Sandbox ammu

• HIV/AIDS
• 1. Antiretroviral regimen options for treatment-naive patients

• 1.1. Integrase strand transfer inhibitor-based regimens

• Preferred regimen (1): Dolutegravir 50 mg PO qd AND Abacavir 600 mg-Lamivudine 300 mg PO qd in patients who are HLA-B*5701-negative
• Preferred regimen (2): Dolutegravir 50 mg PO qd AND Tenofovir 300 mg-Emtricitabine 200 mg PO qd
• Preferred regimen (3): Elvitegravir 150 mg-Cobicistat 150 mg-Tenofovir 300 mg-Emtricitabine 200 mg PO qd in patients with estimated CrCl ≥ 70 mL/min/1.73
• Preferred regimen (4): Raltegravir 400 mg PO bid AND Tenofovir 300 mg-Emtricitabine 200 mg PO qd
• Alternative regimen (1): Efavirenz 600 mg PO qd OR Tenofovir 300 mg-Emtricitabine 200 mg PO qd
• Alternative regimen (2): Rilpivirine 25 mg PO qd AND (Tenofovir 300 mg PO qd OR Emtricitabine 200 mg PO qd) for patients with CD4 count >200 cells/microL
• Alternative regimen (3): Raltegravir 400 mg PO bid AND (Abacavir 600 mg PO qd OR Lamivudine 300 mg PO qd) in patients who are HLA-B*5701-negative

• 1.2. Protease inhibitor-based regimen

• Preferred regimen: Darunavir 800 mg-Ritonavir 100 mg PO qd AND Tenofovir 300 mg-Emtricitabine 200 mg PO qd
• Alternative regimen (1): Atazanavir 300 mg-Cobicistat 150 mg PO qd AND Tenofovir disoproxil fumarate 300 mg-Emtricitabine 200 mg PO qd only for patients with pre-treatment estimated CrCl ≥70 mL/min
• Alternative regimen (2): Atazanavir 300 mg-Ritonavir 100 mg PO qd AND Tenofovir 300 mg-Emtricitabine 200 mg PO qd
• Alternative regimen (3): (Darunavir 800 mg-Cobicistat 150 mg PO qd OR Darunavir 800 mg-Ritonavir 100 mg PO qd) AND Abacavir 600 mg-Lamivudine 300 mg PO qd only for patients who are HLA-B*5701 negative
• Alternative regimen (4): Darunavir 800 mg-Cobicistat 150 mg PO qd AND Tenofovir disoproxil fumarate 300 mg-Emtricitabine 200 mg PO qd only for patients with pre-treatment estimated CrCl ≥70 mL/min
• Alternative regimen (5): Atazanavir 300 mg-Ritonavir 100 mg PO qd AND Abacavir 600 mg-Lamivudine 300 mg PO qd in patients who are HLA-B*5701-negative and with pre-treatment HIV RNA <100,000 copies/mL
• Alternative regimen (6): Lopinavir 400 mg-Ritonavir 100 mg PO qd or bid AND Abacavir 600 mg-Lamivudine 300 mg PO qd only for patients who are HLA-B*5701 negative
• Alternative regimen (7): Lopinavir 400 mg-Ritonavir 100 mg PO qd or bid AND Tenofovir disoproxil fumarate 300 mg-Emtricitabine 200 mg PO qd

• 1.3. A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen

• Alternative regimen (1): Efavirenz 600 mg-Tenofovir 300 mg-Emtricitabine 200 mg PO qd
• Alternative regimen (2): Rilpivirine 25 mg-Tenofovir 300 mg-Emtricitabine 200 mg PO qd

• 1.4. Other regimen options

• 1.4.1. A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen

• Preferred regimen (1): Efavirenz 600 mg PO qd AND Abacavir 600 mg-Lamivudine 300 mg PO qd only for patients who are HLA-B*5701 negative and with pre-treatment HIV RNA <100,000 copies/mL.

• 1.4.2. Other regimens when tenofovir or abacavir cannot be used

• Preferred regimen (1): Darunavir 800 mg-Ritonavir 100 mg PO qd AND Raltegravir 400 mg PO qd only for patients with pre-treatment HIV RNA <100,000 copies/mL and CD4 cell count >200 cells/mm3.
• Preferred regimen (2): Lopinavir 400 mg-Ritonavir 100 mg PO bid AND Lamivudine 300 mg PO bid

• 1.5. Pediatric doses

• Abacavir 300 mg PO bid
• Lamivudine 4 mg/kg/dose PO bid; maximum 150 mg PO bid
• Stavudine 1 mg/kg/dose PO bid
• Tenofovir 8 mg/kg/dose PO bid
• Zidovudine 180-240 mg/m²/dose PO bid or 160 mg/m²/dose PO tid (range 90 mg/m²/dose-180 mg/m²/dose)
• Lopinavir 400 mg PO bid
• Nelfinavir 50 mg/kg/dose PO bid
• Raltegravir 300 mg PO bid
• Didanosine

• 20 to < 25 kg: 200 mg PO qd
• 25 to < 60 kg: 250 mg PO qd
• ≥60 kg: 400 mg PO qd

• Efavirenz

• 10 to < 15 kg: 200 mg PO qd
• 15 to <20 kg: 250 mg PO qd
• 20 to < 25 kg: 300 mg PO qd
• 25 to < 32.5 kg: 350 mg PO qd
• 32.5 to <40 kg: 400 mg PO qd
• ≥ 40 kg: 600 mg PO qd

• Nevirapine maximum 200 mg per dose

• Between 1 day and 8 years: 200 mg/m²/dose PO qd for 14 days, then 200 mg/m²/dose PO bid
• 8 years and above: 120-150 mg/m²/dose PO qd for 14 days, then 120-150 mg/m²/dose PO bid

• Note (1): Anti retroviral therapy for treatment naive patients is a life long therapy.
• Note (2): Tenofovir disoproxil fumarate should be avoided in patients with a creatinine clearance <50 mL/min.
• Note (3): Rilpivirine should be used in patients with a CD4 cell count >200 copies/mL and should not be used with proton pump inhibitors.
• Note (4): Efavirenz should not be used in pregnant women.

• 2. Pre-exposure prophylaxis (PrEP)

• Preferred regimen: Tenofovir disoproxil fumarate 300 mg-Emtricitabine 200 mg PO qd for ≤90-days
• Note (1): People with high risk behavior such as men who have sex with men, intravenous drug abusers, HIV-positive sexual partner, recent bacterial STI, high number of sex partners, history of inconsistent or no condom use, commercial sex work, people in high-prevalence area or network are advised to take pre-exposure prophylaxis of drugs.
• Note (2): Follow-up visits at least every 3 months to provide the following: HIV test, medication adherence counseling, behavioral risk reduction support, side effect assessment, STI symptom assessment, pregnancy testing.
• Note (3): At 3 months and every 6 months thereafter, assess renal function.
• Note (4): Every 6 months, test for bacterial STIs.

• 3. Post- exposure prophylaxis

• Preferred regimen: Raltegravir 400 mg PO bid AND Tenofovir disoproxil fumarate 300 mg-Emtricitabine 200 mg PO qd
• Preferred basic regimen for low-risk exposures (Eg: mucus membrane):
  • Zidovudine 100 mg PO qd AND Lamivudine 300 mg PO qd
  • Zidovudine 100 mg PO qd AND Emtricitabine 200 mg PO qd
  • Tenofovir 300 mg PO qd AND Lamivudine 300 mg PO qd
  • Tenofovir 300 mg PO qd AND Emtricitabine 200 mg PO qd
• Preferred expanded regimen for high-risk exposure (Eg: percutaneous needle stick)
  • Zidovudine 100 mg PO qd AND Lamivudine 300 mg PO qd AND Lopinavir 400 mg-Ritonavir 100 mg PO qd
  • Zidovudine 100 mg PO qd AND Emtricitabine 200 mg PO qd AND Lopinavir 400 mg-Ritonavir 100 mg PO qd
  • Tenofovir 300 mg PO qd AND Lamivudine 300 mg PO qd AND Lopinavir 400 mg-Ritonavir 100 mg PO qd
  • Tenofovir 300 mg PO qd AND Emtricitabine 200 mg PO qdAND Lopinavir 400 mg-Ritonavir 100 mg PO qd
• Note: Ideally therapy should be started within hours of exposure and continued for 28 days.

• 4. Perinatal antiretroviral regimen

• 4.1. Antepartum

• 4.1.1. Protease inhibitor-based regimen

• Preferred regimen: (Tenofovir 300 mg-Emtricitabine 200 mg PO qd (fixed dose combination) OR Tenofovir 300 mg-Lamivudine 300 mg PO qd OR Abacavir 600 mg-Lamivudine 300 mg PO qd OR Zidovudine 100 mg-Lamivudine 300 mg PO qd) AND (Atazanavir 300 mg-Ritonavir 100 mg PO qd OR Lopinavir 400 mg-Ritonavir 100 mg PO qd)

• 4.1.2. A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen:

• Preferred regimen (1): Efavirenz 600 mg-Tenofovir 300 mg-Emtricitabine 200 mg (fixed dose combination) PO qd
• Preferred regimen (2): Efavirenz 600 mg-Tenofovir 300 mg-Lamivudine 300 mg PO qd
• Alternative regimen: (Abacavir 600 mg-Lamivudine 300 mg PO qd OR Zidovudine 100 mg-Lamivudine 300 mg PO qd) AND Efavirenz 600 mg PO qd

• 4.2. Intrapartum

• Note (1): HIV RNA <1000 copies/mL and good adherance-Continue the regimen during delivery or cessarean section.
• Note (2): HIV RNA >1000 copies/mL near delivery, possible poor adherence, or unknown HIV RNA levels- Intravenous Zidovudine 2 mg/kg IV over 1 hr should be given three hours before cesarean section or delivery and then 1 mg/kg/hr IV continuous infusion until umbilical cord clamping.

• 4.3. Postpartum

• Note: Initiate anti retroviral therapy (ART) and continue after delivery and cessation of breastfeeding.

• 5. Infant antiretroviral prophylaxis for prevention of mother-to-child transmission of HIV

• 5.1 Prophylaxis for HIV-exposed infants of women who received antepartum antiretroviral prophylaxis

• Preferred regimen: Zidovudine (ZDV) 100 mg PO given at birth and continued till six weeks
• Note (1): Dose based on gestational age at birth and weight, initiated as soon after birth as possible and preferably within 6 to 12 hours of delivery.
• Note (2): ≥35 weeks gestation at birth: 4 mg/kg/dose orally (or, if unable to tolerate oral agents, 3 mg/kg/dose IV) every 12 hours.
• Note (3): ≥30 to <35 weeks gestation at birth: 2 mg/kg/dose orally (or 1.5 mg/kg/dose IV) every 12 hours, advanced to 3 mg/kg/dose orally (or 2.3 mg/kg/dose IV) every 12 hours at age 15 days.
• Note (4): <30 weeks gestation at birth: 2 mg/kg/dose orally (or 1.5 mg/kg/dose IV) every 12 hours, advanced to 3 mg/kg/dose orally (or 2.3 mg/kg/dose IV) every 12 hours after age four weeks.

