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Revised Guidelines for the Treatment of OIs
This revision includes detailed information on 28 infections and on new challenges -- such as immune reconstitution syndromes and drug interactions -- that have arisen since the advent of potent antiretroviral therapy.
In this massive document, several years in the making, the NIH, CDC, and the HIV Medicine Association of the IDSA have revised the guidelines for treating opportunistic infections (OIs). These guidelines can be considered a companion document to similar works on treating OIs in children, the OI prevention guidelines last updated in 2001, and the frequently updated guidelines for using antiretroviral therapy in adults and adolescents (all available at www.aidsinfo.nih.gov/guidelines). All of these guidelines share important features, including that they are: (1) evidence-based and use the IDSA rating system to describe the strength of the recommendations; (2) developed by a broad panel of clinical and research experts from academic medical centers, government agencies, community-based practices, and consumer advocates; (3) freely available in print media and on the internet, with the online versions periodically updated; and (4) written for healthcare providers who treat HIV-infected patients in the developed world.
The document begins with a summary of the effect of antiretroviral therapy on both the incidence and management of OIs. This useful section describes evidence both for and against initiating antiretroviral therapy in patients with acute OIs, and the panel acknowledges that no data demonstrate conclusively that starting antiretroviral therapy acutely either improves or worsens the prognosis for any given OI. Studies are underway to evaluate the best course in this setting. In the absence of such data, clinicians confronting a patient with a recently diagnosed OI must consider several factors, including the availability of effective treatment for the specific OI, the risk for drug interactions or overlapping drug toxicities, the risk for and consequences of developing an inflammatory immune reconstitution syndrome, and the willingness and ability of the patient to adhere to antiretroviral therapy. Naturally, for opportunistic processes for which therapy is nonexistent or minimally effective -- such as cryptosporidiosis, microsporidiosis, progressive multifocal leukoencephalopathy (PML), and Kaposi sarcoma -- antiretroviral therapy should be started as soon as possible. In contrast, for tuberculosis, Mycobacterium avium complex, and pneumocystis, it is usually prudent to wait for a clinical response to OI treatment before initiating antiretroviral therapy; the timing of this response will vary based on the patient and the condition. Generally, antiretroviral therapy should be continued when an OI occurs in the context of virologic suppression; however, clinicians should consider modifying the regimen if the CD4-cell response has been suboptimal.
The bulk of the document provides specific recommendations regarding 28 individual OIs, covering data on epidemiology, clinical presentation, diagnosis, treatment (including monitoring, adverse events, and treatment failure), preventing recurrence, and special considerations during pregnancy. All recommendations are graded with the IDSA rating scheme, which uses letters to describe the strength of the recommendation (A [strongly in favor of] through E [strongly opposed to]), and Roman numerals to rate the quality of evidence (I [backed by at least one randomized trial] through III [backed by expert opinion and descriptive studies]). For example, the use of TMP-SMX for treating pneumocystis is graded AI, whereas adding or switching to another regimen in the context of antipneumocystis treatment failure -- a strategy for which there are no formal clinical trials -- is graded BIII. All of the sections on individual OIs are excellent resources, but perhaps the most practical portion of the document is Table 6, which summarizes the evidence-based guidelines for treating the 28 OIs, with columns for preferred therapy and duration, alternative therapy, and general comments. The entire work is exhaustively referenced.
Comment: With the decline in the incidence of opportunistic infections that followed the widespread adoption of effective antiretroviral therapy in 1996, many clinicians are no longer familiar with the clinical presentation or management of these potentially life-threatening conditions. In addition, antiretroviral therapy has changed the clinical presentation and complexity of managing these OIs, most notably through the occurrence of inflammatory immune reconstitution syndromes and drug interactions, respectively. These revised guidelines are invaluable and likely will serve as a gold-standard reference, not only in the developed world, but also in resource-poor areas where antiretroviral therapy is currently being introduced.
— Paul E. Sax, MD
Published in AIDS Clinical Care February 1, 2005
Citation(s):
Treating opportunistic infections among HIV-infected adults and adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. MMWR Recomm Rep 2004 Dec 17; 53:1-112.
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