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.

Microsporidiosis

Last Updated: December 15, 2016; Last Reviewed: December 15, 2016

Panel's Recommendations for Microsporidiosis
Panel's Recommendations
  1. In children with HIV infection, what are the best interventions (compared with no intervention) to treat microsporidiosis?
    • Effective antiretroviral therapy (ART) is the primary initial treatment for microsporidiosis in HIV-infected children (strong, very low).
    • Supportive care with hydration, correction of electrolyte abnormalities, and nutritional supplementation should be provided (expert opinion).
    • Albendazole, in addition to ART, is also recommended for initial therapy of microsporidiosis caused by microsporidia other than Enterocytozoon bieneusi and Vittaforma corneae (strong, low).
    • Systemic fumagillin (where available), in addition to ART, is recommended for microsporidiosis caused by E. bieneusi and V. corneae (strong, moderate).
    • Topical therapy with fumagillin eye drops, in addition to ART, is recommended in HIV-infected children with keratoconjunctivitis caused by microsporidia (strong, very low)
    • Oral albendazole can be considered in addition to topical therapy for keratoconjunctivitis due to microsporidia other than E. bieneusi and V. corneae (expert opinion).
  2. In HIV-infected children who have been treated for microsporidiosis, when can treatment (secondary prophylaxis) be safely discontinued?
    Clinicians may consider continuing treatment for microsporidiosis until improvement in severe immunosuppression is sustained (more than 6 months at Centers for Disease Control and Prevention immunologic category 1 or 2) and clinical signs and symptoms of infection are resolved (weak, very low).
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 Microsporidiosis
Preventative Regimen 
Indication First Choice Alternative Comments/Special Issues
Primary Prophylaxis
N/A
N/A
Not recommended
Secondary Prophylaxis
Disseminated, Non-Ocular Infection or GI Infection Caused by Microsporidia Other Than E. Bieneusi or V. Corneae:
  • Albendazole 7.5 mg/kg body weight (maximum 400 mg/dose) by mouth twice daily 
Ocular Infection:
  • Topical fumagillin bicyclohexylammonium (Fumidil B) 3 mg/mL in saline (fumagillin 70 μg/mL) eye drops: 2 drops every 2 hours for 4 days, then 2 drops QID (investigational use only in United States) plus, for infection attributed to microsporidia other than E. bieneusi or V. corneae, albendazole 7.5 mg/kg body weight (maximum 400 mg/dose) by mouth twice daily for management of systemic infection
N/A
Criteria for Discontinuing Secondary Prophylaxis
  • After initiation of ART, resolution of signs and symptoms and sustained immune reconstitution (more than 6 months at CDC immunologic category 1 or 2)  
Treatment Effective ART Therapy
  • Immune reconstitution may lead to microbiologic and clinical response. 
For Disseminated (Not Ocular) and Intestinal Infection Attributed to Microsporidia Other Than E. bieneusi or V. corneae:
  • Albendazole 7.5 mg/kg body weight (maximum 400 mg/dose) by mouth twice daily (in addition to ART)
Treatment Duration: 
  • Continue until sustained immune reconstitution (longer than 6 months at CDC immunologic category 1 or 2) after initiation of ART and resolution of signs and symptoms 
For E. bieneusi or V. corneae Infections:
  • Fumagillin (where available) adult dose 20 mg by mouth 3 times daily, or
  • TNP-470 (a synthetic analogue of fumagillin; where available) recommended for treatment of infections caused by E. bieneusi in HIV-infected adults (in addition to ART)
For Ocular Infection:
  • Topical fumagillin bicyclohexylammonium (Fumidil B) 3 mg/mL in saline (fumagillin 70 µg/mL) eye drops: 2 drops every 2 hours for 4 days, then 2 drops QID (investigational use only in United States) plus, for microsporidial infection other than E. bieneusi and V. corneae, albendazole 7.5 mg/kg body weight (maximum 400 mg/dose) by mouth twice daily for management of systemic infection (in addition to ART)
Treatment Duration: 
  • Continue until sustained immune reconstitution (longer than 6 months at CDC immunologic category 1 or 2) after initiation of ART and resolution of signs and symptoms.  
N/A
  • Supportive care (e.g., hydration, correction of electrolyte abnormalities, nutritional support)
  • Fumagillin for systemic use is unavailable in the United States and data on dosing in children are unavailable. Consultation with an expert is recommended. 
     
Key to Acronyms: ART = antiretroviral therapy; CDC = Centers for Disease Control and Prevention; GI = gastrointestinal; QID = 4 times a day

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