Sandbox ammu

• HIV/AIDS
• 1.Antiretroviral Regimen Options for Treatment-Naive Patients

• 1.1 A Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) Based Regimen:

• Preferred regimen: Efavirenz 600 mg PO qd AND Tenofovir 300 mg-Emtricitabine 200 mg PO qd

• 1.2 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

• 1.3 Protease Inhibitor-Based Regimen

• Preferred regimen: Darunavir 800mg-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 800mg-Cobicistat 150 mg PO qd OR Darunavir 800mg-Ritonavir 100mg PO qd AND Abacavir 600 mg-Lamivudine 300mg PO qd only for patients who are HLA-B*5701 negative
• Alternative Regimen(4): Darunavir 800mg-Cobicistat 150 mg PO qd AND Tenofovir disoproxil fumarate 300mg-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 400mg-Ritonavir 100mg PO qd or BID AND Abacavir 600 mg-Lamivudine 300mg PO qd only for patients who are HLA-B*5701 negative
• Alternative Regimen(7): Lopinavir 400mg-Ritonavir 100mg PO qd or BID AND Tenofovir disoproxil fumarate 300mg-Emtricitabine 200 mg PO qd

• 1.4 Other Regimen Options

• 1.4.1 NNRTI-Based Regimen

• Preferred regimen: Efavirenz 600mg PO qd AND Abacavir 600 mg-Lamivudine 300mg 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 800mg-Ritonavir 100mg PO qd AND Raltegravir 400mg 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 400mg-Ritonavir 100mg PO BID AND Lamivudine 300mg PO BID.

Pediatric dose: Abacavir 300 mg PO BID, Lamivudine 4 mg/kg/dose PO BID; maximum 150 mg PO q12h; Stavudine 1 mg/kg/dose PO q12h, Tenofovir 8 mg/kg; Zidovudine 180 - 240 mg/m2/dose PO BID or 160 mg/m2/dose PO q8h (range 90-180); Nevirapine maximum 200 mg per dose; Lopinavir 400mg; Nelfinavir 50 mg/kg/dose po BID; Raltegravir 300mg;

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
• 15 to <20 kg: 250 mg
• 20 to < 25 kg: 300 mg
• 25 to < 32.5 kg: 350 mg
• 32.5 to <40 kg: 400 mg
• ≥ 40 kg: 600 mg.

• 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 300mg-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 HIV PEP regimen- Raltegravir 400 mg PO q12h + Tenofovir disoproxil fumarate 300mg-Emtricitabine 200 mg PO qd
• Preferred basic regimen for low-risk exposures (Eg: mucus membrane):
  • Zidovudine 100mg PO qd AND Lamivudine 300mg PO qd
  • Zidovudine 100mg PO qd AND Emtricitabine 200 mg PO qd
  • Tenofovir 300mg PO qd AND Lamivudine 300mg PO qd
  • Tenofovir 300mg PO qd AND Emtricitabine 200 mg PO qd
• Preferred expanded regimen for high-risk exposure (Eg: percutaneous needle stick)
  • Zidovudine 100mg PO qd AND Lamivudine 300mg PO qd AND Lopinavir 400mg-Ritonavir 100mg PO qd
  • Zidovudine 100mg PO qd AND Emtricitabine 200 mg PO qd AND Lopinavir 400mg-Ritonavir 100mg PO qd
  • Tenofovir 300mg PO qd AND Lamivudine 300mg PO qd AND Lopinavir 400mg-Ritonavir 100mg PO qd
  • Tenofovir 300mg PO qd AND Emtricitabine 200 mg PO qdAND Lopinavir 400mg-Ritonavir 100mg 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 300mg-Emtricitabine 200mg PO qd (fixed dose combination) OR Tenofovir 300mg-Lamivudine 300mg PO qd OR Abacavir 600mg-Lamivudine 300mg PO qd OR Zidovudine 100mg-Lamivudine 300mg PO qd AND Atazanavir300 mg-Ritonavir 100mg PO qd OR Lopinavir 400mg-Ritonavir 100mg PO qd

