Post on 03-Feb-2018
MANAGEMENT OF
OPPORTUNISTIC INFECTION
Tuti Parwati Merati Division of Tropical and Infectious Diseases,
Department of Internal Medicine Faculty of Medicine,
Udayana University, Bali
Pendahuluan
• Penanganan HIV/AIDS:
– Mengobati IO,
– Pengobatan dengan ARV,
– Pengobatan suportif : fisik/psikologis
• Prinsip : IO di obati terlebih dulu, lalu ART
OIs and CD4 in HIV Infection
1000
900
800
700
600
500
400
300
200
100
50
<50
0
PCP Cryptococcal meningitis
PPE
CD4
COUNT
0 3 6 9 1 2 3 4 5 6 7 8 9 10
Months Years
TB
Oral candida OHL
HZV
CMV
MAC
TB
TB
TB
Cryptosporidial diarrhea
12/04
Mucocutaneous Candidiasis: Clinical Manifestations
Erythematous candidiasis
Credit: D. Greenspan, DSC, BDS, HIV InSite
Pseudomembranous candidiasis
Credit: Pediatric AIDS Pictoral Atlas, Baylor International Pediatric AIDS Initiative
12/04
Mucocutaneous Candidiasis: Clinical Manifestations
Esophageal candidiasis
Credit: P. Volberding, MD, UCSF Center for HIV Information Image Library
12/04
Mucocutaneous Candidiasis: Diagnosis
• Oropharyngeal:
– Usually clinical diagnosis
– KOH preparation, culture
• Esophageal:
– Clinical, with trial of therapy
– Endoscopy with histopathology and culture
• Vulvovaginal:
– Clinical diagnosis, KOH preparation
12/04
Mucocutaneous Candidiasis: Treatment
Oropharyngeal • Preferred (7-14 days):
– Fluconazole 100 mg PO QD – Itraconazole oral solution 200 mg PO QD – Clotrimazole troches 10 mg PO 5 times daily – Nystatin suspension 4-6 mL QID or 1-2 flavored pastilles 4-5
times daily
• If refractory to fluconazole: – Itraconazole oral solution ≥200 mg PO QD – Amphotericin B suspension 100 mg/mL, 1 mL PO QID (not
available in United States) – Amphotericin B 0.3 mg/kg IV QD
12/04
Mucocutaneous Candidiasis: Treatment
Esophageal
• Systemic therapy required
• Preferred (14-21 days):
– Fluconazole 100 mg (up to 400 mg) PO or IV QD
– Itraconazole oral solution 200 mg PO QD*
– Voriconazole 200 mg PO BID*
– Caspofungin 50 mg IV QD
*May have significant drug interactions with certain antiretroviral medications; consult information on drug interactions before coadministering with antiretrovirals.
12/04
Mucocutaneous Candidiasis: Treatment
Esophageal
• If refractory to fluconazole:
– Caspofungin 50 mg IV QD
– Voriconazole 200 mg PO or IV BID*
– Amphotericin B 0.3-0.7 mg/kg IV QD
– Amphotericin liposomal or lipid complex 3-5 mg/kg IV QD
*May have significant drug interactions with certain antiretroviral medications; consult information on drug interactions before coadministering with antiretrovirals.
200 CD4
Typical Tuberculosis
Atypical Pulmonary TB
Extra Pulmonary TB
TB manifestation regarding of CD4 levels
50 CD4
500 CD4
HIV early
stage
Advance and
severe HIV Dis.
Clinical Manifestation of TB- HIV
High CD4 Low CD4
• Clinical finding Tipical Atipical
• PPD (+) commonly (-)
• Rontgen Tipical Atipical
• Rontgen Superior lobe Inf/lower lobe
• Extra pulm TB UnCommon Common
• Hilar adenopati Neg Pos
mediastinum
• Pleural effusion Uncommon common
TB DIAGNOSIS
• History of ilness (anamnesis)
• Physical finding
• Microbiologic examination
• Rontgen
• Tuberculin test
• Suspicion
Diagnostic
• Laboratoris – AFB, 3x
– Cultures
• Negative AFB result not exclude TB dx
• Culture positive rate : – 20 -40% HIV-TB co-infection
Symptoms and sign of Active TB
• Prolonged cough
• Chest pain
• Hemoptysis
• Fever
• Shivering
Night sweating
Fatigue
Loss of apetite
Loss of BW
Clinical manifestation of TB
In HIV+ and HIV -
Sign/symptoms HIV (+) HIV (-)
Respiratory symptoms +++ +++
Extra Lung Diseases +++ +
Cavity + +++
Atypical Chest X ray +++ +
PPD neg ++ +
Drugs Side Effect ++ +
Mortality +++ +
Relaps ++ +
Study Methods
A retrospective study of HIV-TB co-infection
patient’s medical record at VCT clinic on
Sanglah General Hospital during January
2005 to Maret 2011
Results of HIV-TB Coinfection
Results of HIV-TB coinfection
Results of HIV-TB Coinfection
Terapi ARV pada Dual HIV-TB
Kondisi Waktu Pemberian
CD4 < 200 Mulai terapi TB.
