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Toxoplasmosis

  • Toxoplasma gondii (treatment)
  • 1. Lymphadenopathic toxoplasmosis[1]
  • Preferred regimen: Treatment of immunocompetent adults with lymphadenopathic toxoplasmosis is rarely indicated; this form of the disease is usually self-limited.
  • 2. Ocular disease[2]
  • 2.1 Adults
  • 2.2 Pediatric
  • Preferred regimen: Pyrimethamine 2 mg/kg PO first day then 1 mg/kg each day AND Sulfadiazine 50 mg/kg PO bid AND folinic acid (Leucovorin 7.5 mg/day PO ) for 4 to 6 weeks followed by reevaluation of the patient's condition
  • Alternative regimen: The fixed combination of Trimethoprim with Sulfamethoxazole has been used as an alternative.
  • Note: If the patient has a hypersensitivity reaction to sulfa drugs, Pyrimethamine AND Clindamycin can be used instead.
  • 3. Maternal and fetal infection[3]
  • 3.1 First and early second trimesters
  • 3.2 Late second and third trimesters
  • 3.3 Infant
  • 4. Toxoplasma gondii Encephalitis in AIDS[4]
  • 4.1 Treatment for acute infection
  • 4.2 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 q8h AND (Pyrimethamine 25–50 mg AND Leucovorin 10–25 mg) PO qd
  • Alternative regimen (2): TMP-SMX DS 1 tablet bid
  • Alternative regimen (3): Atovaquone 750–1500 mg PO bid AND (Pyrimethamine 25 mg AND Leucovorin 10 mg) PO qd
  • Alternative regimen (4): Atovaquone 750–1500 mg PO bid
  • Alternative regimen (5): Sulfadiazine 2000–4000 mg PO bid/qid
  • Alternative regimen (6): Atovaquone 750–1500 mg PO bid Pyrimethamine and Leucovorin doses are the same as for preferred therapy
  • Note: Adjunctive corticosteroids (e.g., Dexamethasone) should only be administered when clinically indicated to treat mass effect associated with focal lesions or associated edema; discontinue as soon as clinically feasible. Anticonvulsants should be administered to patients with a history of seizures and continued through acute treatment, but should not be used as seizure prophylaxis . If Clindamycin is used in place of Sulfadiazine, additional therapy must be added to prevent PCP.
  • Toxoplasma gondii (prophylaxis)
  • 1. Prophylaxis to prevent first episode of encephalitis in AIDS[5]
  • 1.1 Indications
  • 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 cells/µL. Prophylaxis should be initiated if seroconversion occurred.
  • 1.2 Prophylactic therapy

Varicella zoster

  • 1. Varicella zoster treatment[6]
  • 1.1 Non Immunocompromised person
  • Preferred regimen (1): Acyclovir 500 mg PO five times daily for 7-10 days
  • Preferred regimen (2): Famciclovir 500 mg PO tid daily for 7 days
  • Preferred regimen (3): Valacyclovir 1 g PO tid daily for 7 days
  • Preferred regimen (4): Brivudin 125 mg PO qd daily for 7 days
  • 1.2 Immunocompromised person requiring hospitalization or persons with sever neurologic complications
  • Preferred regimen (1): Acyclovir 10 mg/ kg IV q8h for 7-10 days
  • Preferred regimen (2): Foscarnet 40 mg/ kg IV q8h until lesions are healed
  • Note: Brivudin is not available in USA and has not been approved by FDA. Foscarnet is not approve by FDA
  • 2. Treatment of VZV complications[7]
  • 2.1 VZV ophthalmicus
  • Treatment includes the following
  • (1) Famciclovir OR Valacyclovir for 7–10 days, preferably started within 72 h of rash onset (with Acyclovir IV given as needed for retinitis), to resolve acute disease and inhibit late inflammatory recurrences, AND Prednisone 20 mg PO tid for 4 days or bid for 6 days, and then qd for 4 day
  • (2) Bacitracin-Polymyxin ophthalmic ointment administered bid ,to protect the ocular surface;
  • (3) Topical Prednisolone 0.125%–1% 2–6 times daily prescribed and managed only by an ophthalmologist for corneal immune disease, episcleritis, scleritis, or iritis;
  • (4) Homatropine 5% bid as needed for iritis
  • (5) Latanaprost qd and/or Timolol maleate ophthalmic gel forming solution every morning)ocular pressure–lowering drugs given as needed for glaucoma
  • Note (1): Systemic steroids are indicated in the presence of moderate to severe pain or rash, particularly if there is significant edema, which may cause orbital apex syndrome through pressure on the nerves entering the orbit.
  • Note (2): pain medications and cool to tepid wet compresses (if tolerated) and no topical antivirals, because they are ineffective
  • 2.2 VZV retinitis
  • Preferred regimen: Acyclovir IV 10–15 mg/kg q8h for 10–14 days followed by Valacyclovir PO 1 g tid daily for 4–6 weeks
  • 3 Recommendations for treating varicella zoster virus (VZV) Infections in HIV-Infected adults and adolescents[8]
  • 3.1 Primary Varicella Infection (Chickenpox)
  • 3.1.1 Uncomplicated Cases
  • Preferred regimen:Valacyclovir 1 g PO tid for 5–7 days
  • Preferred regimen: Famciclovir 500 mg PO tid for 5–7 days
  • Alternative regimen: Acyclovir 800 mg PO 5 times daily for 5–7 days
  • 3.2.1 Severe or Complicated Cases
  • 3.2 Herpes Zoster (Shingles)
  • 3.2.1 Acute Localized Dermatomal
  • Preferred regimen: Valacyclovir 1000 mg PO tid for 7–10 days
  • Preferred regimen: Famciclovir 500 mg PO tid for 7–10 days
  • Alternative Therapy: Acyclovir 800 mg PO 5 times daily for 7–10 days
  • Note: Longer duration should be considered if lesions resolve slowly
  • 3.2.2 Extensive Cutaneous Lesion or Visceral Involvement
  • Preferred regimen: Acyclovir 10–15 mg/kg IV q8h until clinical improvement is evident, then switch to oral therapy (Valacyclovir 1 g tid, Famciclovir 500 mg tid, or Acyclovir 800 mg PO 5 times daily)—to complete a 10–14 day course, when formation of new lesions has ceased and signs and symptoms of visceral VZV infection are improving
  • 3.3 PORN (Progressive outer retinal necrosis)
  • Preferred regimen: Ganciclovir 5 mg/kg and/or Foscarnet 90 mg/kg IV q12h AND Ganciclovir 2 mg/0.05mL and/or foscarnet 1.2 mg/0.05mL intravitreal twice weekly (AIII)
  • Note: Duration of therapy is not well defined and should be determined based on clinical, virologic, and immunologic response in consultation with experienced ophthalmologist and optimize ART regimen.
  • Note: Ganciclovir ocular implants are no longer commercially available
  • 3.4 ARN (Acute retinal necrosis)
  • Preferred regimen: Acyclovir 10-15 mg/kg IV q8h for 10–14 days, followed by Valacyclovir 1 g PO tid for 6 weeks AND Ganciclovir 2 mg/0.05mL intravitreal twice weekly X 1-2 doses
  • Note: Duration of therapy is not well defined and should be determined based on clinical, virologic, and immunologic response in consultation with experienced ophthalmologist.

