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.

Cryptosporidiosis

Last Updated: August 29, 2019; Last Reviewed: August 29, 2019

Panel's Recommendations for Cryptosporidiosis
Panel's Recommendations
  1. In children with HIV infection, what are the best interventions (compared with no intervention) to prevent episodes of cryptosporidiosis?
    • Cryptosporidiosis can be prevented by practicing good hygiene (e.g., frequent handwashing), avoiding drinking water that might be contaminated, avoiding high-risk swimming exposures (e.g., drinking swimming water, especially in pools and water playgrounds frequented by very young children), and not eating food that might be contaminated (expert opinion).
    • Children with HIV infection should avoid contact with pre-weaned bovine calves, lambs, goat kids, ill animals, young dogs and cats, stray animals, and animal or human feces or any feces-contaminated surfaces (expert opinion).
    • In children with HIV infection, combination antiretroviral therapy (ART) to reverse or prevent severe immunodeficiency is the primary mode of prevention of severe enteric cryptosporidiosis (strong, low).
  2. In children with HIV infection, what are the best interventions (compared with no intervention) to treat cryptosporidiosis?
    • Effective ART is the primary initial treatment for cryptosporidiosis in children (strong, moderate).
    • Nitazoxanide, in addition to ART, can be considered to treat cryptosporidiosis in children with HIV infection (strong, moderate).
    • Dehydration and electrolyte abnormalities should be corrected, and nutritional support should be provided as appropriate (expert opinion).
Rating System
Strength of Recommendation: Strong; Weak
Quality of Evidence: High; Moderate; Low; or Very Low

Recommendations

  1. In children with HIV infection, what are the best interventions (compared with no intervention) to prevent episodes of cryptosporidiosis?
    • Cryptosporidiosis can be prevented by practicing good hygiene (e.g., frequent handwashing), avoiding drinking water that might be contaminated, avoiding high risk swimming exposures (e.g., drinking swimming water, especially in pools and water playgrounds frequented by very young children), and not eating food that might be contaminated (expert opinion).
    • Children with HIV infection should avoid contact with pre-weaned bovine calves, lambs, goat kids, ill animals, young dogs and cats, stray animals, and stool from any animals or humans or surfaces known to be contaminated with human or animal feces (expert opinion).
    • ART for children with HIV infection to reverse or prevent severe immunodeficiency is the primary mode of prevention of severe enteric cryptosporidiosis (strong, low).

      A prospective, comparative cross-sectional study of ART-treated versus ART-naive pediatric patients with HIV infection in Ethiopia found that Cryptosporidium infections were found only in ART-naive patients with low CD4 counts.24 A retrospective/prospective cohort study in adults with HIV infection in South Ethiopia demonstrated that patients who initiated ART with a CD4 count of <500/mm3 and received health interventions including provision of household water treatment, safe water storage, soap, and anti-helminthic drugs had decreased rate of cryptosporidiosis, even among patients with CD4 counts <200 cells/mm3.71

  2. In children with HIV infection, what are the best interventions (compared with no intervention) to treat cryptosporidiosis?
    • Treatment with ART is the best intervention in children with HIV infection and cryptosporidiosis (strong, moderate).
    • Immune reconstitution resulting from ART often results in clearance of Cryptosporidium infection, and ART is the primary initial treatment for these infections in children with HIV infection who are not already receiving ART.19,24,44
    • Nitazoxanide, in addition to ART, can be considered for cryptosporidiosis in children with HIV (strong, moderate).

      A clinical trial comparing nitazoxanide versus placebo in children without HIV infection demonstrated that resolution of diarrhea and parasitologic cure were significantly higher in children treated with nitazoxanide.59 In a prospective cohort of patients with HIV infection with cryptosporidiosis treated with nitazoxanide, sustained clinical response was achieved in 59% of patients, and 57% of patients had Cryptosporidium-negative stool before completing the study.63 However, a study of malnourished Zambian children demonstrated no benefit from nitazoxanide among children with HIV (clinical response in 8% treated with nitazoxanide and in 25% receiving placebo) but did show benefit when both children with and without HIV infection were included.60
    • Dehydration and electrolyte abnormalities should be corrected, and nutritional support should be provided as appropriate (expert opinion).

      There are no studies that address this specific management issue in cryptosporidiosis. However, recognition and management of hydration status, electrolyte imbalance, and nutritional needs are key to management of infectious diarrhea.

Dosing Recommendations for Prevention and Treatment of Cryptosporidiosis
Indication First Choice Alternative Comments/Special Issues 
Primary Prophylaxis
ARV therapy to avoid advanced immune deficiency N/A
N/A
Secondary Prophylaxis
N/A N/A N/A
Treatment Effective ART:
  • Immune reconstitution might lead to parasitologic and clinical response
There is no consistently effective therapy for cryptosporidiosis in patients with HIV infection; optimized ART and a trial of nitazoxanide should be considered.

Nitazoxanide:
  • 1–3 years of age: Nitazoxanide (20 mg/mL oral solution) 100 mg orally twice daily with food
  • 4–11 years of age: Nitazoxanide (20 mg/mL oral solution) 200 mg orally twice daily with food
  • ≥12 years of age: Nitazoxanide tablet 500 mg orally twice daily with food
Treatment Duration:
  • 3–14 days
Supportive Care:
  • Hydration, correct electrolyte abnormalities, nutritional support
Antimotility agents (such as loperamide) should be used with caution in young children.
Key: ARV = antiretroviral; ART = antiretroviral therapy

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