ARV segera setelah toleransi (2 mgg-2 bl)
CD4 200-350 Mulai terapi TB.
ARV setelah terapi vs ARV setelah toleransi
CD4 > 350 Mulai terapi TB, setelah selesai:
VL > 55.000 ARV
VL < 55.000 tunda ARV, monitor CD4
Tidak tersedia
pemeriksaan
CD4
Mulai terapi TB.
ARV diberikan berdasarkan gejala klinis adanya
def. imun
WHO, 2003
Pengobatan TB pada odha
• Pengobatan untuk infeksi TB pada odha diberikan empat jenis OAT selama 6- 9 – 12 bl (rifampicin, isoniazid, pyrazinamide,ethambutol)
• Berikan steroids pada meningitis & pericarditis
• Pengobatan menjadi tidak sederhana, karena adanya co infeksi oleh virus hepatitis B, hepatitis C, anemia, pemakaian obat antiretrovirus (ARV), dan keluhan saluran cerna.
EVALUASI TERAPI
• BAIK TERHADAP GEJALA HIV MAUPUN M.TB
– EVALUASI KLINIS
– EVALUASI LABORATORIS
– EVALUASI RONTGENOLOGIS
– EFEK SAMPING OBAT (ARV/OAT)
– INTERAKSI OBAT
– RESISTENSI OBAT
– ADHERENCE THD ARV DAN OAT
Masalah terapi: • Adherence / jumlah pil banyak
• Efek toksisitas yang tumpang tindih – mual, muntah, ruam kulit, hepatitis, anemi
• Interaksi obat – Rifampisin merupakan enzyme inducer yang kuat
• ‘Paradoxical worsening’ TB – Reaksi Immune reconstitution
– Sering terjadi jika ART dimulai lebih dini pada OAT
– Jika mungkin tunda ART sampai fase intensif selesai
Terapi ko-infeksi TB-HIV
Pneumocystis jiroveccii
Signs:
• fever
• respiratory rate
• chest often clear to auscultation
Diagnosis:
• CXR:
– bilateral peri-hilar shadowing
– 10% normal,
• induced sputum/BAL: silver methanamine stain
PCP Pneumonia bakterial
PCP (Pneumocystis jiroveccii)
CD4+ < 200 (mean 110) Less common in Indonesia than in USA or Australia Sites: • Pulmonary (most common) Presentation: insidious, often over 3-4 weeks • fever >39oC • dry cough, rarely productive (if purulent sputum – think of
another diagnosis) • increasing dyspnoea – may be subtle in exercise
tolerance in early stages – take a careful history! • Usually with other features of HIV: wasting, oral thrush
12/04
PCP: Histopathology)
Lung biopsy using silver stain to demonstrate P jiroveci organisms in tissue.
Credit: A. Ammann, MD, UCSF Center for HIV Information Image Library
Treatment of Pneumocystis jiroveccii
Often empirical
• iv/oral cotrimoxazole
– 20 mg/kg/d of trimethoprim plus sulfamethoxaxole 100mg/kg/d) for 3/52
• + high dose steroids if pO2 < 70mmHg
Alternatives:
• iv pentamidine 4mg/kg/d
• dapsone 100mg /d plus trimethoprim 20mg/kg/d
• clindamycin 600mg qid + primaquine 15-30mg/d
Prophylaxis of Pneumocystis jiroveccii
Primary / secondary
CD4 < 200/ul or < 20%
TMP/SMZ, drug of choice
Fansidar (pyrimethamine sulfadoxine),
1 tab/week
Dapsone 50 – 100 mg/D
Stop prophylaxis : CD>200 (3 mos)
TERIMA KASIH
MATUR SUKSMA
THANK YOU