• 5.2. Prophylaxis for HIV-exposed infants of women who received no antepartum antiretroviral prophylaxis

Nevirapine

• Dose based on birth weight, initiated as soon after birth as possible.
• Birth weight 1.5 to 2 kg: 8 mg/dose orally.
• Birth weight >2 kg: 12 mg/dose orally.

AND

Zidovudine (ZDV)

• Dose based on gestational age at birth and weight, initiated as soon after birth as possible and preferably within 6 to 12 hours of delivery.

• ≥35 weeks gestation at birth: 4 mg/kg/dose orally (or, if unable to tolerate oral agents, 3 mg/kg/dose IV) every 12 hours.
• ≥30 to <35 weeks gestation at birth: 2 mg/kg/dose orally (or 1.5 mg/kg/dose IV) every 12 hours, advanced to 3 mg/kg/dose orally (or 2.3 mg/kg/dose IV) every 12 hours at age 15 days.
• <30 weeks gestation at birth: 2 mg/kg/dose orally (or 1.5 mg/kg/dose IV) every 12 hours, advanced to 3 mg/kg/dose orally (or 2.3 mg/kg/dose IV) every 12 hours after age four weeks.

• Note (1): Three doses in the first week of life.
• Note (2): First dose within 48 hours of birth (birth to 48 hrs).
• Note (3): Second dose 48 hours after first.
• Note (4): Third dose 96 hours after second.

• 6. Treatment and prevention of opportunistic infections

• 6.1. Pneumocystis pneumonia (PCP)

• 6.1.1. Prevention

• Indication

• CD4 count <200 cells/mm3
• Oropharyngeal candidiasis
• CD4 <14%
• History of AIDS-defining illness
• CD4 count >200 but <250 cells/mm3 if monitoring CD4 cell count every 3 months is not possible.

• Preferred regimen: Trimethoprim/sulfamethoxazole 160 mg/800 mg PO qd or 80 mg/400 mg PO qd
• Alternative regimen (1): Trimethoprim/sulfamethoxazole 160 mg/800 mg PO three times weekly
• Alternative regimen (2): Dapsone 100 mg PO qd or 50 mg PO bid
• Alternative regimen (3): Dapsone 50 mg PO qd AND (Pyrimethamine 50 mg-Leucovorin 25 mg) PO weekly
• Alternative regimen (4): Dapsone 200 mg PO qd AND (Pyrimethamine 75 mg-Leucovorin 25 mg) PO weekly
• Alternative regimen (5): Aerosolized Pentamidine 300 mg via Respigard nebulizer every month
• Alternative regimen (6): Atovaquone 1500 mg PO qd
• Alternative regimen (7): Atovaquone 1500 mg AND (Pyrimethamine 25 mg AND Leucovorin 10 mg) PO qd

• 6.1.2. Treatment

• 6.1.2.1. For Moderate-to-Severe PCP'

• Preferred regimen: Trimethoprim 15–20 mg AND Sulfamethoxazole 75–100 mg/kg/day IV given q6h or q8h, may switch to PO after clinical improvement
• Alternative regimen (1): Pentamidine 4 mg/kg IV daily infused over ≥60 minutes
• Note: Reduce dose to 3 mg/kg IV daily if toxic.
• Alternative regimen (2): Primaquine 30 mg (base) PO qd AND (Clindamycin 600 mg q6h IV OR 900 mg IV q8h OR Clindamycin 450 mg PO qid or 600 mg PO tid)

• 6.1.2.2. For Mild-to-Moderate PCP

• Preferred regimen: Trimethoprim 15–20 mg AND Sulfamethoxazole 75–100 mg/kg/day PO in TID OR Trimethoprim/sulfamethoxazole 160 mg/800 mg 2 tablets PO tid
• Alternative regimen (1): Dapsone 100 mg PO qd AND TMP 5 mg/kg PO tid
• Alternative regimen (2): Primaquine 30 mg (base) PO qd AND (Clindamycin 450 mg PO qid or 600 mg PO tid OR Atovaquone 750 mg PO bid with food)

• 6.1.3. Secondary prophylaxis, after completion of PCP treatment

• Preferred regimen (1): Trimethoprim/Sulfamethoxazole 160 mg/800 mg PO qd OR Trimethoprim/Sulfamethoxazole 80 mg/400 mg PO qd
• Alternative regimen (1): Trimethoprim/sulfamethoxazole 160 mg/800 mg PO three times weekly
• Alternative regimen (2): Dapsone 100 mg PO qd
• Alternative regimen (3): Dapsone 50 mg PO qd AND Pyrimethamine 50 mg PO AND Leucovorin 25 mg PO weekly
• Alternative regimen (4): Dapsone 200 mg PO AND Pyrimethamine 75 mg PO AND Leucovorin 25 mg PO weekly
• Alternative regimen (5): Dapsone 100 mg PO qd
• Alternative regimen (6): Dapsone 50 mg PO qd AND Pyrimethamine 50 mg PO AND Leucovorin 25 mg PO weekly
• Alternative regimen (7): Dapsone 200 mg PO AND Pyrimethamine 75 mg PO AND Leucovorin 25 mg PO weekly
• Alternative regimen (8): Aerosolized Pentamidine 300 mg monthly via Respirgard nebulizer
• Alternative regimen (9): Atovaquone 1500 mg PO qd
• Alternative regimen (10): Atovaquone 1500 mg PO AND Pyrimethamine 25 mg PO AND Leucovorin 10 mg PO qd

• 6.1.4. Adjunctive corticosteroids

• Indications- PaO2 <70 mmHg at room air OR Alveolar-arterial O2 gradient >35 mmHg.
• Preferred regimen:

• Days 1–5: 40 mg PO bid
• Days 6–10: 40 mg PO qd
• Days 11–21: 20 mg PO qd

• Note (1): Trimethoprim/sulfamethoxazole should be permanently discontinued in patients with possible or definite stevens johnson syndrome or toxic epidermal necrosis.
• Note (2): Whenever possible, patients should be tested for G6PD before use of Dapsone or Primaquine. Alternative regimen should be used in patients found to have G6PD deficiency.

• 6.2. Toxoplasma gondii encephalitis

• 6.2.1. Prevention

• 6.2.1.1. Indication

• Toxoplasma IgG-positive patients with CD4 count <100 cells/µL.
• Seronegative patients receiving PCP prophylaxis not active against toxoplasmosis should have toxoplasma serology retested if CD4 count decline to <100 cellsµL.
• Prophylaxis should be initiated if seroconversion occurred.

• Preferred regimen: Trimethoprim/sulfamethoxazole 160 mg/800 mg PO qd
• Alternative regimen (1): Trimethoprim/sulfamethoxazole 160 mg/800 mg PO three times weekly
• Alternative regimen (2): Trimethoprim/sulfamethoxazole 80 mg/400 mg PO qd
• Alternative regimen (3): Dapsone 50 mg PO qd AND Pyrimethamine 50 mg PO weekly AND Leucovorin 25 mg PO weekly
• Alternative regimen (4): Dapsone 200 mg PO weekly AND Pyrimethamine 75 mg PO weekly AND Leucovorin 25 mg PO weekly
• Alternative regimen (5): Atovaquone 1500 mg PO qd
• Alternative regimen (6): Atovaquone 1500 mg PO qd AND Pyrimethamine 25 mg PO qd AND Leucovorin 10 mg PO qd

• 6.2.2. Treatment

• 6.2.2.1. Treatment of acute infection

• Preferred regimen: Pyrimethamine 200 mg PO single dose, followed by weight-based therapy:

• If <60 kg, Pyrimethamine 50 mg PO qd AND Sulfadiazine 1000 mg PO qid AND Leucovorin 10–25 mg PO qd
• If ≥60 kg, Pyrimethamine 75 mg PO qd AND Sulfadiazine 1500 mg PO qid AND Leucovorin 10–25 mg PO qd
• Note: At least 6 weeks; longer duration if clinical or radiologic disease is extensive or response is incomplete at 6 weeks.

• Alternative regimen (1): Pyrimethamine 50 mg PO qdAND Leucovorin 10–25 mg PO qd AND Clindamycin 600 mg IV or PO q6h
• Alternative regimen (2): Trimethoprim 5 mg/kg-Sulfamethoxazole 25 mg/kg IV or PO bid
• Alternative regimen (3): Atovaquone 1500 mg PO bid with food AND Pyrimethamine 50 mg PO qd AND Leucovorin 10–25 mg PO qd
• Alternative regimen (4): Atovaquone 1500 mg PO bid with food AND Sulfadiazine 1000–1500 mg PO qid (weight-based dosing, as in preferred therapy)
• Alternative regimen (5): Atovaquone 1500 mg PO bid with food
• Alternative regimen (6): Pyrimethamine 50 mg-Leucovorin 10–25 mg PO qd AND Azithromycin 900–1200 mg PO qd

• 6.2.2.2. Chronic maintenance therapy

• Preferred regimen: Pyrimethamine 25–50 mg PO qd AND Sulfadiazine 2000–4000 mg PO qd (in 2–4 divided doses) AND Leucovorin 10–25 mg PO qd
• Alternative regimen (1): Clindamycin 600 mg PO tid AND Pyrimethamine 25–50 mg-Leucovorin 10–25 mg PO qd
• Alternative regimen (2): Trimethoprim/sulfamethoxazole 160 mg/800 mg bid
• Alternative regimen (3): Atovaquone 750–1500 mg PO bid AND Pyrimethamine 25 mg-Leucovorin 10 mg PO qd
• Alternative regimen (4): Atovaquone 750–1500 mg PO bid AND Sulfadiazine 2000–4000 mg PO qd in 2–4 divided doses
• Alternative regimen (5): Atovaquone 750–1500 mg PO bid with food

• 6.3. Mycobacterium tuberculosis infection

• 6.3.1. Prevention

• 6.3.1.1. Indication

• Positive screening test for latent tuberculosis infection, with no evidence of active tuberculosis, and no prior treatment for active tuberculosis or latent tuberculosis infection.
• Close contact with a person with infectious tuberculosis, with no evidence of active tuberculosis, regardless of screening test results.
• Preferred regimen: (Isoniazid 300 mg PO qd AND Pyridoxine 25 mg PO qd for 9 months) OR (Isoniazid 900 mg PO two times a week (by DOT) AND Pyridoxine 25 mg PO qd for 9 months)
• Alternative regimen (1): Rifampin 600 mg PO qd for 4 months
• Alternative regimen (2): Rifabutin (dose adjusted based on concomitant ART) PO qd for 4 months

• 6.3.2. Treatment

• Preferred regimen

• Initiation phase: Isoniazid 300 mg PO qd AND (Rifampin 600 mg PO qd OR Rifabutin 300 mg PO qd) AND Pyrazinamide (upto 2000 mg) PO qd AND Ethambutol (upto 1600 mg) PO qd for initial phase for 2 months.

