Sandbox ammu
- 1.1 A Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) Based Regimen:
- Preferred regimen: Efavirenz 600 mg once-daily AND Tenofovir 300 mg-Emtricitabine 200 mg once-daily.
- 1.2 Integrase Strand Transfer Inhibitor-Based Regimens
- Preferred regimen:
- Dolutegravir 50 mg once-daily AND Abacavir 600 mg-Lamivudine 300 mg once-daily in patients who are HLA-B*5701-negative.
- Dolutegravir 50 mg once-daily AND Tenofovir 300 mg-Emtricitabine 200 mg once-daily.
- Elvitegravir 150 mg OR Cobicistat 150 mg OR Tenofovir 300 mg-Emtricitabine 200 mg once-daily in patients with estimated CrCl ≥ 70 mL/min/1.73.
- Raltegravir 400 mg twice-daily AND Tenofovir 300 mg-Emtricitabine 200 mg once-daily.
- Alternative Regimen
- Efavirenz 600 mg once-daily/Tenofovir 300 mg-Emtricitabine 200 mg once-daily.
- Rilpivirine 25 mg once-daily plus Tenofovir 300 mg/Emtricitabine 200 mg once-daily (for patients with CD4 count >200 cells/microL.
- Raltegravir 400 mg twice-daily AND Abacavir 600 mg/Lamivudine 300 mg once-daily in patients who are HLA-B*5701-negative.
- 1.3 Protease Inhibitor-Based Regimen
- Preferred regimen: Darunavir 800mg-Ritonavir 100 mg once-daily AND Tenofovir 300 mg/Emtricitabine 200 mg once-daily.
- Alternative Regimen(1)
- Atazanavir 300 mg/Cobicistat 150 mg AND Tenofovir disoproxil fumarate 300 mg/Emtricitabine 200 mg once-daily—only for patients with pre-treatment estimated CrCl ≥70 mL/min.
- Alternative Regimen(2)
- Atazanavir 300 mg-Ritonavir 100 mg once-daily plus Tenofovir 300 mg/Emtricitabine 200 mg once-daily.
- Alternative Regimen(3)
- Darunavir 800mg /Cobicistat 150 mg OR Darunavir 800mg/Ritonavir 100mg AND Abacavir 600 mg/Lamivudine 300mg —only for patients who are HLA-B*5701 negative.
- Alternative Regimen(4)
- Darunavir 800mg/Cobicistat 150 mg AND Tenofovir disoproxil fumarate 300mg/Emtricitabine 200 mg —only for patients with pre-treatment estimated CrCl ≥70 mL/min.
- Alternate Regimen(5)
- Atazanavir 300 mg-Ritonavir 100 mg once-daily AND Abacavir 600 mg-Lamivudine 300 mg once-daily in patients who are HLA-B*5701-negative and with pre-treatment HIV RNA <100,000 copies/mL.
- Alternate Regimen(6)
- Lopinavir 400mg/Ritonavir 100mg (once or twice daily) AND Abacavir 600 mg-Lamivudine 300mg—only for patients who are HLA-B*5701 negative.
- Alternate Regimen(7)
- Lopinavir 400mg/Ritonavir 100mg (once or twice daily) AND Tenofovir disoproxil fumarate 300mg/Emtricitabine 200 mg.
- 1.4 Other Regimen Options
- 1.4.1 NNRTI-Based Regimen
- Preferred regimen: Efavirenz 600mg AND Abacavir 600 mg/Lamivudine—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
- Darunavir-Ritonavir 100 AND Raltegravir—only for patients with pre-treatment HIV RNA <100,000 copies/mL and CD4 cell count >200 cells/mm3.
- Lopinavir 400mg/Ritonavir 100mg (twice daily) AND Lamivudine 300mg BID.
- Pediatric dose: Abacavir 300 mg po BID, Didanosine 20 to < 25 kg: 200 mg po once daily 25 to < 60 kg: 250 mg po once daily ≥60 kg: 400 mg po once daily; Lamivudine 4 mg/kg/dose po BID; maximum 150 mg po BID; Stavudine 1 mg/kg/dose po q12h, Tenofovir Recommended oral dose is 8 mg/kg; Zidovudine 180 - 240 mg/m2/dose po q12h or 160 mg/m2/dose po q8h (range 90-180); 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; Nevirapine maximum 200 mg per dose; Lopinavir 400mg; Nelfinavir 50 mg/kg/dose po BID; Raltegravir 300mg
- 2. Pre-Exposure Prophylaxis(PrEP)
- Preferred regimen- Daily, continuing, oral doses of Tenofovir disoproxil fumarate 300mg-Emtricitabine 200 mg, ≤90-day supply.
