Morbidity and Mortality Weekly Report Recommendations and Reports December 17, 2004 / Vol. 53 / No. RR-15 Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/ Infectious Diseases Society of America INSIDE: Continuing Education Examination department of health and human services Centers for Disease Control and Prevention MMWR CONTENTS The MMWR series of publications is published by the Epidemiology Program Office, Centers for Disease Introduction......................................................................... 1 Control and Prevention (CDC), U.S. Department of How To Use the Information in This Report .......................... 2 Health and Human Services, Atlanta, GA 30333. Effect of Antiretroviral Therapy on the Incidence and Management of OIs .................................................... 2 SUGGESTED CITATION Initiation of ART in the Setting of an Acute OI Centers for Disease Control and Prevention. Treating (Treatment-Naïve Patients) ................................................. 3 Management of Acute OIs in the Setting of ART .................. 4 opportunistic infections among HIV-infected adults and When To Initiate ART in the Setting of an OI ........................ 4 adolescents: recommendations from CDC, the National Special Considerations During Pregnancy ........................... 4 Institutes of Health, and the HIV Medicine Association/ Disease Specific Recommendations ..................................... 5 Infectious Diseases Society of America. MMWR Pneumocystis Jiroveci Pneumonia ...................................... 5 2004;53(No. RR-15):[inclusive page numbers]. Toxoplasma gondii Encephalitis ......................................... 8 Cryptosporidiosis ............................................................ 10 Centers for Disease Control and Prevention Microsporidiosis .............................................................. 12 Mycobacterium tuberculosis Disease ............................... 14 Julie L. Gerberding, M.D., M.P.H. Disseminated Mycobacterium avium Complex Disease ... 19 Director Bacterial Respiratory Disease .......................................... 21 Dixie E. Snider, M.D., M.P.H. Bacterial Enteric Disease ................................................. 23 Chief of Science Bartonellosis ................................................................... 25 Syphilis ........................................................................... 27 Tanja Popovic, M.D., Ph.D. Mucocutaneous Candidiasis ........................................... 30 (Acting) Associate Director for Science Cryptococcosis ................................................................ 32 Histoplasmosis ................................................................ 34 Coordinating Center for Health Information Coccidioidomycosis......................................................... 35 and Service* Aspergillosis ................................................................... 36 Blake Caldwell, M.D., and Edward J. Sondik, Ph.D. Cytomegalovirus Disease ................................................ 37 (Acting) Directors Herpes Simplex Virus Disease ......................................... 41 Varicella Zoster Virus Disease ......................................... 42 National Center for Health Marketing* Human Herpesvirus-8 Disease ....................................... 44 Steven L. Solomon, M.D. Progressive Multifocal Leukoencephalopathy (Acting) Director Caused by JC Virus ....................................................... 45 Human Papillomavirus Disease ....................................... 46 Division of Scientific Communications* Hepatitis C Virus Disease ................................................ 49 Hepatitis B Virus Disease ................................................ 54 John W. Ward, M.D. Geographic OIs of Special Consideration .......................... 58 (Acting) Director Penicilliosis ..................................................................... 58 Editor, MMWR Series Leishmaniasis ................................................................. 58 Suzanne M. Hewitt, M.P.A. Paracoccidioidomycosis................................................... 61 Managing Editor, MMWR Series Isosporiasis ..................................................................... 62 Chagas Disease .............................................................. 63 C. Kay Smith-Akin, M.Ed. References......................................................................... 65 Lead Technical Writer/Editor Tables ................................................................................ 86 David C. Johnson Project Editor Disclosure of Relationship Beverly J. Holland CDC, our planners, and our content specialists wish to disclose Lead Visual Information Specialist they have no financial interests or other relationships with the manufactures of commercial products, suppliers of commercial Lynda G. Cupell services, or commercial supporters. This report does not include Malbea A. LaPete any discussion of a product under investigational use. However, Visual Information Specialists this report does contain discussion of certain drugs indicated for Kim L. Bright, M.B.A. use in a nonlabeled manner and that are not Food and Drug Quang M. Doan, M.B.A. Administration (FDA) approved for such use. Each drug used in a Erica R. Shaver nonlabeled manner is identified in the text. Information included Information Technology Specialists in these guidelines might not represent FDA approval or approved labeling for the particular products or indications being discussed. * Proposed. Specifically, the terms safe and effective might not be synonymous with the FDA-defined legal standards for product approval. Vol. 53 / RR-15 Recommendations and Reports 1 Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America Prepared by Constance A. Benson, M.D.1 Jonathan E. Kaplan M.D.2 Henry Masur, M.D.3 Alice Pau, Pharm.D.3 King K. Holmes, M.D.4 1University of Colorado Health Sciences Center, Denver, Colorado 2CDC, Atlanta, Georgia 3National Institutes of Health, Bethesda, Maryland 4University of Washington, Seattle, Washington Summary The National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, and CDC have developed guidelines for treatment of opportunistic infections (OIs) among adults and adolescents infected with human immuno- deficiency virus (HIV). These guidelines are intended for clinicians and other health-care providers who care for HIV-infected adults and adolescents, including pregnant women; they complement companion guidelines for treatment of OIs among HIV- infected children and previously published guidelines for prevention of OIs in these populations. They include evidence-based guidelines for treatment of 28 OIs caused by protozoa, bacteria, fungi, and viruses, including certain OIs endemic in other parts of the world but that might be observed in patients in the United States. Each OI section includes information on epidemiology, clinical manifestations, diagnosis, treatment recommendations, monitoring and adverse events, management of treatment fail- ure, prevention of recurrence, and special considerations in pregnancy. Tables address drugs and doses, drug toxicities, drug interactions, adjustment of drug doses in persons with reduced renal function, and data about use of drugs in pregnant women. Introduction and interactions of the drugs to treat and prevent OIs has emerged, management strategies have evolved. New drugs have Opportunistic infections (OIs) continue to cause morbidity also become available that occupy important roles in our and mortality in patients with human immunodeficiency virus therapeutic armamentarium. (HIV)-1 infection throughout the world. Potent combination These guidelines and the accompanying guidelines, Treating antiretroviral therapy (ART) has reduced the incidence of OIs Opportunistic Infections Among HIV-Exposed and Infected for certain patients with access to care. However, certain Children, join two previous guidelines, The United States Public patients in the developed and developing world do not have Health Service-Infectious Diseases Society of America Guidelines access to care and have OIs. Other patients do not have a for the Prevention of Opportunistic Infections in Persons Infected sustained response to antiretroviral agents for multiple reasons, with the Human Immunodeficiency Virus and The Department including poor adherence, drug toxicities, drug interactions, of Health and Human Services (DHHS) Guidelines for the Use or initial acquisition of a drug-resistant strain of HIV-1. of Antiretroviral Agents in HIV-Infected Adults and Adolescents. Therefore, OIs will continue to cause substantial morbidity The current guidelines share key features with their companion and mortality in patients with HIV-1 infection. guidelines: The therapy of OIs has changed substantially during the • They are labeled as guidelines, indicating that the recom- AIDS epidemic. As more information about efficacy, toxicity, mendations should be considered in the context of the individual patient situation and the community where The material in this report originated in the Office of the Director, the patient is being managed. National Center