• Continuation phase: Isoniazid 300 mg PO qd AND (Rifampin 600 mg PO qd OR Rifabutin 300 mg PO qd) (5–7 times/week) or three times a week.
• Duration of therapy:

• Pulmonary tuberculosis: 6 months
• Pulmonary tuberculosis and culture positive after 2 months of tuberculosis treatment: 9 months
• Extra-pulmonary tuberculosis w/CNS infection: 9–12 months
• Extra-pulmonary tuberculosis with bone or joint involvement: 6 to 9 months
• Extra-pulmonary tuberculosis in other sites: 6 months
• Total duration of therapy should be based on number of doses received, not on calendar time

• 6.3.1.3. Treatment for drug-resistant tuberculosis

• Resistant to Isoniazid:

• Preferred regimen (1): (Rifampin 600 mg PO qd OR Rifabutin 300mg PO qd) AND Ethambutol (upto 1600 mg) PO qd AND Pyrazinamide (upto 2000 mg) PO qd AND (Moxifloxacin 400 mg PO or IV qd OR Levofloxacin 500-1000 mg PO or IV qd) for 2 months; followed by Rifampin 600 mg PO qd for 7 months.
• Preferred regimen (2): Rifabutin 300mg PO qd AND Ethambutol (upto 1600 mg) PO qd AND (Moxifloxacin 400 mg PO or IV qdOR Levofloxacin 500-1000 mg PO or IV qd) for 7 months

• 6.4. Disseminated mycobacterium avium complex (MAC) disease

• 6.4.1. Prevention

• 6.4.1.1. Indication-CD4 count <50 cells/µL—after ruling out active disseminated MAC disease based on clinical assessment

• Preferred regimen (1): Azithromycin 1200 mg PO once weekly
• Preferred regimen (2): Clarithromycin 500 mg PO bid
• Preferred regimen (3): Azithromycin 600 mg PO twice weekly.

• 6.4.2. Treatment

• Preferred regimen: Clarithromycin 500 mg PO bid AND Ethambutol 15 mg/kg PO qd OR Azithromycin 500–600 mg PO qd for at least 12 months of therapy
• Note (1): Treatment can be discontinued if no signs and symptoms of MAC disease and sustained (>6 months) CD4 count >100 cells/µL in response to anti retroviral therapy.
• Note (2): Addition of a third or fourth drug should be considered for patients with advanced immunosuppression (CD4 counts <50 cells/µL), high mycobacterial loads (>2 log CFU/mL of blood), or in the absence of effective anti retroviral therapy which include Amikacin 10–15 mg/kg IV qd, Streptomycin 1 g IV or IM qd, Moxifloxacin 400 mg PO qd, Levofloxacin 500 mg PO qd.

• 6.5. Streptococcus pneumoniae infection

• 6.5.1. Prevention

• 6.5.1.1. Indication

• 6.5.1.1.1. For individuals who have not received any pneumococcal vaccine, regardless of CD4 count

• Preferred regimen: PCV13 0.5ml IM single dose
• Alternative regimen: PPV23 0.5 mL IM or SQ single dose
• Note (1): If CD4 count ≥200 cells/µL, administer PPV23 0.5 mL IM or SQ at least 8 weeks after the PCV13 vaccine.
• Note (2): If CD4 count <200 cells/µL, PPV23 can be offered at least 8 weeks after receiving PCV13 or can wait until CD4 count increased to ≥200 cells/µL.

• 6.5.1.1.2. For individuals who have previously received PPV23

• Note: One dose of PCV13 should be given atleast 1 year after the last receipt of PPV23

• 6.5.1.1.3. Re-vaccination

• If age 19–64 years and ≥5 years since the first PPV23 dose PPV23 0.5 mL IM or SQ
• If age ≥65 years, and if ≥5 years since the previous PPV23 dose PPV23 0.5 mL IM or SQ
• If age ≥65 years, and if ≥5 years since the previous PPV23 dose PPV23 0.5 mL IM or SQ

• 6.6. Influenza A and B virus infection

• 6.6.1. Prevention

• 6.6.1.1. Indication

• All HIV-infected patients
• Note (1): Inactivated influenza vaccine annually (per recommendation for the season).
• Note (2): Live-attenuated influenza vaccine is contraindicated in HIV-infected patients.

• 6.7. Syphilis

• 6.7.1. Prevention

• 6.7.1.1. Indication

• For individuals exposed to a sex partner with a diagnosis of primary, secondary, or early latent syphilis within past 90 days.
• For individuals exposed to a sex partner >90 days before syphilis diagnosis in the partner, if serologic test results are not available immediately and the opportunity for follow-up is uncertain.
• Preferred regimen: Benzathine penicillin G 2.4 million units IM single dose
• Alternative regimen (1): Doxycycline 100 mg PO bid for 14 days
• Alternative regimen (2): Ceftriaxone 1 g IM or IV q24h for 8– 10 days
• Alternative regimen (3): Azithromycin 2 g PO single dose
• Note: Azithromycin is not recommended for MSM or pregnant women.

• 6.7.2. Treatment

• 6.7.2.1. Early stage (primary, secondary, and early-latent syphilis)

• Preferred regimen: Benzathine penicillin G 2.4 million units IM single dose
• Alternative regimen (1): Doxycycline 100 mg PO bid for 14 days
• Alternative regimen (2): Ceftriaxone 1 g IM or IV q24h for 10–14 days
• Alternative regimen (3): Azithromycin 2 g PO single dose

• 6.7.2.2. Late-stage (tertiary–cardiovascular or gummatous disease)

• Preferred regimen: Benzathine penicillin G 2.4 million units IM weekly for 3 doses
• Alternative regimen: Doxycycline 100 mg PO bid for 28 days

• 6.7.2.3. Neurosyphilis (including otic or ocular disease)

• Preferred regimen: Aqueous crystalline Penicillin G 18– 24 million units per day (administered as 3–4 million units IV q4h or by continuous IV infusion) for 10–14 days with or without Benzathine penicillin G 2.4 million units IM weekly for 3 doses after completion of IV therapy
• Alternative regimen: Procaine penicillin 2.4 million units IM q24h AND Probenecid 500 mg PO qid for 10–14 days with or without Benzathine penicillin G 2.4 million units IM weekly for 3 doses after completion
• Note (1): The Jarisch-Herxheimer reaction is an acute febrile reaction accompanied by headache and myalgia that can occur within the first 24 hours after therapy for syphilis.
• Note (2): This reaction occurs most frequently in patients with early syphilis, high nontreponemal titers and prior penicillin treatment.

• 6.8. Histoplasma capsulatum infection

• 6.8.1. Prevention

• 6.8.1.1. Indication

• CD4 count ≤150 cells/µL and at high risk because of occupational exposure or live in a community with a hyperendemic rate of histoplasmosis (>10 cases/100 patient-years).
• Preferred regimen: Itraconazole 200 mg PO qd

• 6.8.2. Treatment

• 6.8.2.1. Moderately severe to severe disseminated disease

• Induction therapy (for at least 2 weeks or until clinically improved)

• Preferred regimen: Liposomal Amphotericin B 3 mg/kg IV q24h

• Maintenance therapy:

• Preferred regimen: Itraconazole 200 mg PO tid for 3 days, then 200 mg PO bid

• 6.8.2.2. Less severe disseminated disease

• Induction therapy:

• Preferred regimen: Liposomal Amphotericin B 3 mg/kg IV q24h
• Alternative regimen: Amphotericin B lipid complex 3 mg/kg IV q24h OR Amphotericin B cholesteryl sulfate complete 3 mg/kg IV q24h
• Note: Induction therapy should be for at least 2 weeks or until clinically improved.

• Maintenance therapy:

• Preferred regimen: Itraconazole 200 mg PO tid for 3 days and then Itraconazole 200 mg PO bid for 12 months
• Alternative regimen (1): Voriconazole 400 mg PO bid for 1 day, then 200 mg bid
• Alternative regimen (2): Posaconazole 400 mg PO bid
• Alternative regimen (3): Fluconazole 800 mg PO qd

• 6.8.2.3. Meningitis

• Induction therapy:

• Preferred regimen: Liposomal amphotericin B 5 mg/kg/day for 4–6 weeks

• Maintenance therapy:

• Preferred regimen: Itraconazole 200 mg PO bid to tid for ≥1 year

• Note: Treatment continued until resolution of abnormal CSF findings.
• Long-Term Suppression Therapy

• Preferred regimen: Itraconazole 200 mg PO qd
• Alternative regimen: Fluconazole 400 mg PO qd
• Note: Therapeutic drug monitoring and dosage adjustment may be necessary to ensure Triazole antifungal and ARV efficacy and reduce concentration-related toxicities.

• 6.9. Coccidioidomycosis

• 6.9.1. Prevention
• 6.9.1.1. Indication

• A new positive IgM or IgG serologic test in patients who live in a disease-endemic area and with CD4 count <250 cells/µL.
• Preferred regimen: Fluconazole 400 mg PO qd

• 6.9.2. Treatment

• 6.9.2.1. Clinically mild infections (e.g., focal pneumonia)

• Preferred regimen: Fluconazole 400 mg PO qd OR Itraconazole 200 mg PO bid
• Alternative regimen: Posaconazole 200 mg PO bid OR Voriconazole 200 mg PO bid

• 6.9.2.2. Severe, non-meningeal infection (diffuse pulmonary infection or severely ill patients with extrathoracic, disseminated disease)

• Preferred regimen: Amphotericin B deoxycholate 0.7–1.0 mg/kg IV qd OR Lipid formulation Amphotericin B 4–6 mg/kg IV qd
• Alternative regimen: Fluconazole or Itraconazole, with Itraconazole preferred for bone disease 400 mg per day to Amphotericin B therapy and continue triazole once Amphotericin B is stopped.

• 6.9.2.3. Meningeal infections

• Preferred regimen: Fluconazole 400–800 mg IV or PO qd
• Alternative regimen: Itraconazole 200 mg PO tid for 3 days, then 200 mg PO bid OR Posaconazole 200 mg PO bid OR Voriconazole 200–400 mg PO bid

• 6.9.2.4. Chronic suppressive therapy

• Preferred regimen: Fluconazole 400 mg PO qd OR Itraconazole 200 mg PO bid
• Alternative regimen: Posaconazole 200 mg PO bid OR Voriconazole 200 mg PO bid
• Note (1): Therapy should be continued indefinitely in patients with diffuse pulmonary or disseminated diseases because relapse can occur in 25%–33% of HIV-negative patients. It can also occur in HIV-infected patients with CD4 counts >250 cells/µL.
• Note (2): Therapy should be lifelong in patients with meningeal infections because relapse occurs in 80% of HIV-infected patients after discontinuation of triazole therapy.

• 6.10. Herpes simplex virus (HSV) Disease

• 6.10.1. Orolabial lesions (For 5–10 Days)

• Preferred regimen (1): Valacyclovir 1 g PO bid
• Preferred regimen (2): Famciclovir 500 mg PO bid
• Preferred regimen (3): Acyclovir 400 mg PO tid

• 6.10.2. Initial or recurrent genital HSV (For 5–14 Days)

• Preferred regimen (1): Valacyclovir 1 g PO bid
• Preferred regimen (2): Famciclovir 500 mg PO bid
• Preferred regimen (3): Acyclovir 400 mg PO tid

• 6.10.3. Severe mucocutaneous HSV

• Preferred regimen: Initial therapy Acyclovir 5 mg/kg IV q8h.
• Note: After lesions begin to regress, change to PO therapy as above. Continue until lesions are completely healed.