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

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

• 4.2 Intrapartum

• HIV RNA <1000 copies/mL and good adherance-Continue the regimen during delivery or cessarean section.
• 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

• Initiate 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) 100mg oral 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

• 6.1.1.1 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 1 doublestrength (DS) PO daily OR Trimethoprim/sulfamethoxazole 1 singlestrength (SS) daily
• Alternative regimen(1): Trimethoprim/sulfamethoxazole 1 DS PO three times weekly
• Alternative regimen(2): Dapsone 100 mg PO daily or 50 mg PO BID
• Alternative regimen(3): Dapsone 50 mg PO daily AND (Pyrimethamine 50 mg AND Leucovorin 25 mg) PO weekly
• Alternative regimen(4): Dapsone 200 mg AND Pyrimethamine 75 mg AND Leucovorin 25 mg PO weekly
• Alternative regimen(5): Aerosolized Pentamidine 300 mg via Respigard nebulizer every month
• Alternative regimen(6): Atovaquone 1500 mg PO daily
• Alternative regimen(7): Atovaquone 1500 mg AND Pyrimethamine 25 mg AND Leucovorin 10 mg) PO daily

• 6.1.2 Treatment

• Preferred regimen:
• For Moderate-to-Severe PCP Trimethoprim 15–20 mg AND sulfamethoxazole 75–100 mg]/kg/day IV given q6h or q8h, may switch to PO after clinical improvement.
• For Mild-to-Moderate PCP Trimethoprim 15–20 mg AND sulfamethoxazole 75–100 mg]/kg/day, given PO in 3 divided doses OR Trimethoprim/sulfamethoxazole: 160 mg/800 mg or DS) 2 tablets PO TID.
• Secondary Prophylaxis, after completion of PCP treatment Trimethoprim/sulfamethoxazole DS: 1 tablet PO daily OR Trimethoprim/sulfamethoxazole (80 mg/400 mg or SS): 1 tablet PO daily.
• Alternative regimen:
• For Moderate-to-Severe PCP: Pentamidine 4 mg/kg IV daily infused over ≥60 minutes; can reduce dose to 3 mg/kg IV daily because of toxicities OR Primaquine 30 mg (base) PO daily AND clindamycin 600 mg q6h IV OR 900 mg IV q8h OR clindamycin 450 mg PO QID or 600 mg PO TID.
• For Mild-to-Moderate PCP: Dapsone 100 mg PO daily + TMP 5 mg/kg PO TID OR Primaquine 30 mg (base) PO daily + clindamycin 450 mg PO q6h or 600 mg PO q8h) OR Atovaquone 750 mg PO BID with food.

• 6.1.3 Secondary Prophylaxis, after completion of PCP treatment

• Alternative regimen(1): Trimethoprim/sulfamethoxazole DS: 1 tablet PO three times weekly
• Alternative regimen(2): Dapsone 100 mg PO daily
• Alternative regimen(3): Dapsone 50 mg PO daily AND Pyrimethamine 50 mg AND Leucovorin 25 mg PO weekly
• Alternative regimen(4): Dapsone 200 mg AND Pyrimethamine 75 mg AND Leucovorin 25 mg) PO weekly
• Alternative regimen(5): Dapsone 100 mg PO daily
• Alternative regimen(6): Dapsone 50 mg PO daily AND Pyrimethamine 50 mg AND Leucovorin 25 mg) PO weekly
• Alternative regimen(7): Dapsone 200 mg + Pyrimethamine 75 mg AND Leucovorin 25 mg) PO weekly
• Alternative regimen(8): Aerosolized Pentamidine 300 mg monthly via Respirgard nebulizer
• Alternative regimen(9): Atovaquone 1500 mg PO daily
• Alternative regimen(10):Atovaquone 1500 mg AND Pyrimethamine 25 mg AND Leucovorin 10 mg PO daily

• 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 daily.
• Days 11–21: 20 mg PO daily.

