University of Pennsylvania Medical Center Guidelines for Antibiotic Use

HIV - OPPORTUNISTIC INFECTIONS1

 

Infection Recommended Therapy Dosage Regimen Duration

Pneumocystis carinii Pneumonia

Treatment



1st Choice TMP/SMX2

2nd Choice

mild/moderate

dapsone3 + trimethoprim OR

clindamycin + primaquine3 OR

atovaquone4

severe2

pentamidine

TMP/SMX 15-20mg/kg/d TMP IV/PO in 3-4 divided doses

dapsone3 100mg PO q day

trimethoprim 20mg/kg/d PO in 3-4 divided doses

clindamycin 600mg IV q 6 hour OR 300-450mg PO QID

primaquine3 15mg base PO q day

atovaquone 750mg PO BID4

pentamidine 4mg/kg/d IV

21 days

Prophylaxis

(secondary PCP, CD4 < 200/mm3 or < 20%)

1st Choice TMP/SMX

2nd Choice dapsone3

3rd Choice pentamidine

TMP/SMX 160/800mg (1 DS tablet) PO 3 times/week5

dapsone 50-100mg PO q day6

pentamidine 300mg q month (aerosolized)

Chronic

Toxoplasmosis

Treatment



1st Choice pyrimethamine + sulfadiazine

2nd Choice pyrimethamine + clindamycin

pyrimethamine7 200mg PO x 1 then 75mg PO q day

sulfadiazine 1-1.5 gm PO QID

clindamycin 600mg IV/PO QID

6 weeks
Chronic Suppressive Therapy

1st Choice pyrimethamine + sulfadiazine

2nd Choice pyrimethamine + clindamycin

pyrimethamine7 25mg PO q day

sulfadiazine 500mg PO QID

clindamycin 300mg PO QID

Chronic

Prophylaxis

(IgG antibody to Toxoplasma and CD4 count < 100/mcl)

TMP/SMX TMP/SMX 160/800mg (1 DS tablet) PO q day Chronic

 

1Consultation with experienced HIV practitioner recommended

2Add steroids if PO2 áDþÿ4 70mm Hg on room air

(prednisone 40mg bid x 5 day, then 40mg q day x 5 day then, 20mg q day x 11 day)

3Assay for G-6-PD deficiency recommended before therapy

4Atovoquone must be taken with food (preferrably fatty) for adequate absorption

53x/week = Monday, Wednesday, Friday

6If dapsone 50mg PO q day regimen: add pyrimethamine 50mg PO q week and folinic acid 25mg PO q week

7With folinic acid 10-20mg q day

HIV - OPPORTUNISTIC INFECTIONS

Infection Recommended Therapy Dosage Regimen Duration

Candidiasis

Oral1

1st choice clotrimazole troche

2nd choice fluconazole OR

amphotericin B oral suspension

clotrimazole troche 10mg 5x/day

fluconazole 50-100mg PO q day

amphotericin B oral suspension - 100mg swish, hold then swallow QID

As needed
Esophageal1

1st choice fluconazole

2nd choice amphotericin B

fluconazole 100-200mg PO q day

amphotericin B 0.3mg/kg IV q day (Table VII)

2-3 weeks

7 days

Vaginal

clotrimazole

(if refractory, fluconazole)

clotrimazole 100mg intravaginally q day

fluconazole 100mg PO q day

7 days2
Cryptococcosis

amphotericin B + flucytosine then

fluconazole

amphotericin B 0.7mg/kg/d IV (TableVII)

PLUS

flucytosine 100mg/kg/d PO in 4 divided doses

THEN:

fluconazole 400mg PO q day x 10 weeks, then fluconazole 200mg PO q day for suppressive therapy

amphotericin B + flucytosine 14 days then

fluconazole as noted in dosage regimen section

 

1Primary and secondary prophylaxis controversial

2May require continuous therapy to prevent relapse



HIV - OPPORTUNISTIC INFECTIONS

Infection Recommendation Dosage Regimen Duration

Tuberculosis,

Treatment - Pulmonary or Extrapulmonary1

isoniazid and 300mg PO q day Controversial - discuss with Infectious Diseases consult service
rifampin and 600mg PO q day
pyrazinamide and 25mg/kg/d PO q day
ethambutol 15-25mg/kg/d PO
± levofloxacin 750-1000mg PO q day
± streptomycin 15mg/kg IM q day
Prophylaxis - Primary and Secondary2 isoniazid3 300mg PO q day Controversial - discuss with Infectious Diseases consult service

Disseminated Mycobacterium avium Complex

Treatment

clarithromycin OR 500mg PO BID Chronic
azithromycin PLUS 500mg PO q day
ethambutol THEN 15mg/kg/d PO
consider adding 1 or 2 of the following if symptoms persist or if patient acutely ill
rifabutin 300mg PO q day
ciprofloxacin 500-750mg PO BID
amikacin

15mg/kg/d IM/IV x 7-14 days

then

7.5mg/kg/d IM 3x/week

Prophylaxis

azithromycin OR

clarithromycin

1200mg PO q week

500mg PO BID

Chronic

 

1If patient has a history of noncompliance or has previously received therapy, discuss with an Infectious Diseases Practitioner

2Some evidence suggests that prophylaxis of all patients in high prevalence areas may be advisable regardless of PPD status
3Patients receiving isoniazid should receive pyridoxine 50mg po q day

HIV - OPPORTUNISTIC INFECTIONS

Infection Recommendation Dosage Regimen Duration

Cytomegalovirus (retinitis, colitis, esophagitis)

Treatment

ganciclovir 5 mg/kg IV q 12 hour 14 - 21 days
foscarnet1 (if refractory) 60 mg/kg IV q 8 hour1
cidofovir2 5 mg/kg IV q week x 2 doses
Chronic Suppressive (retinitis) ganciclovir

5 mg/kg IV q day

OR

1 gm PO tid3

Chronic
foscarnet1 (if refractory) 90-120 mg/kg/d IV1
cidofovir2 5 mg/kg IV q 2 weeks

Syphilis4

Primary, Secondary, Latent < 1 year

Latent > 1 year, Indeterminate origin or Cardiovascular

Neurosyphilis



benzathine penicillin

benzathine penicillin



penicillin G



2.4mu IM

2.4mu IM q week


12-24mu/d IV



x 1 dose

x 3 weeks



10 days

Herpes Simplex Virus5

Treatment

Stomatitis/genital

Perirectal





valacyclovir

valacyclovir





500mg PO BID

1 gm PO BID





5 days

5 days

Chronic Suppressive

(if recurrence is frequent or severe)

valacyclovir 500mg PO q day Chronic

 

1Premedicate before each dose with 500-1000ml sodium chloride 0.9% (decreases the incidence of nephrotoxicity)

2Because of toxicity and difficulty of administration, cidofovir may be used only in consultation with Infectious Diseases

3Should be administered with a fatty meal; oral ganciclovir IS NOT for sight-threatening disease

4Recommendations vary, most use standard regimen

5Resistant cases may require foscarnet

Back to Table of Contents