• 6.10.4. Chronic suppressive therapy

• Preferred regimen (1): Valacyclovir 500 mg PO bid
• Preferred regimen (2): Famciclovir 500 mg PO bid
• Preferred regimen (3): Acyclovir 400 mg PO bid

• 6.10.4. For acyclovir-resistant HSV

• Preferred therapy: Foscarnet 80–120 mg/kg/day IV q12h-q8h
• Alternative regimen: Cidofovir IV OR Topical Trifluridine OR Topical Imiquimod for 21-28 days
• Note: Continue indefinitely regardless of CD4 cell count.

• 6.11. Varicella-zoster virus (VZV) infection

• 6.11.1. Varicella-zoster virus (VZV) infection

• 6.11.1.2 Prevention

• 6.11.1.1. Pre-exposure prevention

• Indication: Patients with CD4 counts ≥200 cells/µL who have not been vaccinated, have no history of varicella or herpes zoster, or who are seronegative for VZV.
• Preferred regimen: Primary varicella vaccination, 2 doses (0.5 mL SQ each) administered 3 months apart
• Alternative regimen: VZV-susceptible household contacts of susceptible HIV-infected persons should be vaccinated to prevent potential transmission of VZV to their HIV-infected contacts
• Note (1): Routine VZV serologic testing in HIV-infected adults and adolescents is not recommended.
• Note (2): If vaccination results in disease because of vaccine virus, treatment with Acyclovir is recommended.

• 6.11.1.2. Post-exposure prevention

• Indication: Close contact with a person with chickenpox or herpes zoster; and is susceptible (i.e., no history of vaccination or of either condition, or known to be VZV seronegative).
• Preferred regimen: Varicella-zoster immune globulin (VariZIG™) 125 international units per 10 kg (maximum 625 international units) IM, administered as soon as possible and within 10 days after exposure.
• Alternative regimen (1): Acyclovir 800 mg PO qd for 5– 7 days
• Alternative regimen (2): Valacyclovir 1 g PO tid for 5–7 days
• Note (1): Individuals receiving monthly high-dose IVIG (>400 mg/kg) are likely to be protected if the last dose of IVIG was administered <3 weeks before exposure.
• Note (2): If antiviral therapy is used, varicella vaccines should not be given until at least 72 hours after the last dose of the antiviral drug.

• 6.11.1.2. Treatment

• 6.11.1.2.1 Primary varicella infection (chickenpox)

• 6.11.1.2.1. Uncomplicated cases (For 5–7 Days)

• Preferred regimen (1): Valacyclovir 1 g PO tid
• Preferred regimen (2): Famciclovir 500 mg PO tid

• 6.11.1.2.1. Severe or complicated Cases

• Preferred regimen: Acyclovir 10–15 mg/kg IV q8h for 7–10 days.
• Alternative regimen: Acyclovir 800 mg PO 5 times/day for 5-7 days.

• 6.11.1.2.2. Herpes zoster (Shingles)

• 6.11.1.2.2.1. Acute localized dermatomal

• Preferred regimen (1): Valacyclovir 1 g PO tid for 7–10 days; consider longer duration if lesions are slow to resolve
• Preferred regimen (2): Famciclovir 500 mg tid for 7–10 days; consider longer duration if lesions are slow to resolve

• 6.11.1.2.2.2. Extensive cutaneous lesion or visceral involvement

• Preferred regimen: Acyclovir 10–15 mg/kg IV q8h until clinical improvement is evident.
• Note: Treatment may switch to PO therapy (Valacyclovir, Famciclovir, or Acyclovir) after clinical improvement (i.e., when no new vesicle formation or improvement of signs and symptoms of visceral VZV), to complete a 10–14 day course.
• Alternative regimen: Acyclovir 800 mg PO 5 times/day for 7–10 days; consider longer duration if lesions are slow to resolve.

• 6.11.1.2.2.3. Progressive outer retinal necrosis (PORN)

• Preferred regimen: (Ganciclovir 5 mg/kg with or without Foscarnet 90 mg/kg) IV q12h AND (Ganciclovir 2 mg/0.05mL with or without Foscarnet 1.2 mg/0.05 ml) intravitreal injection biweekly.

• 6.11.1.2.2.4. Acute retinal necrosis (ARN)

• Preferred regimen: Acyclovir 10-15 mg/kg IV q8h AND (Ganciclovir 2 mg/0.05mL intravitreal injection 1-2 doses biweekly for 10-14 days, followed by Valacyclovir 1g PO tid for 6 weeks

• 6.12. Cytomegalovirus (CMV) Disease

• 6.12.1. Treatment

• 6.12.1.1. CMV retinitis

• Induction therapy

• Preferred regimen (1): Ganciclovir 2mg OR Foscarnet 2.4mg intravitreal injections for 1-4 doses over a period of 7-10 days to achieve high intraocular concentration faster
• Preferred regimen (2): Valganciclovir 900 mg PO bid for 14–21 days
• Alternative regimen (1): Ganciclovir 5 mg/kg IV q12h for 14–21 days
• Alternative regimen (2): Foscarnet 90 mg/kg IV q12h or 60 mg/kg q8h for 14–21 days
• Alternative regimen (3): Cidofovir 5 mg/kg/week IV for 2 weeks
• Note: Saline hydration before and after therapy should be given and Probenecid, 2 g PO 3 hours before dose, followed by 1 g PO 2 hours and 8 hours after the dose (total of 4 g) is recommended.

• Chronic maintenance (secondary prophylaxis):

• Preferred regimen: Valganciclovir 900 mg PO qd
• Alternative regimen (1): Ganciclovir 5 mg/kg IV 5–7 times weekly
• Alternative regimen (2): Foscarnet 90–120 mg/kg IV once daily
• Alternative regimen (3): Cidofovir 5 mg/kg/week IV for 2 weeks; saline hydration before and after therapy AND Probenecid, 2 g PO 3 hours before dose, followed by 1 g PO 2 hours and 8 hours after the dose (total of 4 g)

• 6.12.1.2. CMV esophagitis or colitis

• 6.12.1.2.1. Severe condition

• Preferred regimen: Ganciclovir 5 mg/kg IV q12h; may switch to Valganciclovir 900 mg PO bid once the patient can tolerate oral therapy for 21-42 days or till the symptoms are resolved
• Alternative regimen: Foscarnet 90 mg/kg IV q12h or 60 mg/kg q8h for 21-42 days
• Note: For patients with treatment-limiting toxicities to Ganciclovir or with Ganciclovir resistance, above regimen is recommended.

• 6.12.1.2.2. Mild disease and able to tolerate oral therapy

• Preferred regimen: Valganciclovir 900 mg PO bid 21-42 days

• 6.12.1.3. CMV neurological disease

• Preferred regimen: Ganciclovir 5 mg/kg IV q12h AND (Foscarnet 90 mg/kg IV q12h or 60 mg/kg IV q8h) to stabilize disease

• 6.13. HHV-8 Diseases (kaposi sarcoma [KS], primary effusion lymphoma [PEL], multicentric castleman’s disease [MCD])

• 6.13.1. Treatment

• Mild to moderate KS (ACTG Stage T0)

• Note: Initiate or optimize anti retroviral therapy.

• Advanced KS [ACTG Stage T1, Including Disseminated Cutaneous (AI) Or Visceral KS]

• Note: Chemotherapy (per oncology consult) AND anti retroviral therapy.

• Primary effusion lymphoma

• Preferred regimen (1): Valganciclovir 900 mg PO bid for 3 weeks
• Preferred regimen (2): Ganciclovir 5 mg/kg IV q12h for 3 weeks
• Preferred regimen (3): Valganciclovir 900 mg PO bid AND Zidovudine 600 mg PO qid for 7– 21 days
• Alternative regimen: Rituximab (375 mg/m² given weekly for 4–8 weeks) may be an alternative to or used adjunctively with antiviral therapy
• Note: Valganciclovir PO OR Ganciclovir IV can be used as adjunctive therapy

• 6.14. Human papillomavirus (HPV) infection

• 6.14.1. Prevention

• For females aged 13–26 years

• Preferred regimen (1): HPV quadrivalent vaccine 0.5 mL IM at months 0, 1–2, and 6 OR HPV bivalent vaccine 0.5 mL IM at months 0, 1–2, and 6

• Males aged 13–26 years

• Preferred regimen (1): HPV quadrivalent vaccine 0.5 mL IM at months 0, 1–2, and 6

• 6.14.2. Treatment

• 6.14.2.1. Patient-applied therapy for uncomplicated external warts that can be easily identified by patients

• Preferred regimen (1): Podophyllotoxin (e.g., podofilox 0.5% solution or 0.5% gel)
• Note: Apply to all lesions bid for 3 consecutive days, followed by 4 days of no therapy, repeat weekly for up to 4 cycles, until lesions are no longer visible)
• Preferred regimen (2): Imiquimod 5% cream
• Note: Apply to lesion at bedtime and remove in the morning on 3 nonconsecutive nights weekly for up to 16 weeks, until lesions are no longer visible. Each treatment should be washed with soap and water 6–10 hours after application.
• Preferred regimen (3): Sinecatechins 15% ointment
• Note: Apply to affected areas tid for up to 16 weeks, until warts are completely cleared and not visible

• 6.14.2.2. Provider-applied therapy for complex or multicentric lesions, or lesions inaccessible to patient

• Note (1): Cryotherapy (liquid nitrogen or cryoprobe): Apply until each lesion is thoroughly frozen. Repeat every 1–2 weeks for up to 4 weeks, until lesions are no longer visible. Some providers allow the lesion to thaw, then freeze a second time in each session.
• Note (2): Trichloroacetic acid or bichloroacetic acid cauterization: 80%–90% aqueous solution, apply to wart only, allow to dry until a white frost develops. Repeat weekly for up to 6 weeks, until lesions are no longer visible.
• Note (3): Surgical excision or laser surgery to external or anal warts.
• Note (4): Podophyllin resin 10%–25% in tincture of benzoin: Apply to all lesions (up to 10 cm2 ), then wash off a few hours later, repeat weekly for up to 6 weeks until lesions are no longer visible.

• 6.15. Hepatitis A virus (HAV) infection

• 6.15.1. Prevention

• Indication: HAV-susceptible patients with chronic liver disease, or who are injection-drug users or homosexuals
• Preferred regimen: Hepatitis A vaccine 1 mL IM 2 doses at 0 and 6–12 months.
• Alternative regimen: Combined HAV and HBV vaccine 1 mL IM as a 3-dose (0, 1, and 6 months) or 4-dose series (days 0, 7, 21 to 30, and 12 months).
• Note (1): For patients susceptible to both HAV and hepatitis B virus (HBV) infection, alternative regimen is recommended.
• Note (2): IgG antibody response should be assessed 1 month after vaccination; nonresponders should be revaccinated when CD4 count >200 cells/µL.