• Note(1): Trimethoprim/sulfamethoxazole should be permanently discontinued in patients with possible or definite StevensJohnson Syndrome or toxic epidermal necrosis.
• Note(2): Whenever possible, patients should be tested for G6PD before use of Dapsone or Primaquine. Alternative therapy 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 1 DS PO daily
• Alternative regimen(1): Trimethoprim/sulfamethoxazole 1 DS PO three times weekly
• Alternative regimen(2): Trimethoprim/sulfamethoxazole 1 SS PO daily
• Alternative regimen(3): Dapsone 50 mg PO daily + Pyrimethamine 50 mg + Leucovorin 25 mg) PO weekly
• Alternative regimen(4): Dapsone 200 mg + Pyrimethamine 75 mg + Leucovorin 25 mg) PO weekly
• Alternative regimen(5): Atovaquone 1500 mg PO daily
• Alternative regimen(6): Atovaquone 1500 mg + Pyrimethamine 25 mg + Leucovorin 10 mg) PO daily

• 6.2.2 Treatment

• 6.2.2.1 Treatment of Acute Infection

• Preferred regimen: At least 6 weeks (BII); longer duration if clinical or radiologic disease is extensive or response is incomplete at 6 weeks
• Pyrimethamine 200 mg PO 1 time, followed by weight-based therapy:

• If <60 kg, Pyrimethamine 50 mg PO qd + Sulfadiazine 1000 mg PO QID + Leucovorin 10–25 mg PO qd
• If ≥60 kg, Pyrimethamine 75 mg PO qd + Sulfadiazine 1500 mg PO QID + Leucovorin 10–25 mg PO qd

• Alternative regimen(1): Pyrimethamine (Leucovorin) AND Clindamycin 600 mg IV or PO q6h
• Alternative regimen(2): Trimethoprim/sulfamethoxazole (Trimethoprim 5 mg/kg and Sulfamethoxazole 25 mg/kg ) IV or PO BID
• Alternative regimen(3): Atovaquone 1500 mg PO BID with food AND Pyrimethamine (Leucovorin)
• Alternative regimen(4): Atovaquone 1500 mg PO BID with food AND Sulfadiazine 1000–1500 mg PO q6h (weight-based dosing, as in preferred therapy)
• Alternative regimen(5): Atovaquone 1500 mg PO BID with food
• Alternative regimen(6): Pyrimethamine (Leucovorin) 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 Therapy(1): Clindamycin 600 mg PO TID + (pyrimethamine 25–50 mg + leucovorin 10–25 mg) PO qd.
• Alternative Therapy(2): Trimethoprim/sulfamethoxazole DS 1 tablet BID.
• Alternative Therapy(3): Atovaquone 750–1500 mg PO BID AND (Pyrimethamine 25 mg- Leucovorin 10 mg) PO qd.
• Alternative Therapy(4): Atovaquone 750–1500 mg PO BID + Sulfadiazine 2000–4000 mg PO daily (in 2–4 divided doses.
• Alternative Therapy(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 AND Pyridoxine 25 mg) PO daily for 9 months OR Isoniazid 900 mg PO two times a week (by DOT) AND Pyridoxine 25 mg PO qd for 9 months
• Alternative Therapy(1): Rifampin 600 mg PO qd for 4 months
• Alternative Therapy(2): Rifabutin (dose adjusted based on concomitant ART)d for 4 months

• 6.3.1.2 Treatment

• Preferred regimen: Isoniazid 300 mg PO qd AND Rifampin PO qd OR Rifabutin PO qd AND Pyridoxine PO qd AND Ethambutol PO qd for initial phase for 2 months.
• Continuation Phase: Isoniazid AND Rifampin PO qd OR Rifabutin PO qd daily (5–7 times/week) or three times a week.
• Duration of therapy:

• Pulmonary TB: 6 months
• Pulmonary TB and culturepositive after 2 months of TB 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 PO qd OR Rifabutin PO qd AND Ethambutol PO qd AND Pyrazinamide PO qd AND (Moxifloxacin or Levofloxacin) for 2 months; followed by Rifampin PO qd for 7 months.
• Preferred regimen(2): Rifabutin PO qd AND Ethambutol PO qd AND (Moxifloxacin PO qd OR Levofloxacin PO 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 and can discontinue if no signs and symptoms of MAC disease and sustained (>6 months) CD4 count >100 cells/µL in response to ART
• Note

• 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 ART 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 Indication

• For individuals who have not received any pneumococcal vaccine, regardless of CD4 count, followed by PCV13 0.5 mL IM x 1

• If CD4 count ≥200 cells/µL PPV23 0.5 mL IM or SQ at least 8 weeks after the PCV13 vaccine
• If CD4 count <200 cells/µL PPV23 can be offered at least 8 weeks after receiving PCV13 (CIII) or can wait until CD4 count increased to ≥200 cells/µL.
• For individuals who have previously received PPV23
• Alternative PPV23 0.5 mL IM or SQ x 1 One dose of PCV13 should be given at least 1 year after the last receipt of PPV23

• 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. Indication

• All HIV-infected patients

• Inactivated influenza vaccine annually (per recommendation for the season).
• 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 for 1 dose
• Alternative regimen(1): Doxycycline 100 mg PO BID for 14 days
• Alternative regimen(2): Ceftriaxone 1 g IM or IV daily for 8– 10 days
• Alternative regimen(3): Azithromycin 2 g PO for 1 dose (BII)– not recommended for MSM or pregnant women

• 6.7.1.2 Treatment

• 6.7.1.2.1 Early Stage (Primary, Secondary, and Early-Latent Syphilis

• Preferred regimen: Benzathine penicillin G 2.4 million units IM for 1 dose
• Alternative regimen: Doxycycline 100 mg PO BID for 14 days OR Ceftriaxone 1 g IM or IV daily for 10–14 days OR Azithromycin 2 g PO for 1 dose

• 6.7.1.2.1 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.

• 6.7.1.2.3 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 +/- 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 daily AND probenecid 500 mg PO QID for 10–14 days +/- Benzathine penicillin G 2.4 million units IM weekly for 3 doses after completion

• Note:

• 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. 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. 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 daily.

• 6.8.2. Treatment

• 6.8.2.1. Moderately Severe to Severe Disseminated Disease
• Preferred regimen:

• Induction Therapy (for at least 2 weeks or until clinically improved): Liposomal amphotericin B 3 mg/kg IV daily
• Maintenance Therapy: Itraconazole 200 mg PO TID for 3 days, then 200 mg PO BID.

• 6.8.2.2. Less Severe Disseminated Disease

• Induction and Maintenance Therapy

• Preferred regimen: Itraconazole 200 mg PO TID for 3 days, then 200 mg PO BID for 12 months.

• Alternative regimen

• Induction Therapy (for at least 2 weeks or until clinically improved): Amphotericin B lipid complex 3 mg/kg IV daily OR Amphotericin B cholesteryl sulfate complete 3 mg/kg IV daily.
• Alternatives to Itraconazole for Maintenance Therapy or Treatment of Less Severe Disease: Voriconazole 400 mg PO BID for 1 day, then 200 mg BID OR [[[Posaconazole]] 400 mg PO BID OR Fluconazole 800 mg PO daily.

• 6.8.2.3. Meningitis

• Preferred regimen:

• Induction Therapy (4–6 weeks): Liposomal amphotericin B 5 mg/kg/day
• Maintenance Therapy: Itraconazole 200 mg PO BID to TID for ≥1 year and until resolution of abnormal CSF findings.

• Long-Term Suppression Therapy

• Preferred regimen: Itraconazole 200 mg PO daily
• Alternative regimen: Fluconazole 400 mg PO daily.

• 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. 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 daily.