- Note(1): People with high risk behaviour 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 BID + Tenofovir disoproxil fumarate 300mg/Emtricitabine 200 mg 1 QD.
- Preferred Basic regimen for low-risk exposures (Eg: mucus membrane):
- Zidovudine 100mg AND Lamivudine 300mg.
- Zidovudine 100mg AND Emtricitabine 200 mg.
- Tenofovir 300mg AND Lamivudine 300mg.
- Tenofovir 300mg AND Emtricitabine 200 mg.
- Preferred Expanded regimen for high-risk exposure (Eg: percutaneous needle stick).
- Zidovudine 100mg AND Lamivudine 300mg AND Lopinavir 400mg-Ritonavir 100mg.
- Zidovudine 100mg AND Emtricitabine 200 mg AND Lopinavir 400mg-Ritonavir 100mg.
- Tenofovir 300mg AND Lamivudine 300mg AND Lopinavir 400mg-Ritonavir 100mg.
- Tenofovir 300mg AND Emtricitabine 200 mg AND Lopinavir 400mg-Ritonavir 100mg.
- 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 (fixed dose combination) OR Tenofovir 300mg-Lamivudine 300mg OR Abacavir 600mg-Lamivudine 300mg OR Zidovudine 100mg-Lamivudine 300mg AND Atazanavir300 mg-Ritonavir 100mg OR Lopinavir 400mg-Ritonavir 100mg.
- 4.1.2 A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen:
- Preferred regimen-Efavirenz 600mg-Tenofovir 300mg-Emtricitabine 200mg (fixed dose combination) or Efavirenz 600mg-Tenofovir 300 mg-Lamivudine 300mg.
- Alternate regimen-Abacavir 600mg-Lamivudine 300mg OR Zidovudine 100mg-Lamivudine 300mg AND Efavirenz 600mg.
- 4.2 Intrapartum
- HIV RNA <1000 copies/mL and good afherance-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 Preferred regimen: Zidovudine (ZDV) 100mg 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.
- <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
-
- 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: TMP-SMX 1 doublestrength (DS) PO daily OR TMP-SMX 1 singlestrength (SS) daily
- Alternative regimen: TMP-SMXa 1 DS PO three times weekly OR Dapsone 100 mg PO daily or 50 mg PO BID OR Dapsone 50 mg PO daily + (pyrimethamine 50 mg + leucovorin 25 mg) PO weekly OR (Dapsone 200 mg + pyrimethamine 75 mg + leucovorin 25 mg) PO weekly OR Aerosolized pentamidine 300 mg via Respigard nebulizer every month OR Atovaquone 1500 mg PO daily OR Atovaquone 1500 mg + pyrimethamine 25 mg + leucovorin 10 mg) PO daily.
- 6.1.2 Treatment
- Preferred regimen:
- For Moderate-to-Severe PCP TMP-SMX 15–20 mg AND SMX 75–100 mg]/kg/day IV given q6h or q8h, may switch to PO after clinical improvement.
- For Mild-to-Moderate PCP TMP 15–20 mg AND SMX 75–100 mg]/kg/day, given PO in 3 divided doses OR TMP-SMX: 160 mg/800 mg or DS) 2 tablets PO TID.
- Secondary Prophylaxis, after completion of PCP treatment TMP-SMX DS: 1 tablet PO daily OR TMP-SMX (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 q6h or 600 mg PO q8h.
- For Mild-to-Moderate PCPDapsone 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
- Alternate regimen(1): TMP-SMX DS: 1 tablet PO three times weekly.
- Alternate regimen(2): Dapsone 100 mg PO daily.
- Alternate regimen(3): Dapsone 50 mg PO daily AND Pyrimethamine 50 mg AND Leucovorin 25 mg PO weekly.
- Alternate regimen(4): Dapsone 200 mg AND Pyrimethamine 75 mg AND Leucovorin 25 mg) PO weekly.
- Alternate regimen(5): Dapsone 100 mg PO daily.
- Alternate regimen(6): Dapsone 50 mg PO daily AND Pyrimethamine 50 mg AND Leucovorin 25 mg) PO weekly.