• 6.16. Hepatitis B virus (HBV) infection

• 6.16.1. Prevention

• 6.16.1.1. Indication

• Patients without chronic HBV or without immunity to HBV (i.e., anti-HBs <10 international units/mL).
• Patients with isolated anti-HBc and negative HBV DNA.
• Early vaccination is recommended before CD4 count falls below 350 cells/µL.
• However, in patients with low CD4 cell counts, vaccination should not be deferred until CD4 count reaches >350 cells/µL, because some patients with CD4 counts <200 cells/µL do respond to vaccination.
• Preferred regimen (1): HBV vaccine IM (Engerix-B 20 µg/mL or Recombivax HB 10 µg/mL), 0, 1, and 6 months
• Preferred regimen (2): HBV vaccine IM (Engerix-B 40 µg/mL or Recombivax HB 20 µg/mL) 0, 1, 2 and 6 months
• Preferred regimen (3): Combined HAV and HBV vaccine, 1 mL IM as a 3-dose (0, 1, and 6 months) or 4-dose series (days 0, 7, 21 to 30, and 12 months)
• Alternative regimen: Some experts recommend vaccinating with 40-µg doses of either HBV vaccine
• Note: Anti-HBs should be obtained 1 month after completion of the vaccine series. Patients with anti-HBs <10 international units/mL at 1 month are considered nonresponders.
• Vaccine Non-Responders:

• Preferred regimen (1): HBV vaccine IM (Engerix-B 40 µg/mL or Recombivax HB 20 µg/mL), 0, 1, 2 and 6 months.
• Note (1): Vaccination non-responders have anti-HBs <10 international units/mL 1 month after vaccination series.
• Note (2): For patients with low CD4 counts at time of first vaccine series, some experts might delay revaccination until after a sustained increase in CD4 count with anti retroviral therapy.

• 6.16.2. Treatment

• Preferred regimen: Tenofovir 300 mg PO qdAND Emtricitabine 200 mg PO qd OR Lamivudine 300 mg PO qd AND additional drug(s) for HIV
• Note: Anti retroviral therapy regimen should include 2 drugs that are active against both HBV and HIV.
• Alternative regimen: Peginterferon alfa-2a 180 μg SQ once weekly for 48 weeks OR Peginterferon alfa 2b 1.5 μg/kg SQ once weekly for 48 weeks.
• Note: For HBV treatment is indicated for patients with elevated ALT and HBV DNA >2,000 IU/mL significant liver fibrosis, advanced liver disease or cirrhosis, above regimen is indicated.

• 6.17. Penicilliosis marneffei

• 6.17.1. Prevention

• 6.17.1.1. Indication

• Patients with CD4 cell counts <100 cells/µL who live or stay for a long period in rural areas in northern Thailand, Vietnam, or Southern China.
• Preferred regimen: Itraconazole 200 mg PO qd
• Alternative regimen: Fluconazole 400 mg PO once weekly

• 6.17.2. Treatment

• 6.17.2.1. For acute infection in severely ill patients

• Preferred regimen: Liposomal amphotericin B 3–5 mg/kg/day IV for 2 weeks, followed by Itraconazole 200 mg PO bid for 10 weeks, followed by chronic maintenance therapy
• Alternative regimen: Voriconazole 6 mg/kg IV q12h for 1 day, then 4 mg/kg IV q12h for at least 3 days, followed by 200 mg PO bid for a maximum of 12 weeks, followed by maintenance therapy

• 6.17.2.2. For mild disease

• Preferred regimen: Itraconazole 200 mg PO bid for 8 weeks; followed by chronic maintenance therapy
• Alternative regimen: Voriconazole 400 mg PO bid for 1 day, then 200 mg bid for a maximum of 12 weeks, followed by chronic maintenance therapy

• 6.17.2.3. Chronic Maintenance Therapy (Secondary Prophylaxis)

• Preferred regimen: Itraconazole 200 mg PO qd
• Note (1): Anti retroviral therapy should be initiated simultaneously with treatment for penicilliosis to improve treatment outcome.
• Note (2): Itraconazole and Voriconazole may have significant interactions with certain ARV agents. These interactions are complex and can be bi-directional.
• Note (3): Therapeutic drug monitoring and dosage adjustment may be necessary to ensure triazole antifungal and ARV efficacy and reduce concentration-related toxicities.

• 6.18. Isosporiasis

• 6.18.1. Treatment

• For Acute Infection:

• Preferred regimen (1): Trimethoprim/Sulfamethoxazole 160 mg/800 mg PO (or IV) qid for 10 days
• Preferred regimen (2): Trimethoprim/Sulfamethoxazole 160 mg/800 mg PO (or IV) bid for 7–10 days
• Alternative regimen (1): Pyrimethamine 50–75 mg PO daily AND Leucovorin 10–25 mg PO qd
• Alternative regimen (2): Ciprofloxacin 500 mg PO bid for 7 days as a second line alternative

• Chronic Maintenance Therapy (Secondary Prophylaxis):

• Preferred regimen (1): In patients with CD4 count <200/µL, Trimethoprim/sulfamethoxazole 160 mg/800 mg PO three times a week
• Alternative regimen (1): Trimethoprim/sulfamethoxazole 160 mg/800 mg PO qd or (320 mg/1600 mg) three times a week
• Alternative regimen (2): Pyrimethamine 25 mg PO qd AND Leucovorin 5–10 mg PO qd
• Alternative regimen (3): Ciprofloxacin 500 mg three times a week as a second-line alternative
• Note (1): Fluid and electrolyte management in patients with dehydration.
• Note (2): Immune reconstitution with anti retroviral therapy may result in fewer relapses.
• Note (3): IV therapy may be used for patients with potential or documented mal-absorption.

• 6.19. Chagas disease (American trypanosomiasis)

• 6.19.1. Treatment

• For acute, earlychronic, and reactivated Disease:

• Preferred regimen: Benznidazole 5–8 mg/kg/day PO in 2 divided doses for 30–60 days
• Alternative regimen: Nifurtimox 8–10 mg/kg/day PO for 90–120 days.

• 6.20. Leishmaniasis, visceral

• 6.20.1. Leishmaniasis, visceral

• 6.20.1.1. Treatment

• For initial infection:

• Preferred regimen (1): Liposomal amphotericin B 2–4 mg/kg IV qd
• Preferred regimen (2): Liposomal amphotericin B interrupted schedule (e.g., 4 mg/kg on days 1–5, 10, 17, 24, 31, 38)
• Alternative regimen (1): Amphotericin B deoxycholate 0.5–1.0 mg/kg IV q24h for total dose of 1.5–2.0 g
• Alternative regimen (2): Sodium stibogluconate (pentavalent antimony) 20 mg/kg IV or IM q24h for 28 days
• Alternative regimen (3): Miltefosine 100 mg PO qd for 4 weeks

• Chronic maintenance therapy (secondary prophylaxis); Especially in Patients with CD4 Count <200 cells/µL:

• Preferred regimen (1): Liposomal amphotericin B 4 mg/kg every 2–4 weeks
• Preferred regimen (2): Amphotericin B lipid complex 3 mg/kg every 21 days
• Alternative regimen: Sodium stibogluconate 20 mg/kg IV or IM every 4 weeks

• 6.20.2. Leishmaniasis, cutaneous

• Preferred regimen (1): Liposomal amphotericin B 2–4 mg/kg IV daily for 10 days
• Preferred regimen (2): Liposomal amphotericin B interrupted schedule (e.g., 4 mg/kg on days 1–5, 10, 17, 24, 31, 38) to achieve total dose of 20–60 mg/kg
• Preferred regimen (3): Sodium stibogluconate 20 mg/kg IV or IM daily for 3–4 weeks

• 6.21. Aspergillosis, invasive

• 6.21.1. Treatment

• Preferred regimen: Voriconazole 6 mg/kg IV q12h for 1 day, then 4 mg/kg IV q12h, followed by Voriconazole 200 mg PO q12h after clinical improvement until CD4 cell count >200 cells/µL and the infection appears to be resolved.
• Alternative regimen (1): Lipid formulation of Amphotericin B 5 mg/kg IV q24h
• Alternative regimen (2): Amphotericin B deoxycholate 1mg/kg IV q24h
• Alternative regimen (3): Caspofungin 70 mg IV single dose, then 50 mg IV q24h
• Alternative regimen (4): Micafungin 100–150 mg IV q24h
• Alternative regimen (5): Anidulafungin 200 mg IV single dose, then 100 mg IV q24h
• Alternative regimen (6): Posaconazole 200 mg PO qid, then, after condition improved, 400 mg PO bid

• 6.22. Malaria

• 6.22.1. Prevetion

• 6.22.1.1. Prophylaxis in all areas

• Preferred regimen (1): Atovaquone 250 mg and Proguanil hydrochloride 100 mg PO qd
• Pediatric doses: Pediatric tablets contain 62.5 mg atovaquone and 25 mg proguanil hydrochloride

• 5–8 kg: 1/2 pediatric tablet daily
• >8–10 kg: 3/4 pediatric tablet daily
• >10–20 kg: 1 pediatric tablet daily
• >20–30 kg: 2 pediatric tablets daily
• >30–40 kg: 3 pediatric tablets daily

• Note (1): Begin 1–2 days before travel to malarious areas. Take daily at the same time each day while in the malarious area and for 7 days after leaving such areas. Contraindicated in people with severe renal impairment (creatinine clearance <30 mL/min).
• Note (2): Atovaquone-proguanil should be taken with food or a milky drink. Not recommended for prophylaxis for children weighing <5 kg, pregnant women, and women breastfeeding infants weighing <5 kg. Partial tablet doses may need to be prepared by a pharmacist and dispensed in individual capsules.
• Preferred regimen (2): Doxycycline 100 mg PO qd
• Pediatric dose: ≥8 years of age: 2.2 mg/kg up to adult dose of 100 mg/day
• Note: Begin 1–2 days before travel to malarious areas. Take daily at the same time each day while in the malarious area and for 4 weeks after leaving such areas. Contraindicated in children <8 years of age and pregnant women.

• 6.22.1.2. Prophylaxis only in areas with chloroquine-sensitive malaria

• Preferred regimen: Chloroquine phosphate 300 mg base (500 mg salt) PO once a week
• Note: Begin 1–2 weeks before travel to malarious areas. Take weekly on the same day of the week while in the malarious area and for 4 weeks after leaving such areas. May exacerbate psoriasis.
• Alternative regimen: Hydroxychloroquine sulfate 400 mg salt PO once a week
• Note: Begin 1–2 weeks before travel to malarious areas. Take weekly on the same day of the week while in the malarious area and for 4 weeks after leaving such areas.
• Pediatric doses: Chloroquine phosphate 5 mg/kg base (8.3 mg/kg salt) orally, once/week, up to maximum adult dose of 300 mg base; Hydroxychloroquine sulfate 5 mg/kg base (6.5 mg/kg salt) orally, once/week, up to a maximum adult dose of 310 mg base

• 6.22.1.3. Prophylaxis in areas with mefloquine-sensitive malaria

• Preferred regimen: Mefloquine 250 mg PO once a week
• Note (1): Begin ≥2 weeks before travel to malarious areas. Take weekly on the same day of the week while in the malarious area and for 4 weeks after leaving such areas. Contraindicated in people allergic to mefloquine or related compounds (quinine, quinidine) and in people with active depression, a recent history of depression, generalized anxiety disorder, psychosis, schizophrenia, other major psychiatric disorders, or seizures.
• Note (2): Use with caution in persons with psychiatric disturbances or a previous history of depression. Not recommended for persons with cardiac conduction abnormalities.
• Pediatric dose: Mefloquine ≤9 kg: 4.6 mg/kg base (5 mg/kg salt) orally, once/week

• >9–19 kg: 1/4 tablet once/week
• >19–30 kg: 1/2 tablet once/week
• >30–45 kg: 3/4 tablet once/week
• >30–45 kg: 3/4 tablet once/week