• 6.9.2 Treatment
• 6.9.2.1 Clinically Mild Infections (e.g., Focal Pneumonia)

• Preferred regimen: Fluconazole 400 mg PO daily 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 daily OR Lipid formulation amphotericin B 4–6 mg/kg IV daily
• 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 daily
• 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

• 6.8.2.4. Chronic Suppressive Therapy

• Preferred regimen: Fluconazole 400 mg PO daily 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: Valacyclovir 1 g PO BID OR Famciclovir 500 mg PO BID OR Acyclovir 400 mg PO TID

• Initial or Recurrent Genital HSV (For 5–14 Days)

• Preferred regimen: Valacyclovir 1 g PO BID OR Famciclovir 500 mg PO BID OR Acyclovir 400 mg PO TID.

• 6.10.2. 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.
• 6.10.3. 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 in 2–3 divided doses until clinical response.
• Alternative regimen: IV Cidofovir OR Topical Trifluridine OR Topical Trifluridine OR Topical Imiquimod for 21-28 days.

• 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 (Varivax™), 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:

• If vaccination results in disease because of vaccine virus, treatment with Acyclovir is recommended.
• Routine VZV serologic testing in HIV-infected adults and adolescents is not 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 for 5– 7 days.
• Alternative regimen(2): Valacyclovir 1 g PO TID for 5–7 days.
• Note:

• 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.
• 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

• Primary Varicella Infection (Chickenpox)

• Uncomplicated Cases (For 5–7 Days):

• Preferred regimen: Valacyclovir 1 g PO TID OR Famciclovir 500 mg PO TID.

• 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.

• 6.11.2. Herpes Zoster (Shingles)

• 6.11.2.1. 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

• 6.11.2.2. Extensive Cutaneous Lesion or Visceral Involvement

• Preferred regimen: Acyclovir 10–15 mg/kg IV q8h until clinical improvement is evident.
• Note

• 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.

• 6.11.2.3. Progressive Outer Retinal Necrosis (PORN)

• Preferred regimen: (Ganciclovir 5 mg/kg +/- foscarnet 90 mg/kg) IV q12h + (ganciclovir 2 mg/0.05mL +/- foscarnet 1.2 mg/0.05 ml) intravitreal injection BIW.

• 6.11.2.4. Acute Retinal Necrosis (ARN)

• Preferred regimen: (Acyclovir 10-15 mg/kg IV q8h) + (ganciclovir 2 mg/0.05mL intravitreal injection BIW X 1-2 doses) for 10-14 days, followed by [[[valacyclovir]] 1g PO TID for 6 weeks.

• 6.12 Cytomegalovirus (CMV) Disease

• 6.12.1. 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: Ganciclovir 5 mg/kg IV q12h for 14–21 days OR Foscarnet 90 mg/kg IV q12h or 60 mg/kg q8h for 14–21 days OR 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).

• Chronic Maintenance (Secondary Prophylaxis):

• Preferred regimen: Valganciclovir 900 mg PO daily
• 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)

• 6.12.2. CMV Esophagitis or Colitis

• 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 patients with treatment-limiting toxicities to Ganciclovir or with Ganciclovir resistance for 21-42 days.
• Alternative regimen: Valganciclovir 900 mg PO BID in milder disease and if able to tolerate PO therapy for 21-42 days.

• 6.12.3. 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]).

• Treatment

• Mild To Moderate KS (ACTG Stage T0):

• Mild To Moderate KS (ACTG Stage T0)

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

• Chemotherapy (per oncology consult) + ART

• Primary Effusion Lymphoma

• Chemotherapy (per oncology consult) + ART.
• PO valganciclovir or IV ganciclovir can be used as adjunctive therapy.
• 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 + Zidovudine 600 mg PO q6h 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.

• 6.14 Human Papillomavirus (HPV) infection

• Prevention

• Preferred regimen(1): For females aged 13–26 years 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.
• Preferred regimen(2): Males aged 13–26 years HPV quadrivalent vaccine 0.5 mL IM at months 0, 1–2, and 6.

• Treatment

• 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): 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: 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: Apply to affected areas TID for up to 16 weeks, until warts are completely cleared and not visible.

