4 Opportunistic Infections and prophylaxis.ppt

MANAGING OIs

1. Opportunistic
Infections

2. Objectives
At the end of this session we should be able
to -
Describe how HIV weakens our immune
system
Describe and manage OIs
Discuss OI prophylaxis

3. How Does HIV Weaken Our
Immune System? -1
White blood cells play an important role to
defend the body against all kinds of diseases.
There are 2 types of WBCs; granulocytes
(neutrophils, monocytes, basophils, &
eosinophils), and lymphocytes.
 A CD4 cell is a special type of lymphocyte
with a marker on its surface called CD4.

4. How Does HIV Weaken Our
Immune System? -2
CD4 cell plays a central role, just as a captain does,
in organising all the WBCs to fight off a disease.
HIV attacks mostly these CD4 cells.
As the infection progresses, the number of CD4
cells decreases.
 CD4 cell count is therefore a good way of checking
how far advanced an HIV infection is.

5. How Does HIV Weaken Our
Immune System? -3
After several years of HIV infection, a
person’s immune system will be very weak,
so that it becomes vulnerable to diseases
that it could normally fight off.
These diseases are called opportunistic
infections because they take advantage of a
weakened immune system to cause disease.

6. What are Opportunistic
Infections (OIs)?
Opportunistic Infections are diseases that occur in a
person because of a weakened immune system.
Such diseases DO NOT normally occur in a person
with strong immune system
They may present as unusually severe disease by
a common organism, or infection by an unusual
organism

7. Importance of OIs in HIV
Management
OIs are the main causes of deaths in PLHIV
(i.e. mortality).
They are also major causes of the
infections/diseases that afflict PLHIV (i.e.
morbidity)
OIs also give clues in identifying who is infected
with HIV (i.e. diagnosis) e.g. oral thrush

8. 17/10/25
Some Common OIs
Diarrhoeal Diseases
Chest infection
Skin diseases
Infections of the brain
Diseases of the blood
Diseases of the heart

9. Diarrhoea
Definition
 3 or more watery stools/day,
 May be recurrent or persistent
Causes--
 Infections including TB
 Non Infectious Agent eg. Drugs—ferrous sulphate
 Others- Lymphomas of intestine, Kaposi’s sarcoma
Classification
 Watery diarrhoea eg cholera, cryptosporidium
 Mucoid/ Bloody diarrhoea eg amoebiasis, shigellosis with
or without FEVER

10. Management of Diarrhoea
Investigations
Stool for pus cells, red blood cells, and ova
Mainstay of Management is Fluid replacement
Assess dehydration
Mild- oral fluids
Moderate- oral and IV fluids
Severe- Patient may be in hypovolemic shock with or
without renal shutdown -IV fluids

11. Management of Diarrhoea ctd
Antibiotics: Common ones are
Septrin,
Flagyl and
Ciproflaxacin
Anti Diarrhoeal Agents
Loperamide or Imodium 4mg st, then 2mg after each stool
Lomotil (diphenoxylate and atropine) 2 tablets every 6 hrs till
diarrhoea stops (8tabs max per day)
Other Measures
Maintain nutrition
Vitamins
Diet Modification eg. No milk or milk products, no caffeine

12. Mouth Ulcers
Mouth Ulcers/Sores are very common and must be
treated so patient can eat, drink and swallow
medicines.
The same ulcers can occur in the oesophagus causing
difficulty in swallowing
Common Causes
Herpes simplex –herpes labialis, nasolabial herpes
Candida- thrush
Anaerobic bacteria- gingivitis/periodontitis
Drug Reactions-Steven-Johnsons syndrome
Kaposi’s sarcoma

13. Treatment of Mouth Ulcers
General measures
 Antiseptic mouth washes: chlorhexidine, povidine iodine etc.
 Dilute saline mouth rinses
Bonjela gel- effective relief from pain, discomfort and inflammation of
mouth ulcers
Specific treatment
 Thrush:

Fluconazole 200mg daily x 2 weeks
 Nystatin mouth wash, oral tablet
 Miconazole(daktarin) oral gel
 Herpes simplex / Oral Herpes Labialis
 Oral Acyclovir 400mg po 5x/day
 Periodontitis / Gingivitis
Behavioural change
Oral metronidazole 500mg po bid x 7 to 14 days (doxycycline)

14. Oral Candidiasis
White plaques in the
mouth
Usually appears when
the CD4 count falls
below 200 cells/mm3
The most frequent OI
associated with AIDS