- Alternate regimen(7): Dapsone 200 mg + Pyrimethamine 75 mg AND Leucovorin 25 mg) PO weekly.
- Alternate regimen(8): Aerosolized pentamidine 300 mg monthly via Respirgard nebulizer.
- Alternate regimen(9): Atovaquone 1500 mg PO daily.
- Alternate 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
- TMP-SMX should be permanently discontinued in patients with possible or definite StevensJohnson Syndrome or toxic epidermal necrosis.
- 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: TMP-SMXa 1 DS PO daily.
- Alternate regimen(1): TMP-SMXa 1 DS PO three times weekly.
- Alternate regimen(2): TMP-SMXa 1 SS PO daily
- Alternate regimen(3): Dapsoneb 50 mg PO daily + (pyrimethamine 50 mg + leucovorin 25 mg) PO weekly
- Alternate regimen(4): Dapsoneb 200 mg + pyrimethamine 75 mg + leucovorin 25 mg) PO weekly
- Alternate regimen(5): Atovaquone 1500 mg PO daily
- Alternate regimen(6):Atovaquone 1500 mg + pyrimethamine 25 mg + leucovorin 10 mg) PO daily.
Bronchiolitis
Treatment
- Note[2]
- Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally
- Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis.
- Clinicians should not administer epinephrine to infants and children with a diagnosis of bronchiolitis.
- Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting.
- Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one.
- Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department.
- Clinicians should not use chest physiotherapy for infants and children with a diagnosis of bronchiolitis.
- Note[2]
Prophylaxis
- Regimen: Palivizumab (15 mg/kg/dose) during the respiratory syncytial virus season to infants who qualify for palivizumab in the first year of life.
- Note
- Clinicians should administer palivizumab during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity defined as preterm infants <32 weeks 0 days’ gestation who require >21% oxygen for at least the first 28 days of life.
- Clinicians should not administer palivizumab to otherwise healthy infants with a gestational age of 29 weeks, 0 days or greater.
- All people should disinfect hands before and after direct contact with patients, after contact with inanimate objects in the direct vicinity of the patient, and after removing gloves.
- All people should use alcoholbased rubs for hand decontamination when caring for children with bronchiolitis. When alcoholbased rubs are not available, individuals should wash their hands with soap and water.
- Clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and smoking cessation when assessing a child for bronchiolitis.
Influenza
Treatment
- Preferred Regimen(1): Zanamivir 10 mg (two 5-mg inhalations) BID for 5 days.
- Preferred Regimen(2): Oseltamivir 75 mg BID for 5 days.
- Preferred Regimen(3): Peramivir 600 mg dose, IV for 15-30 minutes for 1 day.
Prophylaxis
- The chemoprophylaxis dosage of Zanamivir is 10 mg (2 inhalations) once a day.
- The chemoprophylaxis of Oseltamivir is from 3 months and older age group.
- Pediatric dose
- Oseltamivir
- If younger than 1 yr old1:
- 3 mg/kg/dose twice daily2,3
- If 1 yr or older, dose varies by child’s weight:
- 15 kg or less, the dose is 30 mg twice a day
- >15 to 23 kg, the dose is 45 mg twice a day>23 to 40 kg, the dose is 60 mg twice a day>40 kg, the dose is 75 mg twice a day.
- Zanamivir
- 10 mg (two 5-mg inhalations) twice daily
- (FDA approved and recommended for use in children 7 yrs or older).
Dosing in Adult Patients with Renal Impairment
- Oral oseltamivir
- Creatinine clearance 61 to 90 mL/min-
- Recommended Treatment Regimen- 75 mg BID
- Recommended Chemoprophylaxis Regimen- 75 mg qd
- Creatinine clearance 31 to 60 mL/min-
- Recommended Treatment Regimen- 30 mg BID
- Recommended Chemoprophylaxis Regimen- 30 mg qd
- Creatinine clearance 10 to 30 mL/min
- Recommended Treatment Regimen- 30 mg qd
- Recommended Chemoprophylaxis Regimen- 30 mg every other day
- ESRD Patients on Hemodialysis Creatinine clearance ≤10 mL/min
- Recommended Treatment Regimen- 30 mg after every hemodialysis cycle. Treatment duration not to exceed 5 days
- Recommended Chemoprophylaxis Regimen- 30 mg after alternate hemodialysis cycles.