• Provider-Applied Therapy for Complex or Multicentric Lesions, or Lesions Inaccessible to Patient.

• 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.
• 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.
• Surgical excision or laser surgery to external or anal warts.
• 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

• Prevention

• Indication: HAV-susceptible patients with chronic liver disease, or who are injection-drug users, or MSM.
• Preferred regimen: Hepatitis A vaccine 1 mL IM x 2 doses at 0 and 6–12 months.
• Alternative regimen: For patients susceptible to both HAV and hepatitis B virus (HBV) infection (see below): Combined HAV and HBV vaccine (Twinrix®), 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:
• IgG antibody response should be assessed 1 month after vaccination; nonresponders should be revaccinated when CD4 count >200 cells/µL.

• 6.16Hepatitis B virus (HBV) infection

• Prevention
• 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 (Twinrix®), 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:
• Indication

• Anti-HBs <10 international units/mL 1 month after vaccination series.
• 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 ART.

• Preferred regimen(1):Re-vaccinate with a second vaccine series.
• Preferred regimen(2): HBV vaccine IM (Engerix-B 40 µg/mL or Recombivax HB 20 µg/mL), 0, 1, 2 and 6 months.

• Treatment

• Preferred regimen: ART regimen should include 2 drugs that are active against both HBV and HIV, such as [tenofovir 300 mg + emtricitabine 200 mg (or lamivudine 300 mg)] PO once daily (+ additional drug(s) for HIV).
• For Patients Who Refuse or Are Unable to Take ART or Who Are HIV Long-Term Non-Progressors

• Alternative regimen: 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 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.

• 6.17: Penicilliosis marneffei

• Prevention:

• 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 once daily.
• Alternative regimen: Fluconazole 400 mg PO once weekly.

• Treatment:

• 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 (AII), followed by chronic maintenance therapy (as below).
• 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 (BII), followed by maintenance therapy.

• For Mild Disease

• Preferred regimen: Itraconazole 200 mg PO BID for 8 weeks (BII); followed by chronic maintenance therapy.
• Alternaate regimen: Voriconazole 400 mg PO BID for 1 day, then 200 mg BID for a maximum of 12 weeks (BII), followed by chronic maintenance therapy.

• Chronic Maintenance Therapy (Secondary Prophylaxis):
• Itraconazole 200 mg PO daily.

• Note:

• ART should be initiated simultaneously with treatment for penicilliosis to improve treatment outcome.
• Itraconazole and voriconazole may have significant interactions with certain ARV agents. These interactions are complex and can be bi-directional.
• Therapeutic drug monitoring and dosage adjustment may be necessary to ensure triazole antifungal and ARV efficacy and reduce concentration-related toxicities.

• 6.18: Isosporiasis

• Treatment:

• For Acute Infection:

• Preferred regimen(1): TMP-SMX (160 mg/800 mg) PO (or IV) QID for 10 days.
• Preferred regimen(2): TMP-SMX (160 mg/800 mg) PO (or IV) BID for 7–10 days.
• Alternative regimen(1): Pyrimethamine 50–75 mg PO daily + leucovorin 10–25 mg PO daily.
• 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, TMP-SMX (160 mg/800 mg) PO TIW
• Alternative regimen(1): TMP-SMX (160 mg/800 mg) PO daily or (320 mg/1600 mg) TIW
• Alternative regimen(2): Pyrimethamine 25 mg PO daily + leucovorin 5–10 mg PO daily.
• Alternative regimen(3): Ciprofloxacin 500 mg TIW as a second-line alternative.

• Note:

• Fluid and electrolyte management in patients with dehydration.
• Immune reconstitution with ART may result in fewer relapses.
• IV therapy may be used for patients with potential or documented mal-absorption.

• 6.19: Chagas Disease (American Trypanosomiasis)

• Treatment

• For Acute, Early Chronic, and ReActivated Disease:

• Preferred regimen: For Acute, Early Chronic, and ReActivated Disease.
• Allternate regimen: Nifurtimox 8–10 mg/kg/day PO for 90–120 days.