15. Respiratory Infections
One of the commonest complications of HIV
infection
Most common manifestation is Pneumonia
Causes
Bacteria infections
Mycobacteria Tuberculosis
Pneumocystis jiroveci (carinii) (PCP)
Fungal
Nonspecific interstitial pneumonitis in children

16. Pneumococcal Pneumonia
Present with cough productive of
whitish or yellow green sputum,
fever and sometimes chest pain
Chest X-ray appearance varies
depending on the degree of
immunosuppression
Focal infiltrates are more common
with high CD4 counts, more diffuse
infiltrates with more advanced
disease

17. Complications of Bacterial
Pneumonia
Pleural Effusions
Pneumothorax
Pyopneumothorax
Lung Abscesses
Lung Collapse
Fibrosis

18. Genital Warts

19. Symptoms and Signs of CNS
Disease
Clinical Presentation
Altered mental status
Abnormal behaviour
Fever
Seizures
Headache
Focal Neurological Signs eg
(monoplegia, hemiplegia, cranial palsies especially facial nerve,
aphasia, sometimes quadriplegia, cerebellar signs eg abnormal
gait)

20. Other Presentations of CNS
Disorders
 Stroke (“stroke” in a young person without
HPT or diabetes)
 Spinal cord disease (myelopathy)
 Peripheral Neuropathy (pins ,needles,
numbness etc)
 Myopathy (muscle weakness and pain)

21. Differential Diagnosis of CNS
Disease
Cerebral Toxoplasmosis
Cryptococcal Meningitis
Bacterial Meningitis
Tuberculous Meningitis
CNS Lymphoma

22. Cerebral Toxoplasmosis
Caused by a parasite, Toxoplasma gondii
Spread through the faeces of cats and dogs
and eating uncooked meat
Primary lesion is an encephalitis after which
cerebral abscesses develop
CD4 count usually less than 100cells/mm
3
Diagnosis is clinical

23. Treatment
Empirical treatment is practised worldwide
Response to empirical treatment > 85%
Most patients respond by day 7- refer if not responding to
treatment
Sulphadiazine 1gm 6hrly x 6 weeks and
Pyrimethamine 100mg st, 50mg dly x 6 weeks,
Folinic acid 10-25mg dly
Or
Septrin 4 tablets (1920mg) bd Or
Clindamycin 450-600mg +Pyrimethamine 200mg stat then 50-
75mg daily + leucovorin/folinic acid 10-20mg daily X 6 weeks

24. Treatment Ctd
Response to first line treatment is rapid, usually in 3 to 7
days,
If no response, consider another diagnosis but complete
treatment
Other treatment
Anti convulsants
Fluid and electrolyte maintenance
NG tube for feeding, medications
Skin, bowel, bladder care

25. Prevention
Hand Washing after handling night soil (faeces) or
pets
Avoid keeping or playing with pets especially cats
Avoid partially cooked meat eg khebab
Primary (given before disease occurs) and
secondary prophylaxis (after disease has been
treated)
Pyrimethamine + Sulphadiazine for treatment
Septrin 960mg daily (as primary prophylaxis, adult dose)

26. Meningitis
 Clinical features include fever, headache, neck
stiffness, unconscious, confusion or change in
mental state.
Lumbar puncture for evaluation of the CSF
remains the mainstay of diagnosis !!!!
Refer for further management if beyond you

27. Treatment of Meningitis
Bacterial
IV Ceftriaxone 2g/day
IV X`pen 4mu 4hrly +
IV Chloramphenicol
500mg 6hrly x 14
Complications
Cerebral abscess,
Deafness,
Blindness
Recurrent seizures
Fungal
Fluconazole 800mg dly
x many months
REFER if at sub-
district level
Supportive measures

28. Seizures
May be presenting symptom in HIV
disease and could be due to
Cerebral Toxoplasmosis
Tuberculous meningitis
Cryptococcal meningitis
Primary CNS Lymphoma

29. Seizures
Commonest Causes
• Cerebral Toxoplasmosis
• Tuberculosis

30. Management of Seizures
Emperical anti-toxoplasmosis treatment
Anti-epileptics except when cause can be
rapidly reversed-phenytoin, phenobarb
Lumbar puncture is a must to enable definite
diagnosis.
Must be done at the appropriate time
All seizures must be investigated

