travel to chloroquine-resistant areas, preferred drugs are atovaquone/proguanil, doxycycline (for children aged ≥8 years) or mefloquine.
|For Travel to Chloroquine-Resistant Areas:
||For P. vivax or P. ovale:
||This regimen, known as PART, is recommended only for individuals who have resided in a malaria-endemic area for an extended period of time. Adult dose: 30 mg base (52.6 mg salt) orally, daily for 14 days after departure from the malarious area.
|Treatment||Uncomplicated P. Falciparum or Unknown Malaria Species, from Chloroquine-Resistant Areas (All Malaria Areas Except Those Listed as Chloroquine Sensitive) or Unknown Region:
Initial Therapy (Followed by Anti-Relapse Therapy for P. Ovale and P. Vivax):
|For quinine-based regimens, doxycycline or tetracycline should be used only in children aged ≥8 years. An alternative for children aged ≥8 years is clindamycin 7 mg/kg body weight per dose by mouth given every 8 hours. Clindamycin should be used for children aged <8 years.
Before primaquine is given, G6PD status must be verified. Primaquine may be given in combination with chloroquine if the G6PD status is known and negative, otherwise give after chloroquine (when G6PD status is available)
For most updated prevention and treatment recommendations for specific region, refer to updated CDC treatment table available at http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf
For sensitive and resistant malaria map: http://cdc-malaria.ncsa.uiuc.edu/
High treatment failure rates due to chloroquine-resistant P. vivax have been documented in Papua New Guinea and Indonesia. Treatment should be selected from one of the three following options:
Quinidine gluconate 10 mg/kg body weight IV loading dose over 1–2 hours, then 0.02 mg/kg body weight/minute infusion for ≥24 hours (Treatment duration: 7 days in Southeast Asia, Oceania, otherwise 3 days)
PLUS One of the Following:
PLUS One of the Following:
|Quinidine gluconate is a class 1a anti-arrhythmic agent not typically stocked in pediatric hospitals. When regional supplies are unavailable, the CDC Malaria hotline may be of assistance (see below). Do not give quinidine gluconate as an IV bolus. Quinidine gluconate IV should be administered in a monitored setting. Cardiac monitoring required. Adverse events including severe hypoglycemia, prolongation of the QT interval, ventricular arrhythmia, and hypotension can result from the use of this drug at treatment doses.
IND: IV artesunate is available from CDC. Contact the CDC Malaria Hotline at (770) 488-7788 from 8 a.m.–4:30 p.m. EST or (770) 488-7100 after hours, weekends, and holidays. Artesunate followed by one of the following: Atovaquone-proguanil (Malarone™), clindamycin, mefloquine, or (for children aged >8 years) doxycycline.
Quinidine gluconate: 10 mg = 6.25 mg quinidine base.
Doxycycline (or tetracycline) should be used in children aged ≥8 years. For patients unable to take oral medication, may give IV. For children <45 kg, give 2.2 mg/kg IV every 12 hours and then switch to oral doxycycline. For children >45 kg, use the same dosing as per adults. For IV use, avoid rapid administration.
For patients unable to take oral clindamycin, give 10 mg base/kg loading dose IV, followed by 5 mg base/kg IV every 8 hours. Switch to oral clindamycin (oral dose as above) as soon as a patient can take oral medication. For IV use, avoid rapid administration.
|Key to Acronyms: CDC = Centers for Disease Control and Prevention; G6PD = glucose-6-phosphate dehydrogenase; IND = investigational new drug; IV = intravenous; PART = presumptive anti-relapse therapy