Question 3 - Opportunistic Infections: Treatment Question Bank

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Opportunistic Infections: TreatmentQuestion 3/20

A 32-year-old cisgender woman with HIV and a CD4 count of 115 cells/mm³ is admitted to the medical intensive care unit for fever, cough, dyspnea, and significant hypoxia. She is not currently taking antiretroviral therapy or any opportunistic infection prophylactic medications. Chest computed tomographic (CT) imaging reveals scattered ground glass opacities and cystic cavities (Figure 1). An arterial blood gas shows a pO2 = 66 mm Hg. The plan is to perform bronchoscopy and start empiric treatment for Pneumocystis pneumonia with adjunctive corticosteroids. She has a history of a life-threatening rash to trimethoprim-sulfamethoxazole.

Which one of the following is an acceptable alternative to trimethoprim-sulfamethoxazole for the treatment of this woman with moderate-to-severe Pneumocystis pneumonia?

Oral primaquine plus oral clindamycin

Inhaled pentamidine

Oral pyrimethamine plus sulfadiazine

Oral atovaquone

Computed tomographic (CT) scan of lungs in patient with <em>Pneumocystis</em> pneumonia showing diffuse infiltrates and cavitary lesions.

Figure 1. Computed Tomographic (CT) Scan of Lungs

Computed tomographic (CT) scan of lungs in patient with Pneumocystis pneumonia showing diffuse infiltrates and cavitary lesions.

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Question Last Updated
September 28th, 2023

Table 1. **Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV**

Treating Moderate-Severe PCP—Total Duration = 21 days (AII)
Note—Patients who develop PCP despite trimethoprim-sulfamethoxazole prophylaxis usually can be treated effectively with standard doses of trimethoprim-sulfamethoxazole (BIII)
Preferred Therapy: Trimethoprim-sulfamethoxazole: (trimethoprim 15–20 mg and sulfamethoxazole 75–100 mg)/kg/day IV given q6h or q8h (AI), may switch to PO formulations after clinical improvement (AI)
Alternative Therapy: Pentamidine 4 mg/kg IV once daily infused over at least 60 minutes (AI); may reduce the dose to 3 mg/kg IV once daily in the event of toxicities (BI) or Primaquine* 30 mg (base) PO once daily + (Clindamycin [IV 600 q6h or 900 mg q8h] or [PO 450 mg q6h or 600 mg q8h]) (AI)
Adjunctive Corticosteroids: for Moderate to Severe PCP Based on Following Criteria: (AI): PaO2 <70 mm Hg at room air or Alveolar-arterial O2 gradient ≥35 mm Hg Dosing Schedule: Prednisone doses (beginning as early as possible and within 72 hours of PCP therapy) (AI): Days 1–5: 40 mg PO BID Days 6–10: 40 mg PO daily Days 11–21: 20 mg PO daily IV methylprednisolone can be given as 75% of prednisone dose
*Whenever possible, patients should be tested for G6PD deficiency before administration of primaquine. Alternative agent should be used if the patient is found to have G6PD deficiency. Rating System for Prevention and Treatment Recommendations Strength of Recommendation: A = Strong; B = Moderate; C = Optional Quality of Evidence for the Recommendation: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, non-randomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Source:

Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Pneumocystis Pneumonia. Updated: March 28, 2019. [HIV.gov]

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Opportunistic Infections: TreatmentQuestion 3/20

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Which one of the following is an acceptable alternative to trimethoprim-sulfamethoxazole for the treatment of this woman with moderate-to-severe Pneumocystis pneumonia?

Treating Moderate-Severe PCP—Total Duration = 21 days (AII)

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