• 6.22.1.4. Prophylaxis for short-duration travel to areas with principally Plasmodium vivax

• Preferred regimen: Primaquine 52.6 mg PO qd
• Note: Begin 1–2 days before travel to malarious areas. Take daily at the same time each day while in the malarious area and for 7 days after leaving such areas. Contraindicated in people with G6PD deficiency. Also contraindicated during pregnancy and lactation, unless the infant being breastfed has a documented normal G6PD level.
• Pediatric dose: Primaquine 0.5 mg/kg base (0.8 mg/kg salt) up to adult dose orally, daily

• 6.22.1.5. Terminal prophylaxis to decrease the risk for relapses of Plasmodium vivax and Plasmodium ovale

• Preferred regimen: Primaquine 52.6 mg PO qd for 14 days after departure from the malarious area
• Note: Indicated for people who have had prolonged exposure to P. vivax, P. ovale, or both. Contraindicated in people with G6PD deficiency. Also contraindicated during pregnancy and lactation, unless the infant being breastfed has a documented normal G6PD level.
• Pediatric dose: Primaquine 0.5 mg/kg base (0.8 mg/kg salt) up to adult dose orally, daily for 14 days after departure from the malarious area

• 6.22.2. Treatment

• Note (1): Patients coinfected with HIV should avoid Artesunate AND Sulfadoxine-Pyrimethamine if they are also receiving Co-trimoxazole, and avoid Artesunate AND Amodiaquine if they are also receiving Efavirenz OR Zidovudine.
• Note (2): Because Plasmodium falciparum malaria can progress within hours from mild symptoms or low-grade fever to severe disease or death, all HIV-infected patients with confirmed or suspected P. falciparum infection should be hospitalized for evaluation, initiation of treatment, and observation.
• 6.22.2.1. Plasmodium falciparum

• 6.22.2.1.1. Treatment of uncomplicated Plasmodium falciparum malaria

• 6.22.2.1.1.1. Treat children and adults with uncomplicated Plasmodium falciparum malaria (except pregnant women in their first trimester) with one of the following recommended ACT (artemisinin-based combination therapy)

• Preferred regimen (1): Artemether 5–24 mg/kg/day PO bid AND Lumefantrine 29–144 mg/kg/day PO bid for 3 days
• Note: The first two doses should, ideally, be given 8 hours apart.
• Dosage regimen based on Body weight (kg)

• Body weight (kg)-5 to < 15- Artemether 20 mg PO bid AND Lumefantrine 120 mg PO bid for 3 days
• Body weight (kg)-15 to < 25- Artemether 40 mg PO bid AND Lumefantrine 240 mg PO bid for 3 days
• Body weight (kg)-25 to < 35- Artemether 60 mg PO bid AND Lumefantrine 360 mg PO bid for 3 days
• Body weight (kg) ≥ 35- Artemether 80 mg PO bid AND Lumefantrine 480 mg PO bid for 3 days

• Preferred regimen (2): Artesunate 2–10 mg/kg/day PO qd AND Amodiaquine 7.5–15 mg/kg/day PO qd for 3 days
• Note: A total therapeutic dose range of 6–30 mg/kg/day Artesunate and 22.5–45 mg/kg/day per dose Amodiaquine is recommended.
• Dosage regimen based on body weight (kg)

• Body weight (kg)-4.5 to < 9- Artesunate 25 mg PO qd AND Amodiaquine 67.5 mg PO qd for 3 days
• Body weight (kg)-9 to < 18 - Artesunate 50 mg PO qd AND Amodiaquine 135 mg PO qd for 3 days
• Body weight (kg)-18 to < 36- Artesunate 100 mg PO qd AND Amodiaquine 270 mg PO qd for 3 days
• Body weight (kg) ≥ 36 - Artesunate 200 mg PO qd AND Amodiaquine 540 mg PO qd for 3 days

• Preferred regimen (3): Artesunate 2–10 mg/kg/day PO qd AND Mefloquine 2–10 mg/kg/day PO qd for 3 days
• Dosage regimen based on body weight (kg)

• Body weight (kg)-5 to < 9- Artesunate 25 mg PO qd AND Mefloquine 55 mg PO qd for 3 days
• Body weight (kg)-9to < 18- Artesunate 50 mg PO qd AND Mefloquine 110 mg PO qd for 3 days
• Body weight (kg)-18 to < 36- Artesunate 100 mg PO qd AND Mefloquine 220 mg PO qd for 3 days
• Body weight (kg)- ≥ 36 - Artesunate 200 mg PO qd AND Mefloquine 440 mg PO qd for 3 days

• Preferred regimen (4): Artesunate 2–10 mg/kg/day PO qd for 3 days AND Sulfadoxine-Pyrimethamine 1.25 (25–70 / 1.25–3.5) mg/kg/day PO given as a single dose on day 1
• Dosage regimen based on body weight (kg)

• Body weight (kg)- 5 to < 10- Artesunate 25 mg PO qd for 3 days AND Sulfadoxine-Pyrimethamine 250/12 mg PO given as a single dose on day 1
• Body weight (kg)- 10 to < 25- Artesunate 50 mg PO qd for 3 days AND Sulfadoxine-Pyrimethamine 500/25 mg PO given as a single dose on day 1
• Body weight (kg)- 25 to < 50- Artesunate 100 mg PO qd for 3 days AND Sulfadoxine-Pyrimethamine 1000/50 mg PO given as a single dose on day 1
• Body weight (kg)- ≥50- Artesunate 200 mg PO qd for 3 days AND Sulfadoxine-Pyrimethamine 1500/75 mg PO given as a single dose on day 1

• Preferred regimen (5): Dihydroartemisinin 2–10 mg/kg/day PO qd AND Piperaquine16–27 mg/kg/day PO qd for 3 days
• Dosage regimen based on Body weight (kg)

• Body weight (kg)-5 to < 8: Dihydroartemisinin 20 mg PO qd AND Piperaquine 160 mg PO qd for 3 days
• Body weight (kg)-8 to < 11: Dihydroartemisinin 30 mg PO qd AND Piperaquine 240 mg PO qd for 3 days
• Body weight (kg)-11 to < 17: Dihydroartemisinin 40 mg PO qd AND Piperaquine 320 mg PO qd for 3 days
• Body weight (kg)-17 to < 25: Dihydroartemisinin 60 mg PO qd AND Piperaquine 480 mg PO qd for 3 days
• Body weight (kg)-25 to < 36: Dihydroartemisinin 80 mg PO qd AND Piperaquine 640 mg PO qd for 3 days
• Body weight (kg)-36 to < 60: Dihydroartemisinin 120 mg PO qd AND Piperaquine 960 mg PO qd for 3 days
• Body weight (kg)-60 < 80: Dihydroartemisinin 160 mg PO qd AND Piperaquine 1280 mg PO qd for 3 days
• Body weight (kg)- >80: Dose of Dihydroartemisinin 200 mg PO qd AND Piperaquine 1600 mg PO qd for 3 days

• 6.22.2.1.1.2 Reducing the transmissibility of treated Plasmodium falciparum infections In low-transmission areas in patients with Plasmodium falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months)

• Preferred regimen: Primaquine 0.25 mg/kg PO single dose with ACT

• 6.22.2.1.2. Recurrent falciparum malaria

• 6.22.2.1.2.1. Failure within 28 days

• Note: The recommended second-line treatment is an alternative ACT known to be effective in the region. Adherence to 7-day treatment regimens with Artesunate or Quinine both of which should be co-administered with Tetracycline, or Doxycycline or Clindamycin) is likely to be poor if treatment is not directly observed; these regimens are no longer generally recommended.

• 6.22.2.1.2.2. Failure after 28 days

• Note: All presumed treatment failures after 4 weeks of initial treatment should, from an operational standpoint, be considered new infections and be treated with the first-line ACT. However, reuse of Mefloquine within 60 days of first treatment is associated with an increased risk for neuropsychiatric reactions, and an alternative ACT should be used.

• 6.22.2.1.3. Reducing the transmissibility of treated Plasmodium falciparum infections in low-transmission areas in patients with Plasmodium falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months)

• Note: Single dose of 0.25 mg/kg biweekly Primaquine with ACT

• 6.22.2.1.4. Treating uncomplicated Plasmodium falciparum malaria in special risk groups

• 6.22.2.1.4.1. Pregnancy

• First trimester of pregnancy : Quinine AND Clindamycin 10 mg/kg/day PO bid for 7 days
• Second and third trimesters : Mefloquine is considered safe for the treatment of malaria during the second and third trimesters; however, it should be given only in combination with an artemisinin derivative.
• Note (1): Quinine is associated with an increased risk for hypoglycaemia in late pregnancy, and it should be used (with clindamycin) only if effective alternatives are not available.
• Note (2): Primaquine and Tetracyclines should not be used in pregnancy.

• 6.22.2.1.4.2. Infants less than 5kg body weight

• Note: They should be treated with an ACT at the same mg/kg bw target dose as for children weighing 5 kg.

• 6.22.2.1.4.4. Large and obese adults

• Note: For obese patients, less drug is often distributed to fat than to other tissues; therefore, they should be dosed on the basis of an estimate of lean body weight, ideal body weight. Patients who are heavy but not obese require the same mg/kg bw doses as lighter patients.

• 6.22.2.1.4.5. Non-immune travellers

• Note: Treat travellers with uncomplicated P. falciparum malaria returning to nonendemic settings with an ACT.

• 6.22.2.1.4.6. Uncomplicated hyperparasitaemia

• Note: People with P. falciparum hyperparasitaemia are at increased risk of treatment failure, severe malaria and death so should be closely monitored, in addition to receiving an ACT.

• 6.22.2.2. Treatment of uncomplicated malaria caused by Plasmodium vivax, Plasmodium ovale, Plasmodium malariae or Plasmodium knowlesi

• 6.22.2.2.1. Blood Stage infection

• 6.22.2.2.1.1. Uncomplicated malaria caused by Plasmodium vivax

• 6.22.2.2.1.1.1. In areas with chloroquine-sensitive Plasmodium vivax

• Preferred regimen: Chloroquine total dose of 25 mg/kg PO. Chloroquine is given at an initial dose of 10 mg/kg, followed by 10 mg/kg on the second day and 5 mg/kg on the third day PO

• 6.22.2.2.1.1.2. In areas with chloroquine-resistant Plasmodium vivax

• Note: ACTs containing Piperaquine, Mefloquine OR Lumefantrine are the recommended treatment, although Artesunate AND Amodiaquine may also be effective in some areas. In the systematic review of ACTs for treating P. vivax malaria, Dihydroartemisinin AND Piperaquine provided a longer prophylactic effect than ACTs with shorter half-lives (Artemether ANDLumefantrine) OR (Artesunate AND Amodiaquine), with significantly fewer recurrent parasitaemias during 9 weeks of follow-up.

• 6.22.2.2.1.2. Uncomplicated malaria caused by Plasmodium ovale, Plasmodium malariae or Plasmodium knowlesi malaria

• Note: Resistance of P. ovale, P. malariae and P. knowlesi to antimalarial drugs is not well characterized, and infections caused by these three species are generally considered to be sensitive to Chloroquine. In only one study, conducted in Indonesia, was resistance to Chloroquine reported in P. malariae. The blood stages of P. ovale, P. malariae and P. knowlesi should therefore be treated with the standard regimen of ACT or Chloroquine, as for vivax malaria.