• 6.20: Leishmaniasis, visceral

• Leishmaniasis, visceral

• Treatment

• For Initial Infection:

• Preferred regimen(1): Liposomal amphotericin B 2–4 mg/kg IV daily.
• 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 daily for total dose of 1.5–2.0 g.
• Alternative regimen(2): Sodium stibogluconate (pentavalent antimony) 20 mg/kg IV or IM daily for 28 days.
• Alternative regimen(3): Miltefosine 100 mg PO daily for 4 weeks (available in the United States under a treatment IND)

• 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.

• 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

• 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: Lipid formulation of Amphotericin B 5 mg/kg IV daily OR Amphotericin B deoxycholate 1mg/kg IV daily OR Caspofungin 70 mg IV 1 time, then 50 mg IV daily OR Micafungin 100–150 mg IV daily OR Anidulafungin 200 mg IV 1 time, then 100 mg IV daily OR Posaconazole 200 mg PO QID, then, after condition improved, 400 mg PO BID.

• 6.22: :* 6.16: Malaria

• Prevention

• Indication: Travel to disease-endemic area

• Preferred regimen:

• 6.23: Cryptococcosis

• Treatment

• Cryptococcal Meningitis

• Preferred regimen

• Induction Therapy (for at least 2 weeks, followed by consolidation therapy): Liposomal amphotericin B 3–4 mg/kg IV daily AND Flucytosine 25 mg/kg PO QID

• Alternative regimen

• Induction Therapy (for at least 2 weeks, followed by consolidation therapy): Amphotericin B deoxycholate 0.7 mg/kg IV daily + Flucytosine 25 mg/kg PO QID OR Amphotericin B lipid complex 5 mg/kg IV daily + Flucytosine 25 mg/kg PO QID OR Liposomal amphotericin B 3-4 mg/kg IV daily + Fluconazole 800 mg PO or IV daily OR Amphotericin B deoxycholate 0.7 mg/kg IV daily + Fluconazole 800 mg PO or IV daily OR Fluconazole 400–800 mg PO or IV daily + Flucytosine 25 mg/kg PO QID OR Fluconazole 1200 mg PO or IV daily.

• Consolidation Therapy (for at least 8 weeks (AI), followed by maintenance therapy)

• Preferred regimen: Fluconazole 400 mg PO (or IV) daily
• Alternative regimen: Itraconazole 200 mg PO BID for 8 weeks.

• Non-CNS Cryptococcosis with Mildto-Moderate Symptoms and Focal Pulmonary Infiltrates:

• Preferred regimen: Fluconazole, 400 mg PO daily 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

• Treatment

• For Oropharyngeal Candidiasis; Initial Episodes (For 7–14 Days):

• Oral Therapy

• Preferred regimen: Fluconazole 100 mg PO daily
• Alternative regimen: Itraconazole oral solution 200 mg PO daily OR Posaconazole oral suspension 400 mg PO BID for 1 day, then 400 mg daily

• Topical therapy

• Preferred regimen: Clotrimazole troches, 10 mg PO 5 times daily OR Miconazole mucoadhesive buccal 50-mg tablet—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.

• For Esophageal Candidiasis (For 14–21 Days):

• Preferred regimen: Fluconazole 100 mg (up to 400 mg) PO or IV daily OR Itraconazole oral solution 200 mg PO daily.
• Alternative regimen: Voriconazole 200 mg PO or IV BID OR Anidulafungin 100 mg IV 1 time, then 50 mg IV daily OR Caspofungin 50 mg IV daily OR Micafungin 150 mg IV daily OR Amphotericin B deoxycholate 0.6 mg/kg IV daily OR Lipid formulation of amphotericin B 3–4 mg/kg IV daily.

• 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 daily for 3–7 days.