Influenza

  • 1. Adults
  • Preferred regimen (1): Oseltamivir (Tamiflu®) 75 mg bid
  • Preferred regimen (2): Zanamivir (Relenza®) 10 mg (two 5-mg inhalations) bid
  • Preferred regimen (3): Peramivir (Rapivab®) 600 mg IV for 15-30 minutes (single dose)
  • Note: FDA approved and recommended Peramivir (Rapivab®) for use in adults ≥18 yrs
  • 2. Children
  • 2.1 < 1 yr
  • Preferred regimen: Oseltamivir (Tamiflu®) 3 mg/kg/dose bid
  • 2.2 > 1 yr
  • 2.2.1 ≤ 15 kg
  • 2.2.2 > 15 to 23 kg
  • 2.2.3 > 23 to 40 kg
  • 2.2.4 > 40 kg
  • Preferred regimen: Oseltamivir (Tamiflu®) 75 mg bid
  • Note: Zanamivir (Relenza®) 10 mg (two 5-mg inhalations) bid may be considered for children > 7 yrs old
  • Adult Patients with Renal Impairment or End Stage Renal Disease (ESRD) on Dialysis
  • Oral Oseltamivir
  • Creatinine clearance 61 to 90 mL/min-75 mg twice a day
  • Creatinine clearance 31 to 60 mL/min-30 mg twice a day
  • Creatinine clearance 10 to 30 mL/min-30 mg once daily
  • ESRD Patients on Hemodialysis
  • Creatinine clearance ≤10 mL/min-30 mg after every hemodialysis cycle. Treatment duration not to exceed 5 days
  • ESRD Patients on Continuous Ambulatory Peritoneal Dialysis-A single 30 mg dose administered immediately after a dialysis exchange
  • Intravenous Peramivir (single dose)
  • Creatinine clearance >50 mL/min-600mg
  • Creatinine clearance 30 to 49 mL/min-200mg
  • Creatinine clearance 10 to 29 mL/min-100mg
  • ESRD Patients on Hemodialysis-Dose administered after dialysis at a dose adjusted based on creatinine clearance




Children- < 1 yr: 3 mg/kg/dose twice daily > 1 yr: dose depends on weight. ≤ 15 kg: 30 mg twice a day > 15 to 23 kg: 45 mg twice a day > 23 to 40 kg: 60 mg twice a day > 40 kg: 75 mg twice a day.

Zanamivir (Relenza®) Adults 10 mg (two 5-mg inhalations) twice daily

For children > 7 yrs old. 10 mg (two 5-mg inhalations) twice daily


Peramivir (Rapivab®) Adults 600 mg IV for 15-30 minutes (single dose)

  1. "Parasites - Toxoplasmosis (Toxoplasma infection)".
  2. "Parasites - Toxoplasmosis (Toxoplasma infection)".
  3. "Parasites - Toxoplasmosis (Toxoplasma infection)".
  4. "Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents" (PDF).
  5. "Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents" (PDF).
  6. Cohen JI (2013). "Clinical practice: Herpes zoster". N Engl J Med. 369 (3): 255–63. doi:10.1056/NEJMcp1302674. PMID 23863052.
  7. Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M; et al. (2007). "Recommendations for the management of herpes zoster". Clin Infect Dis. 44 Suppl 1: S1–26. doi:10.1086/510206. PMID 17143845.
  8. "VZV". Text "https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-oi-prevention-and-treatment-guidelines/341/vzv " ignored (help); Missing or empty |url= (help)