• 6.22.2.2.1.3. Mixed malaria infections

• Note: ACTs are effective against all malaria species and so are the treatment of choice for mixed infections.

• 6.22.2.2.2. Liver stages (hypnozoites) of Plasmodium vivax and Plasmodium ovale

• Note: To prevent relapse, treat P. vivax or P. ovale malaria in children and adults (except pregnant women, infants aged < 6 months, women breastfeeding infants < 6 months, women breastfeeding older infants unless they are known not to be G6PD deficient and people with G6PD deficiency) with a 14-day course of Primaquine in all transmission settings. Strong recommendation, high-quality evidence In people with G6PD deficiency, consider preventing relapse by giving primaquine base at 0.75 mg base/kg bw once a week for 8 weeks, with close medical supervision for potential primaquine-induced adverse haematological effects.

• 6.22.2.2.2.1. Primaquine for preventive relapse

• Preferred regimen: Primaquine 0.25–0.5 mg/kg/day PO qd for 14 days

• 6.22.2.2.2.2. Primaquine and glucose-6-phosphate dehydrogenase deficiency

• Preferred regimen: Primaquine 0.75 mg base/kg/day PO once a week for 8 weeks
• Note: The decision to give or withhold Primaquine should depend on the possibility of giving the treatment under close medical supervision, with ready access to health facilities with blood transfusion services.

• 6.22.2.2.2.3. Prevention of relapse in pregnant or lacating women and infants

• Note: Primaquine is contraindicated in pregnant women, infants < 6 months of age and in lactating women (unless the infant is known not to be G6PD deficient)

• 6.22.2.3. Treatment of severe malaria

• 6.22.2.3.1. Treatment of severe falciparum infection with Artesunate

• 6.22.2.3.1.1. Adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women)

• Preferred regimen: Artesunate IV/IM for at least 24 h and until they can tolerate oral medication. Once a patient has received at least 24 h of parenteral therapy and can tolerate oral therapy, complete treatment with 3 days of an ACT (add single dose Primaquine in areas of low transmission).

• 6.22.2.3.1.2. Young children weighing < 20 kg

• Preferred regimen:Artesunate 3 mg/kg per dose IV/IM q24h
• Alternative regimen: use Artemether in preference to quinine for treating children and adults with severe malaria

• 6.22.2.3.2.Treating cases of suspected severe malaria pending transfer to a higher-level facility (pre-referral treatment)

• 6.22.2.3.2.1. Adults and children

• Preferred regimen: Artesunate IM q24h
• Alternative regimen: Artemether IM OR Quinine IM

• 6.22.2.3.2.2. Children < 6 years

• Preferred regimen: Where intramuscular injections of artesunate are not available, treat with a single rectal dose (10 mg/kg) of Artesunate, and refer immediately to an appropriate facility for further care.
• Note: Do not use rectal artesunate in older children and adults.

• 6.22.2.3.3. Pregancy

• Note: Parenteral artesunate is the treatment of choice in all trimesters. Treatment must not be delayed.

• 6.22.2.3.4. Treatment of severe Plasmodium Vivax infection

• Note: Parenteral Artesunate, treatment can be completed with a full treatment course of oral ACT or Chloroquine (in countries where Chloroquine is the treatment of choice). A full course of radical treatment with Primaquine should be given after recovery.

• 6.22.2.3.5. Additional aspects of management in severe malaria

• Fluid therapy: It is not possible to give general recommendations on fluid replacement; each patient must be assessed individually and fluid resuscitation based on the estimated deficit.
• Blood Transfusion: In high-transmission settings, blood transfusion is generally recommended for children with a haemoglobin level of < 5 g/100 mL(haematocrit < 15%). In low-transmission settings, a threshold of 20% (haemoglobin,7 g/100 mL) is recommended.
• Exchange blood transfusion: Exchange blood transfusion requires intensive nursing care and a relatively large volume of blood, and it carries significant risks. There is no consensus on the indications, benefits and dangers involved or on practical details such as the volume of blood that should be exchanged. It is, therefore, not possible to make any recommendation regarding the use of exchange blood transfusion.

• 6.23. Cryptococcosis

• 6.23.1. Treatment

• 6.23.1.1. Cryptococcal meningitis

• 6.23.1.1.1. Induction therapy

• Preferred regimen: Liposomal amphotericin B 3–4 mg/kg IV q24h AND Flucytosine 25 mg/kg PO qid for at least 2 weeks, followed by consolidation therapy
• Alternative regimen (1): Amphotericin B deoxycholate 0.7 mg/kg IV q24h AND Flucytosine 25 mg/kg PO qid
• Alternative regimen (2): Amphotericin B lipid complex 5 mg/kg IV q24h AND Flucytosine 25 mg/kg PO qid
• Alternative regimen (3): Liposomal Amphotericin B 3-4 mg/kg IV q24h AND Fluconazole 800 mg PO or IV q24h
• Alternative regimen (4): Amphotericin B deoxycholate 0.7 mg/kg IV q24h AND Fluconazole 800 mg PO or IV q24h
• Alternative regimen (5): Fluconazole 400–800 mg PO or IV qd AND Flucytosine 25 mg/kg PO qid
• Alternative regimen (6): Fluconazole 1200 mg PO or IV qd

• 6.23.1.1.2. Consolidation therapy

• Preferred regimen: Fluconazole 400 mg PO (or IV) qd for atleast 8 weeks
• Note: Preferred therapy followed by maintenance therapy.
• Maintenance therapy: Fluconazole 200 mg PO qd for at least 12 months
• Alternative regimen: Itraconazole 200 mg PO bid for 8 weeks

• 6.23.1.2. Non-CNS cryptococcosis with mild-to-moderate symptoms and focal pulmonary infiltrates

• Preferred regimen: Fluconazole, 400 mg PO qd for 12 months
• Note: Patients receiving Flucytosine should have either blood levels monitored (peak level 2 hours after dose should be 30–80 mcg/mL) or close monitoring of blood counts for development of cytopenia. Dosage should be adjusted in patients with renal insufficiency.

• 6.24. Mucocutaneous candidiasis

• 6.24.1. Treatment

• 6.24.1.1. For oropharyngeal candidiasis

• Oral Therapy

• Preferred regimen: Fluconazole 100 mg PO qd for 7-14 days.
• Alternative regimen: Itraconazole oral solution 200 mg PO qd for 7-14 days OR Posaconazole oral suspension 400 mg PO bid for 1 day, then 400 mg qd 7-14 days

• Topical therapy

• Preferred regimen: Clotrimazole troches, 10 mg PO 5 times daily OR Miconazole mucoadhesive buccal 50-mg tablet
• Note: Apply to mucosal surface over the canine fossa once daily (do not swallow, chew, or crush).
• Alternative regimen: Nystatin suspension 4–6 mL qid or 1–2 flavored pastilles 4– 5 times daily

• 6.24.1.2. For esophageal candidiasis

• Preferred regimen: Fluconazole 100 mg (up to 400 mg) PO or IV qd for 14-21 days OR Itraconazole oral solution 200 mg PO qd for 14-21 days
• Alternative regimen (1): Voriconazole 200 mg PO or IV bid for 14-21 days
• Alternative regimen (2): Anidulafungin 100 mg IV single dose, then 50 mg IV qd for 14-21 days
• Alternative regimen (3): Caspofungin 50 mg IV qd for 14-21 days
• Alternative regimen (4): Micafungin 150 mg IV qd for 14-21 days
• Alternative regimen (5): Amphotericin B deoxycholate 0.6 mg/kg IV qd for 14-21 days
• Alternative regimen (6): Lipid formulation of amphotericin B 3–4 mg/kg IV qd for 14-21 days

• 6.24.1.3. For uncomplicated vulvo-vaginal candidiasis

• Preferred regimen: Oral Fluconazole 150 mg for 1 dose OR Topical azoles (Clotrimazole, Butoconazole, Miconazole, Tioconazole, or Terconazole) for 3– 7 days
• Alternative regimen: Itraconazole oral solution 200 mg PO qd for 3–7 days

• 6.24.1.4. For severe or recurrent vulvovaginal candidiasis

• Preferred regimen: Fluconazole 100–200 mg PO qd for ≥7 days OR Topical antifungal ≥7 days

• 6.25. Bartonellosis

• 6.25.1. Treatment

• 6.25.1.1. For bacillary angiomatosis, peliosis hepatis, bacteremia, and osteomyelitis

• Preferred regimen (1): Doxycycline 100 mg PO or IV q12h for 3 months
• Preferred regimen (2): Erythromycin 500 mg PO or IV q6h for 3 months
• Alternative regimen (1): Azithromycin 500 mg PO qd
• Alternative regimen (2):} Clarithromycin 500 mg PO bid

• 6.25.1.2. Confirmed bartonella endocarditis

• Preferred regimen: Doxycycline 100 mg IV q12h AND Gentamicin 1 mg/kg IV q8h) for 2 weeks, then continue with Doxycycline 100 mg IV or PO q12h
• Altered regimen: Doxycycline 100 mg IV AND Rifabutin 300 mg PO or IV q12h for 2 weeks, then continue with Doxycycline 100 mg IV or PI q12h

• 6.25.1.3. CNS infections

• Preferred regimen: (Doxycycline 100 mg with or without Rifabutin 300 mg PO or IV q12h

• 6.25.1.4. Other severe infections

• Preferred regimen (1): Doxycycline 100 mg PO or IV with or without Rifabutin 300 mg PO or IV) q12h for 3 months
• Preferred regimen (2): Erythromycin 500 mg PO or IV q6h) with or without Rifabutin) 300 mg PO or IV q12h for 3 months.

• Note: If relapse occurs after initial (>3 month) course of therapy, longterm suppression with Doxycycline or a macrolide is recommended as long as CD4 count <200 cells/µL.

• 6.26. Campylobacteriosis

• 6.26.1. Treatment

• 6.26.1.1. For mild-to-moderate disease (If Susceptible)

• Preferred regimen: Ciprofloxacin 500–750 mg PO or 400 mg IV q12h OR Azithromycin 500 mg PO qd
• Alternative regimen: Levofloxacin 750 mg PO or IV q24h OR Moxifloxacin 400 mg (PO or IV) q24h

• 6.26.1.2. For campylobacter bacteremia

• Preferred regimen: Ciprofloxacin 500–750 mg PO or 400 mg IV q12h AND an aminoglycoside.
• Duration of Therapy:

• Gastroenteritis: 7–10 days (5 days with Azithromycin)
• Bacteremia: ≥14 days
• Recurrent bacteremia: 2–6 weeks.

• 6.27. Shigellosis

• 6.27.1. Treatment

• Preferred regimen: Ciprofloxacin 500–750 mg PO or 400 mg IV q12h
• Duration of Therapy:

• Gastroenteritis: 7–10 days
• Bacteremia: ≥14 days
• Recurrent Infections: 2–6 weeks

• Alternative regimen (1): Levofloxacin 750 mg PO or IV q24h for 5 days
• Alternative regimen (2): Moxifloxacin 400 mg PO or IV q24h for 5 days
• Alternative regimen (3): Trimethoprim/Sulfamethoxazole 160 mg/800 mg PO or IV q12h for 5 days
• Alternative regimen (4): Azithromycin 500 mg PO qd for 5 days
• Note: Antimotility agents should be avoided.