• For Severe or Recurrent VulvoVaginal Candidiasis:

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

• 6:25. Bartonellosis

• Treatment

• For Bacillary Angiomatosis, Peliosis Hepatis, Bacteremia, and Osteomyelitis

• Preferred regimen: Doxycycline 100 mg PO or IV q12h OR Erythromycin 500 mg PO or IV q6h for 3 months.
• Alternative regimen: Azithromycin 500 mg PO daily OR Clarithromycin 500 mg PO BID.

• Confirmed Bartonella Endocarditis:

• Preferred regimen: (Doxycycline 100 mg IV q12h + 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 + RIF 300 mg PO or IV) q12h for 2 weeks, then continue with Doxycycline 100 mg IV or PI q12h

• CNS Infections:

• Preferred regimen: (Doxycycline 100 mg +/- RIF 300 mg) PO or IV q12h

• Other Severe Infections:

• Preferred regimen: (Doxycycline 100 mg PO or IV +/- RIF 300 mg PO or IV) q12h OR (Erythromycin 500 mg PO or IV q6h) +/- RIF 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

• Treatment

• For Mild-to-Moderate Disease (If Susceptible):

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

• For Campylobacter Bacteremia

• Preferred regimen: Ciprofloxacin 500–750 mg PO (or 400 mg IV) q12h (BIII) + an aminoglycoside.

• Duration of Therapy:

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

• 6:27 Shigellosis

• 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: Levofloxacin 750 mg (PO or IV) q24h OR Moxifloxacin 400 mg (PO or IV) q24h OR TMP 160 mg-SMX 800 mg (PO or IV) q12h OR Azithromycin 500 mg PO daily for 5 days.
• Note

• Antimotility agents should be avoided.

• 6:28 Salmonellosis

• Treatment

• Preferred regimen: Ciprofloxacin 500–750 mg PO (or 400 mg IV) q12h.

• 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 (AIII); 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.

• Secondary Prophylaxis Should Be Considered For:

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

• Alternative regimen: Levofloxacin 750 mg (PO or IV) q24h OR Moxifloxacin 400 mg (PO or IV) q24h OR TMP, 160 mg-SMX 800 mg (PO or IV) q12h OR Ceftriaxone 1 g IV q24h OR Cefotaxime 1 g IV q8h.
• Note

• 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.

• 6:29 Bacterial Enteric Infections:

• 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

• Treatment

• Empiric Outpatient Therapy:

• Preferred regimen: A PO beta-lactam + a PO macrolide (Azithromycin or Clarithromycin) for 7-10 days.
• Alternative regimen: A PO beta-lactam + PO Doxycycline

• For penicillin-allergic patients:

• Preferred regimen: An IV beta-lactam + a macrolide (Azithromycin or Clarithromycin) for 7-10 days.

• Empiric Therapy for Non-ICU Hospitalized Patients

• Preferred regimen: An IV beta-lactam + a macrolide (Azithromycin or Clarithromycin)
• Alternative regimen: For penicillin-allergic patients: Aztreonam IV + (Levofloxacin 750 mg IV once daily or Moxifloxacin 400 mg IV once daily).

• Empiric Therapy for Patients at Risk of Pseudomonas Pneumonia:

• Preferred regimen: An IV antipneumococcal, antipseudomonal beta-lactam + (Ciprofloxacin 400 mg IV q8–12h or Levofloxacin 750 mg IV once daily).

• Alternative regimen: An IV antipneumococcal, antipseudomonal beta-lactam + an aminoglycoside + Azithromycin OR Above beta-lactam + an aminoglycoside + (Levofloxacin 750 mg IV once daily or Moxifloxacin 400 mg IV once daily).

• Empiric Therapy for Patients at Risk for Methicillin-Resistant Staphylococcus aureus Pneumonia:

• Preferred regimen: A PO beta-lactam + a PO macrolide (Azithromycin or Clarithromycin) AND Add Vancomycin IV or Linezolid (IV or PO).

• Note

• Empiric therapy with a macrolide alone is not routinely recommended, because of increasing pneumococcal resistance.
• Chemoprophylaxis can be considered for patients with frequent recurrences of serious bacterial pneumonia.