- ESRD Patients on Continuous Ambulatory Peritoneal Dialysis Creatinine clearance ≤10 mL/min.
- Recommended Treatment Regimen- A single 30 mg dose administered immediately after a dialysis exchange
- Recommended Chemoprophylaxis Regimen- 30 mg once weekly immediately after dialysis exchange
- Recommended Chemoprophylaxis Regimen- 30 mg after alternate hemodialysis cycles.
Note:
- Early treatment of hospitalized patients can reduce death.
- An emphasis on close monitoring and early initiation of antiviral treatment if fever and/or respiratory symptoms develop is an alternative to chemoprophylaxis after a suspected exposure for some persons.
- To be effective as chemoprophylaxis, an antiviral medication must be taken each day for the duration of potential exposure to a person with influenza and continued for 7 days after the last known exposure. For persons taking antiviral chemoprophylaxis after inactivated influenza vaccination, the recommended duration is until immunity after vaccination develops (antibody development after vaccination takes about two weeks in adults and can take longer in children depending on age and vaccination history).
- Antiviral chemoprophylaxis generally is not recommended if more than 48 hours have elapsed since the first exposure to an infectious person.
- Patients receiving antiviral chemoprophylaxis should be encouraged to seek medical evaluation as soon as they develop a febrile respiratory illness that might indicate influenza.
- Zanamivir is contraindicated in patients with history of allergy to milk protein.
- Oral oseltamivir is preferred for treatment of pregnant women.
- For control of outbreaks in institutional settings (e.g. long-term care facilities for elderly persons and children) and hospitals, CDC recommends antiviral chemoprophylaxis for a minimum of 2 weeks, and continuing up to 1 week after the last known case was identified. Antiviral chemoprophylaxis is recommended for all residents, including those who have received influenza vaccination, and for unvaccinated institutional employees.
Empyema
Culture negative pleural infection
- Preferred regimen: Cefuroxime 1.5 g IV q8h AND Metronidazole 500 mg IV q8h OR Template:Benzyl penicillin 1.2 g IV q6h PLUS Ciprofloxacin 400 mg IV q12h OR meropenem 1 g IV q8h PLUS metronidazole 500 mg q8h.[3]
- Preferred regimen(2): Amoxycillin 1 g oral q8h PLUS clavulanic acid 125 mg oral q8h PLUS metronidazole 400mg oral q8h OR clindamycin 300 mg oral q8h.LastName, FirstName (2007). Sanford guide to antimicrobial therapy. Place of publication not identified: Antimicrobial Therapy. ISBN 9781930808386.
For culture negative hospital acquired infection
- Preferred regimen: Piperacillin 3 gm IV q4h PLUS tozobactam 4.5g IV q6h OR ceftazidime 2g IV q8h OR meropenem 1g IV q8h PLUS metronidazole 500mg q8h.
Pathogen based empyema
Strep. pneumoniae, Group A strep
- Preferred regimen(1):Ceftriaxone ≤30 days old, 75 mg/kg IV/IM q24h (use with caution in infants with jaundice) or >30 days old 100 mg/kg IV/IM q24h
Staph. aureus
- Preferred regimen(1): Nafcillin 2 gm IV q4h OR oxacillin 2 gm IV q4h if MSSA
- Alternate regimen(1): Vancomycin 1 gm IV q12h OR Linezolid 600 mg po bid if MRSA
H. influenzae
- Preferred regimen: Ceftriaxone 75 mg/kg IV/IM q24h
- Alternate regimen: TMP-SMX 1 tab po 5 days/wk or AM-SB
Subacute/chronic empyema
Anaerobic strep, Strep. milleri, Bacteroides sp., Enterobacteriaceae, M. tuberculosis
- Preferred regimen: Clindamycin 450–900 mg IV q8h + Ceftriaxone
- Alternate regimen: Cefoxitin or IMP or TC-CL or PIP-TZ or AM-SB
References
- ↑ "AIDSinfoNIH".
- ↑ Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM; et al. (2014). "Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis". Pediatrics. 134 (5): e1474–502. doi:10.1542/peds.2014-2742. PMID 25349312.
- ↑ Ahmed AE, Yacoub TE (2010). "Empyema thoracis". Clin Med Insights Circ Respir Pulm Med. 4: 1–8. PMC 2998927. PMID 21157522.