Morbidity and Mortality Weekly Report www.cdc.gov/mmwr Recommendations and Reports September 4, 2009 / Vol. 58 / No. RR-11 Guidelines for the Prevention and Treatment of Opportunistic Infections Among HIV-Exposed and HIV-Infected Children Recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics 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 Coordinating Center for Health Information and Service, Centers for Disease Background ...........................................................................................2 Control and Prevention (CDC), U.S. Department of Health and Opportunistic Infections in HIV-Infected Children in the Era of Potent Human Services, Atlanta, GA 30333. Antiretroviral Therapy .......................................................................2 Suggested Citation: Centers for Disease Control and Prevention. History of the Guidelines ......................................................................3 [Title]. MMWR 2009;58(No. RR-#):[inclusive page numbers]. Why Pediatric Prevention and Treatment Guidelines? .............................3 Diagnosis of HIV Infection and Presumptive Lack of HIV Infection in Centers for Disease Control and Prevention Children with Perinatal HIV Exposure ..................................................4 Thomas R. Frieden, MD, MPH Antiretroviral Therapy and Management of Opportunistic Infections ........5 Director Preventing Vaccine-Preventable Diseases in HIV-Infected Children Tanja Popovic, MD, PhD and Adolescents ................................................................................7 Chief Science Officer Bacterial Infections .................................................................................8 James W. Stephens, PhD Bacterial Infections, Serious and Recurrent ............................................8 Associate Director for Science Bartonellosis .....................................................................................13 Syphilis ............................................................................................16 Steven L. Solomon, MD Mycobacterial Infections ......................................................................19 Director, Coordinating Center for Health Information and Service Mycobacterium tuberculosis ...............................................................19 Jay M. Bernhardt, PhD, MPH Mycobacterium avium Complex Disease .............................................25 Director, National Center for Health Marketing Fungal Infections ..................................................................................28 Katherine L. Daniel, PhD Aspergillosis .....................................................................................28 Deputy Director, National Center for Health Marketing Candida Infections ............................................................................30 Editorial and Production Staff Coccidioidomycosis ...........................................................................35 Frederic E. Shaw, MD, JD Cryptococcosis ..................................................................................38 Editor, MMWR Series Histoplasmosis ..................................................................................41 Pneumocystis Pneumonia ...................................................................45 Christine G. Casey, MD Parasitic Infections ................................................................................50 Deputy Editor, MMWR Series Cryptosporidiosis/Microsporidiosis ....................................................50 Susan F. Davis, MD Malaria ............................................................................................54 Associate Editor, MMWR Series Toxoplasmosis ...................................................................................58 Teresa F. Rutledge Viral Infections .....................................................................................62 Managing Editor, MMWR Series Cytomegalovirus ...............................................................................62 David C. Johnson Hepatitis B Virus ................................................................................68 (Acting) Lead Technical Writer-Editor Hepatitis C Virus ...............................................................................75 Karen L. Foster, MA Human Herpesvirus 6 and 7 ..............................................................80 Project Editor Human Herpesvirus 8 Disease ............................................................82 Martha F. Boyd Herpes Simplex Virus ........................................................................84 Lead Visual Information Specialist Human Papillomavirus ......................................................................88 Malbea A. LaPete Progressive Multifocal Leukodystrophy ................................................93 Stephen R. Spriggs Varicella-Zoster Virus ........................................................................94 Terraye M. Starr References ...........................................................................................99 Visual Information Specialists Tables ................................................................................................127 Figures ..............................................................................................161 Kim L. Bright Abbreviations and Acronyms ..............................................................165 Quang M. Doan, MBA Phyllis H. King Continuing Education Activity .............................................................CE-1 Information Technology Specialists Editorial Board Disclosure of Relationship William L. Roper, MD, MPH, Chapel Hill, NC, Chairman CDC, our planners, and our content specialists wish to disclose they have no financial Virginia A. Caine, MD, Indianapolis, IN interests or other relationships with the manufactures of commercial products, suppli- Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA ers of commercial services, or commercial supporters, with the exception of Kenneth David W. Fleming, MD, Seattle, WA Dominguez, who serves on Advisory Board for Committee on Pediatric AIDS (COPD) – William E. Halperin, MD, DrPH, MPH, Newark, NJ Academy of Pediatrics and Kendel International, Inc. antiretroviral Pregnancy Registry King K. Holmes, MD, PhD, Seattle, WA and Peter Havens serves on the Advisory board for Abbott Laboratories, Grant Co. Deborah Holtzman, PhD, Atlanta, GA Investigator for Gilead, Merck, and Bristrol-Myers Squibb as well as a Grant Recipient John K. Iglehart, Bethesda, MD for BI, GlaxoSmithKline, Pfizer, Tibotec and Orthobiotech. This report contains Dennis G. Maki, MD, Madison, WI discussion of certain drugs indicated for use in a non-labeled manner and that are not Sue Mallonee, MPH, Oklahoma City, OK Food and Drug Administration (FDA) approved for such use. Each drug used in a Patricia Quinlisk, MD, MPH, Des Moines, IA non-labeled manner is identified in the text. Information included in these guidelines Patrick L. Remington, MD, MPH, Madison, WI might not represent FDA approval or approved labeling for the particular products Barbara K. Rimer, DrPH, Chapel Hill, NC or indications being discussed. Specifically, the terms safe and effective might not be John V. Rullan, MD, MPH, San Juan, PR synonymous with the FDA-defined legal standards for product approval. These are William Schaffner, MD, Nashville, TN pediatric guidelines, and many drugs, while approved for us in adults, do not have a Anne Schuchat, MD, Atlanta, GA specific pediatric indication. Thus, many sections of the guidelines provide information Dixie E. Snider, MD, MPH, Atlanta, GA about drugs commonly used to treat specific infections and are FDA approved, but do John W. Ward, MD, Atlanta, GA not have a pediatric-specific indication. Vol. 58 / RR-11 Recommendations and Reports 1 Guidelines for the Prevention and Treatment of Opportunistic Infections Among HIV-Exposed and HIV-Infected Children Recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics Prepared by Lynne M. Mofenson, MD1 Michael T. Brady, MD2 Susie P. Danner3 Kenneth L. Dominguez, MD, MPH3 Rohan Hazra, MD1 Edward Handelsman, MD1 Peter Havens, MD4 Steve Nesheim, MD3 Jennifer S. Read, MD, MS, MPH, DTM&H1 Leslie Serchuck, MD1 Russell Van Dyke, MD5 1National Institutes of Health, Bethesda, Maryland 2Nationwide Children’s Hospital, Columbus, Ohio 3Centers from Disease Control and Prevention, Atlanta, Georgia 4Childrens Hospital of Wisconsin, Milwaukee, Wisconsin 5Tulane University School of Medicine, New Orleans, Louisiana Summary This report updates and combines into one document earlier versions of guidelines for preventing and treating opportunistic infections (OIs) among HIV-exposed and HIV-infected children, last published in 2002 and 2004, respectively. These guidelines are intended for use by clinicians and other health-care workers providing medical care for HIV-exposed and HIV-infected chil- dren in the United States. The guidelines discuss opportunistic pathogens that occur in the United States