• 6.28. Salmonellosis

• 6.28.1. Treatment

• Preferred regimen: Ciprofloxacin 500–750 mg PO or 400 mg IV q12h
• Alternative regimen (1): Levofloxacin 750 mg PO or IV q24h
• Alternative regimen (2): Moxifloxacin 400 mg PO or IV q24h
• Alternative regimen (3): Trimethoprim/Sulfamethoxazole 160 mg/800 mg PO or IV q12h
• Alternative regimen (4): Cefotaxime 1 g IV q8h
• Alternative regimen (5): Ceftriaxone 1 g IV q24h
• Duration of therapy:

• For gastroenteritis without bacteremia:

• If CD4 count ≥200 cells/µL: 7–14 days.
• If CD4 count <200 cells/µL: 2–6 weeks.

• For gastroenteritis with bacteremia:

• If CD4 count ≥200/µL: 14 days; longer duration if bacteremia persists or if the infection is complicated (e.g., if metastatic foci of infection are present)
• If CD4 count <200 cells/µL: 2–6 weeks

• Note (1): The role of long-term secondary prophylaxis in patients with recurrent Salmonella bacteremia is not well established. Must weigh benefit against risks of long-term antibiotic exposure.
• Note (2): Secondary Prophylaxis Should Be Considered For:

• Patients with recurrent Salmonella gastroenteritis +/- bacteremia.
• Patients with CD4 <200 cells/µL with severe diarrhea.

• 6.29. Bacterial enteric infections

• 6.29.1. Empiric therapy

• Preferred regimen: Ciprofloxacin 500–750 mg PO or 400 mg IV q12h
• Alternative regimen: Ceftriaxone 1 g IV q24h OR Cefotaxime 1 g IV q8h
• Note: Antimotility agents should be avoided if there is concern about inflammatory diarrhea, including Clostridium-difficile-associated diarrhea.

• 6.30.Bacterial respiratory diseases

• 6.30.1. Treatment

• 6.30.1.1. Empiric outpatient therapy

• Preferred regimen: Amoxicillin 500 mg PO AND (Azithromycin 500 mg PO OR Clarithromycin 500 mg PO) qd for 7-10 days
• Alternative regimen: Amoxicillin 500 mg PO AND Doxycycline 100mg PO qd
• Note: Therapy should be adjusted based on the results of diagnostic workup.

• 6.30.1.2. For penicillin-allergic patients

• Preferred regimen: Ceftriaxone 1 g IV q24h AND (Azithromycin 500 mg PO OR Clarithromycin 500 mg PO) qd for 7-10 days
• Alternative regimen: Aztreonam 1 g IV q24h AND Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

• 6.30.1.3. Empiric therapy for non-ICU hospitalized patients

• Preferred regimen: Ceftriaxone 1 g IV q24h AND (Azithromycin 500 mg PO OR Clarithromycin 500 mg PO) qd

• 6.30.1.3. Empiric therapy for patients at risk of pseudomonas pneumonia

• Preferred regimen: : Piperacillin-Tazobactam 2 g-0.25 g IV q24h AND (Ciprofloxacin 400 mg IV q8–12h OR Levofloxacin 750 mg IV) q24h

• 6.30.1.4. Empiric therapy for patients at risk for methicillin-resistant staphylococcus aureus pneumonia

• Preferred regimen: Amoxicillin 500 mg PO AND (Azithromycin 500 mg PO OR Clarithromycin 500 mg) PO AND Linezolid 600 mg (IV or PO).
• Note (1): Empiric therapy with a macrolide alone is not routinely recommended, because of increasing pneumococcal resistance.
• Note (2): Chemoprophylaxis can be considered for patients with frequent recurrences of serious bacterial pneumonia.

• 6.31. Cryptosporidiosis

• 6.31.1. Treatment

• Note (1): Initiate or optimize ART for immune restoration to CD4 count >100 cells/µL. Aggressive oral or IV rehydration and replacement of electrolyte loss and symptomatic treatment of diarrhea with anti-motility agents.
• Preferred regimen (1): Nitazoxanide 500–1000 mg PO bid for 14 days
• Preferred regimen (2): Paromomycin 500 mg PO qid for 14–21 days
• Note (2): With optimized anti retroviral therapy, symptomatic treatment and rehydration and electrolyte replacement is recommended. Tincture of opium may be more effective than Loperamide in management of diarrhea.

• 6.32. Microsporidiosis

• 6.32.1. Treatment

• 6.32.1.1. For GI infections caused by enterocytozoon bienuesi

• Note: Initiate or optimize anti retroviral therapy as immune restoration to CD4 count >100 cells/µL AND manage severe dehydration, malnutrition, and wasting by fluid support.
• Preferred therapy (1): Fumagillin 60 mg/day PO bid
• Preferred therapy (2): TNP-470 PO bid
• Preferred therapy (3): Nitazoxanide 1000 mg PO bid

• 6.32.1.2. For intestinal and disseminated (not ocular) infections caused by microsporidia other than E. bienuesi and vittaforma corneae

• Preferred regimen: Albendazole 400 mg PO bid, continue until CD4 count >200 cells/µL for >6 months after initiation of anti retroviral therapy
• Alternative regimen: Itraconazole 400 mg PO qd AND Albendazole 400 mg PO bid

• 6.32.1.3. For ocular infection

• Preferred regimen: Topical fumagillin bicylohexylammonium (Fumidil B) eye drops: 3 mg/mL in saline (fumagillin 70 µg/mL)—2 drops q2h for 4 days, then 2 drops qid AND Albendazole 400 mg PO bid, for management of systemic infection
• Note: Therapy should be continued until resolution of ocular symptoms and CD4 count increase to >200 cells/µL for >6 months in response to anti retroviral therapy.

• 6.33. Progressive Multifocal Leukoencephalopathy (PML)

• Note (1): There is no specific antiviral therapy for JC virus infection. The main treatment approach is to reverse the immunosuppression caused by HIV.
• Note (2): Initiate anti retroviral therapy immediately in anti retroviral therapy naive patients.
• Note (3): Optimize anti retroviral therapy in patients who develop PML in phase of HIV viremia on anti retroviral therapy.
• Note (4): Corticosteroids may be used for PML-IRIS characterized by contrast enhancement, edema or mass effect, and with clinical deterioration.

• West nile virus

• 1.1. Prevention

• No WNV vaccines are licensed for use in humans. In the absence of a vaccine, prevention of WNV disease depends on community-level mosquito control programs to reduce vector densities, personal protective measures to decrease exposure to infected mosquitoes, and screening of blood and organ donors.
• Personal protective measures include use of mosquito repellents, wearing long-sleeved shirts and long pants, and limiting outdoor exposure from dusk to dawn. Using air conditioning, installing window and door screens, and reducing peridomestic mosquito breeding sites, can further decrease the risk for WNV exposure.
• Blood and some organ donations in the United States are screened for WNV infection; health care professionals should remain vigilant for the possible transmission of WNV through blood transfusion or organ transplantation. Any suspected WNV infections temporally associated with blood transfusion or organ transplantation should be reported promptly to the appropriate state health department.

• 1.2. Treatment

• There is no specific treatment for WNV disease; clinical management is supportive. Patients with severe meningeal symptoms often require pain control for headaches and antiemetic therapy and rehydration for associated nausea and vomiting. Patients with encephalitis require close monitoring for the development of elevated intracranial pressure and seizures. Patients with encephalitis or poliomyelitis should be monitored for inability to protect their airway. Acute neuromuscular respiratory failure may develop rapidly and prolonged ventilatory support may be required.

• Measles

• 1.1. Prevention

• 1.1.1. Vaccines

• Note (1): Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for protection against measles, mumps, rubella and varicella. Single-antigen measles vaccine is not available.
• Note (2): Vaccination recommendations

• Children: CDC recommends routine childhood immunization for MMR vaccine starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age or at least 28 days following the first dose.
• Students at post-high school educational institutions: Students at post-high school educational institutions without evidence of measles immunity need two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose.
• Adults: People who are born during or after 1957 who do not have evidence of immunity against measles should get at least one dose of MMR vaccine.
• International travelers: People 6 months of age or older who will be traveling internationally should be protected against measles. Before travelling internationally,

• Infants 6 through 11 months of age should receive one dose of MMR vaccine
• Children 12 months of age or older should have documentation of two doses of MMR vaccine (the first dose of MMR vaccine should be administered at age 12 months or older; the second dose no earlier than 28 days after the first dose)
• Teenagers and adults born during or after 1957 without evidence of immunity against measles should have documentation of two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose

• 1.1.2. Post-exposure Prophylaxis

• 1.1.2.1. Indication

• People exposed to measles who cannot readily show that they have evidence of immunity against measles should be offered post-exposure prophylaxis (PEP) or be excluded from the setting (school, hospital, childcare). MMR vaccine, if administered within 72 hours of initial measles exposure, or immunoglobulin (IG), if administered within six days of exposure, may provide some protection or modify the clinical course of disease.
• Note (1): If MMR vaccine is not administered within 72 hours of exposure as PEP, MMR vaccine should still be offered at any interval following exposure to the disease in order to offer protection from future exposures. People who receive MMR vaccine or IG as PEP should be monitored for signs and symptoms consistent with measles for at least one incubation period.
• Note (2): If many measles cases are occurring among infants younger than 12 months of age, measles vaccination of infants as young as 6 months of age may be used as an outbreak control measure. Note that children vaccinated before their first birthday should be revaccinated when they are 12 through 15 months old and again when they are 4 through 6 years of age.
• Note (3): People who are at risk for severe illness and complications from measles, such as infants younger than 12 months of age, pregnant women without evidence of measles immunity, and people with severely compromised immune systems, should receive IG. Intramuscular IG (IGIM) should be given to all infants younger than 12 months of age who have been exposed to measles.
• Note (4): For infants aged 6 through 11 months, MMR vaccine can be given in place of IG, if administered within 72 hours of exposure. Because pregnant women might be at higher risk for severe measles and complications, intravenous IG (IGIV) should be administered to pregnant women without evidence of measles immunity who have been exposed to measles. People with severely compromised immune systems who are exposed to measles should receive IGIV regardless of immunologic or vaccination status because they might not be protected by MMR vaccine.
• Preferred regimen: The recommended dose of IGIM is 0.5 mL/kg of body weight (maximum dose = 15 mL) and the recommended dose of IGIV is 400 mg/kg.
• Note (5): If a healthcare provider without evidence of immunity is exposed to measles, MMR vaccine should be given within 72 hours, or IG should be given within 6 days when available. Exclude healthcare personnel without evidence of immunity from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine.

• 1.2. Treatment

• Note (1): There is no specific antiviral therapy for measles. Medical care is supportive and to help relieve symptoms and address complications such as bacterial infections.
• Note (2): Severe measles cases among children, such as those who are hospitalized, should be treated with vitamin A. Vitamin A should be administered immediately on diagnosis and repeated the next day. The recommended age-specific daily doses are

• 50,000 IU for infants younger than 6 months of age
• 100,000 IU for infants 6–11 months of age
• 200,000 IU for children 12 months of age and older

==References==.