31. Stroke and Other Localising
Signs
Cerebral toxoplasmosis
Tuberculous meningitis
Tuberculomas
Lymphomas

32. Headaches
Cerebral toxoplasmosis
Cryptococcal Meningitis
Tuberculous meningitis
Others

33. Photo A
Persistent Generalized Lymphadenopathy

34. Photo C
Seborrhea

35. Photo D
Prurigo

36. Photo E
Herpes Zoster (‘Ananse’)

37. Photo B
Angular Cheilitis

38. Photo F
Mouth Ulcers

39. Photo G
Oral Thrush

40. Photo H
Oral Hairy Leukoplakia

41. Prophylaxis

42. Outline
Prevention of Opportunistic Infections
Co-Trimoxazole Prophylaxis
- the criteria for use
- the regimen
- the side effects
- when to stop
Fluconazole Prophylaxis (as above)

43. Prevention Of Opportunistic
Infections
Risk of the Client developing some
opportunistic infections can be decreased
giving certain drugs to the HIV positive
person on a daily basis.
This is called prophylaxis.
A good prophylaxis is not expensive or
complicated and can increase the duration
and quality of life.

44. Prevention Of Opportunistic
Infections
The most commonly used prophylactic
medicine is co-trimoxazole.
Fluconazole is also used but in Ghana, it is a
secondary prophylaxis
Cotrimoxazole prophylaxis is effective in
reducing morbidity, hospitalisation and
mortality in symptomatic HIV patients

45. Prevention of Opportunistic
Infections
General measures ie hand washing, food
hygiene
Immunisations – Childhood Immunisations
Prophylaxis against bacterial and parasitic
infections. e.g. Septrin/cotrimoxazole - 2
tablets dly or 960mg dly for adults

46. Opportunistic Diseases For Which
The Risk Is Reduced With Co-
trimoxazole Prophylaxis
Pneumocystis jirovecii pneumonia (PJP): this
presents with shortness of breath on exertion,
dry cough, fever, hypoxemia (decreased level
of oxygen in the blood).
Toxoplasma brain abscess: this may cause
hemiparesis, often together with headache
and fever.

47. Opportunistic Diseases For Which
The Risk Is Reduced With Co-
trimoxazole Prophylaxis
Pneumonia from Strept. pneumoniae.
Isospora belli: this micro-organism is
responsible for some cases of chronic
diarrhoea with weight loss.
Salmonella species: gastro-intestinal
symptoms and fever.
Malaria

48. Criteria For Starting Co-trimoxazole
Primary Prophylaxis In Adults
All HIV+ people with WHO clinical stage 2, 3,
4 or with a CD4 count less than 350
cells/mm³ should start co-trimoxazole
prophylaxis.
Clients in malaria endemic regions and areas
which have severe bacterial infections
Clients with previous history of sulpha allergy
should not be given co-trimoxazole.

49. Drug Regimen For Co-
trimoxazole Prophylaxis
Co-trimoxazole 480 mg, 2 tablets daily
OR
Co-trimoxazole 960 mg, 1 tablet daily
Children - generally given by weight
Pharmacists guide the dosing
There are printed charts to support this

50. Duration Of Primary Prophylaxis
If an HIV+ client has no access to ART, the
primary co-trimoxazole prophylaxis should be
taken for the rest of his/her life.
If the client is on antiretroviral therapy, the co-
trimoxazole primary prophylaxis can be
stopped when there is viral suppression from
ART or
CD4 count has increased to 500 cells/mm³, and
remains above 500 cells/mm³ for 6 months or more.

51. Co-trimoxazole : Side Effects
Stevens Johnson’s Syndrome
A very severe drug reaction that can be fatal if not
recognised.
These Clients need to have co-trimoxazole stopped and
should be referred urgently to hospital.
Fixed drug eruptions
One or several dark areas on the skin.
They disappear when the drug is stopped and reappear at
the same location when the drug is restarted.
Other new generalised drug rashes
If the Client has peeling or involves the eye or mouth or are
associated with fever, stop and refer.

52. Co-trimoxazole: Side Effects
Liver failure
This is detected by jaundice.
Stop all drugs.
Call for advice or refer.
Haematological failure
In rare cases, co-trimoxazole can suppress the bone marrow.
This can present in several ways:
severe anaemia, and/or
decrease in white blood cells (leading to infections) and/or
easy bleeding due to a decrease in blood platelets.
In all cases of serious side effects, co-trimoxazole should be
stopped and the Client referred.

53. Fluconazole Prophylaxis
Give after full treatment for cryptococcal meningitis
(secondary prophylaxis)
Dosage: 200 mg/day until immune status
reconstituted from ART.
Discuss risks and benefits if pregnant or planning
pregnancy.
Not safe in pregnancy

54. Thank you