Consensus statement
Executive summary: Prevention and treatment of opportunistic infections and other coinfections in HIV-infected patients: May 2015Executive summary: Prevención y tratamiento de infecciones oportunistas y otras coinfecciones en pacientes infectados por el VIH: mayo de 2015

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Abstract

Opportunistic infections continue to be a cause of morbidity and mortality in HIV-infected patients. They often arise because of severe immunosuppression resulting from poor adherence to antiretroviral therapy, failure of antiretroviral therapy, or unawareness of HIV infection by patients whose first clinical manifestation of AIDS is an opportunistic infection.

The present article is an executive summary of the document that updates the previous recommendations on the prevention and treatment of opportunistic infections in HIV-infected patients, namely, infections by parasites, fungi, viruses, mycobacteria, and bacteria, as well as imported infections. The article also addresses immune reconstitution inflammatory syndrome. This document is intended for all professionals who work in clinical practice in the field of HIV infection.

Resumen

Las infecciones oportunistas siguen siendo una causa importante de morbi mortalidad en pacientes con infección por VIH. Ello ocurre en muchos casos debido a la inmunodepresión grave, bien ante la falta de adherencia al tratamiento antirretroviral, el fracaso del mismo o el desconocimiento de la existencia de la infección por el VIH en pacientes que comienzan con una infección oportunista.

Este artículo es un resumen del documento de consenso que actualiza las recomendaciones previas de GESIDA respecto a la prevención y el tratamiento de las diferentes infecciones oportunistas en pacientes infectados por VIH: parasitarias, fúngicas, víricas, micobacterianas, bacterianas e importadas, además del síndrome de reconstitución inmune. Está dirigido a los profesionales que trabajan en la práctica clínica en el campo del VIH, con el objetivo de facilitarles una atención de calidad en la prevención y tratamiento de estas infecciones

Introduction

Opportunistic infections (OIs) have been the main cause of morbidity and mortality in HIV-infected patients since the beginning of the HIV epidemic.

Efficacious regimens for primary and secondary prophylaxis to prevent OIs were the first major advance in therapy for HIV-infected patients, significantly decreasing mortality, even before the advent of highly active antiretroviral therapy (ART). ART brought about a notable change in the progression of HIV infection by dramatically reducing mortality and the incidence of OIs. However, today, we continue to see cases of OI in various settings: patients who are unaware of their HIV infection and whose first manifestation is an OI; patients who do not receive ART; and failure of ART due to poor adherence or other causes. Accordingly, treatment of OIs continues to be a relevant topic in the care of HIV-infected patients1.

The present document is an update of our previous recommendations on prevention and treatment of OIs in HIV-infected patients. The strength of the recommendation and ranking of the tests that support it are based on a modification of the criteria of the Infectious Diseases Society of America. According to these criteria, each recommendation should be offered always (A), generally (B), or optionally (C), based on data from 1 or more randomized clinical trials with clinical or laboratory results (I), 1 or more nonrandomized trials or observational cohort data (II), or expert opinion (III).

Owing to space limitations, we strongly recommend to the reader to consult the tables of the leading document, which display the various prophylaxis and treatment regimens (both preferred and alternative) and the corresponding doses. Available at http://www.gesida-seimc.org/contenidos/guiasclinicas/2015/gesida-guiasclinicas-2015-InfeccionesOportunistasyCoinfeccionesVIH.pdf.

Section snippets

Toxoplasma gondii

Patients who have not been exposed to Toxoplasma gondii (confirmed by a negative anti-Toxoplasma gondii IgG result) should avoid contact with the parasite.

  • Handwashing is recommended after contact with animals, especially cats, and after handling raw meat. Patients should try to eat meat that has been adequately cooked (or previously frozen to −20 °C) and wash fruit and vegetables that are to be eaten raw (BIII).

  • Primary prophylaxis should be with cotrimoxazole in patients with anti-Toxoplasma

Pneumocystis jiroveci

  • Prevention of exposure. Although available epidemiologic data indicate that respiratory isolation should be considered in patients with Pneumocystis jiroveci pneumonia, there is insufficient evidence to support this recommendation (CIII).

  • Primary prophylaxis is indicated in patients with a CD4+ T-lymphocyte count <200 cells/μL (AI), previous oropharyngeal candidiasis (AII), CD4+ <14% (BII), or a previous AIDS-defining disease (BII). It should be considered in patients with 200–250 CD4+ cells/μL

Herpes simplex virus

  • The most common clinical forms of herpes simplex virus (HSV) are genital herpes, which is generally caused by HSV-2, and orolabial herpes, which is usually caused by HSV-1. Recurrences are more common in genital herpes. Treatment is more efficacious if started early, during the prodromal phase, or on the day immediately following the appearance of lesions.

  • Treatment of herpesvirus encephalitis is similar in HIV-infected patients and immunocompetent patients. It should be started empirically as

Mycobacterium tuberculosis

  • Treatment of mycobacterial infections in HIV-infected patients is generally the same as in non–HIV-infected patients. As a rule, patients infected with Mycobacterium tuberculosis who are sensitive to all drugs should receive isoniazid, rifampicin, pyrazinamide, and ethambutol (2 months) followed by isoniazid and rifampicin (for a further 4–7 months) (AI).

  • A 6-month course is sufficient for most HIV-infected patients with tuberculosis (TB). The continuation phase should be extended to 7 months if

Infections caused by other bacteria

  • Recommendations for the treatment of bacterial respiratory infection caused by Streptococcus pneumoniae, less prevalent bacteria (Haemophilus influenzae type b, Pseudomonas aeruginosa, and Staphylococcus aureus), and unusual bacteria (Nocardia species or Rhodococcus equi) are similar for HIV-infected and non-HIV-infected individuals.

  • Treatment of intestinal infections caused by Salmonella species, Campylobacter species, or Clostridium difficile is similar to that administered to the general

Imported parasitic diseases

Immigration, international travel, and more favorable prognosis in HIV-infected persons mean that imported parasitic infections are increasingly common in the HIV-infected population. This section only addresses more severe parasitic diseases or those that act opportunistically in HIV-infected patients.

Malaria (especially malaria caused by Plasmodium falciparum) is one of the most relevant infections, since it affects both severely immunodepressed patients and those with normal CD4+

Immune reconstitution inflammatory syndrome

IRIS is caused by restoration of the cellular inflammatory response in very immunodepressed patients who initiate ART. It has 2 manifestations: unmasking IRIS, which reveals a pre-existing occult OI, and paradoxical IRIS, which involves clinical deterioration of a previously diagnosed OI that has been treated appropriately.

Diagnosis is by exclusion, that is, ruling out other possible causes of worsening after initiating ART, such as drug-induced toxicity, failure of ART, failure of

Conflict of interest

These authors and reviewers have not received any aid or grant related to this document.

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Readers who prefers to have this review in Castilian, can be obtained from the following address: http://www.gesida-seimc.org/contenidos/guiasclinicas/2015/gesida-guiasclinicas-2015-InfeccionesOportunistasyCoinfeccionesVIH.pdf

1

See Appendix A for the contributions of the Authors and Reviewers.

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