Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Cryptosporidiosis Slide Set

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Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and AdolescentsCryptosporidiosis Slide Set

• Prepared by the AETC National Resource Center
  based on recommendations from the CDC, National
  Institutes of Health, and HIV Medicine
  Association/Infectious Diseases Society of America

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About This Presentation
These slides were developed using recommendations
published in May 2013. The intended audience is
clinicians involved in the care of patients with
HIV. Users are cautioned that, because of the
rapidly changing field of HIV care, this
information could become out of date quickly.
Finally, it is intended that these slides be used
as prepared, without changes in either content or
attribution. Users are asked to honor this
intent. -AETC National Resource
Center http//www.aidsetc.org
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Cryptosporidiosis Epidemiology

• Caused by Cryptosporidium species
• Protozoan parasites
• Infect small intestine mucosa in
  immunosuppressed patients, also infect large
  intestine and other sites
• Advanced immunosuppression (eg, CD4 lt100
  cells/µL) associated with prolonged, severe, or
  extraintestinal disease

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Cryptosporidiosis Epidemiology (2)

• Infection results from ingestion of oocysts
  excreted in feces of infected humans or animals
• Water supplies and recreational water sources
  (oocysts may withstand standard chlorination)
• Person-to-person transmission common, via
  oral-anal contact, from infected children to
  adults (eg, during diapering), or care of
  patients with diarrhea

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Cryptosporidiosis Epidemiology (3)

• Common cause of chronic diarrhea in AIDS patients
  in developing countries
• In developed countries with low rates of
  envrionmental contamination and widespread use of
  effective ART, lt1 case per 1,000 person-years in
  AIDS patients

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Cryptosporidiosis Clinical Manifestations

• Acute or subacute onset of profuse watery,
  nonbloody diarrhea, often with nausea, vomiting,
  and abdominal cramping
• Fever in 1/3 of patients
• Can be very severe, especially with immune
  suppression
• Malabsorption is common dehydration, electrolyte
  abnormalities, malnutrition may result
• Biliary tract and pancreatic duct may be
  infected, causing scleroding cholangitis and
  pancreatitis
• Pulmonary infection is possible

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Cryptosporidiosis Diagnosis

• Microscopic identification of oocysts in stool or
  tissue
• DFA very sensitive, specific, is current gold
  standard for stool specimens
• Acid-fast staining often used
• PCR extremely sensitive
• ELISA or immunochromatographic tests
• Small intestine biopsy with identification of
  Cryptosporidium organisms

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Cryptosporidiosis Diagnosis (2)

• Single specimen usually sufficient in profuse
  diarrhea
• Repeat stool sampling is recommended in mild
  disease

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Cryptosporidiosis Prevention

• Preventing exposure
• Avoid exposure to infected contacts
• Contact with diarrhea
• Potential oral exposure to feces during sex
• Direct contact with farm animals, stool from pets
• Scrupulous handwashing after potential contact
  with feces (eg, after diapering), after handling
  pets or other animals, gardening, before
  preparing food or eating, before and after sex

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Cryptosporidiosis Prevention (2)

• Avoid exposure to contaminated water, food
• Do not drink or swallow water from recreational
  sources (lakes, streams, pools)
• Ice, fountain beverages, water fountains may be
  contaminated
• Avoid raw oysters

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Cryptosporidiosis Prevention (3)

• Boil tap water for 1 minute during outbreaks or
  when community advisory is issued
• Submicron water filters or bottled water may
  reduce risk
• For non-outbreak settings, data are inadequate to
  recommend that all persons with low CD4 counts
  avoid drinking tap water
• Consider drinking only filtered water

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Cryptosporidiosis Prevention (4)

• Preventing disease
• Primary prophylaxis
• Appropriate initiation of ART before severe
  immunosuppression should prevent disease
• Rifabutin and possibly clarithromycin are
  protective, but data insufficient to recommend as
  chemoprophylaxis

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Cryptosporidiosis Treatment

• Preferred strategies
• ART with immune restoration (to CD4 count gt100
  cells/µL)
• Usually results in complete resolution should be
  offered as part of initial management of
  cryptosporidiosis
• Symptomatic treatment antidiarrheals
• Tincture of opium may be more effective than
  loperamide
• Octreotide usually not recommended (no more
  effective than other antidiarrheals)
• Supportive care aggressive hydration,
  electrolyte repletion, nutritional support (IV
  therapies may be needed)

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Cryptosporidiosis Treatment (2)

• Alternative strategies
• No consistently effective antimicrobial therapy
  in absence of ART
• Consider nitazoxanide or other antiparasitic
  drugs in conjunction with ART, not instead of ART
• Nitazoxanide 500-1,000 mg PO BID for 14 days
  ART and other measures above
• Some studies show clinical improvement with
  nitazoxanide
• Paromomycin 500 mg PO QID for 14-21 days ART
  and other measures above
• Limited data may improve clinical response in
  conjunction with ART

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Cryptosporidiosis Starting ART

• ART should be offered as part of initial
  management of this infection
• PIs inhibit Cryptosporidium in animal models
  some experts prefer PI-based ART

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Cryptosporidiosis Monitoring and Adverse Events

• Monitor closely for volume depletion, electrolyte
  loss, weight loss, and malnutrition
• TPN may be indicated
• IRIS not reported

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Cryptosporidiosis Treatment Failure

• Supportive treatment
• Optimization of ART

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Cryptosporidiosis Prevention of Recurrence

• No effective prevention, other than immune
  restoration with ART

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Cryptosporidiosis Considerations in Pregnancy

• Rehydration and ART initiation as with
  nonpregnant adults
• Nitazoxanide not teratogenic in animals, but no
  data in pregnant humans
• Use after 1st trimester in severely symptomatic
  women
• Paromomycin limited information on
  teratogenicity minimal systemic absorption with
  PO administration
• Use after 1st trimester in severely
  symptomaticwomen

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Cryptosporidiosis Considerations in Pregnancy (2)

• Loperamide possible risk of hypospadias with
  1st-trimester exposure
• Avoid during 1st trimester, unless benefits
  expected to outweigh risks
• Preferred antimotility agent during late
  pregnancy
• Tincture of opium not recommended during late
  pregnancy
• Opiate exposure during late pregnancy associated
  with neonatal respiratory depression chronic
  exposure may result in neonatal withdrawal

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Websites to Access the Guidelines

• http//www.aidsetc.org
• http//aidsinfo.nih.gov

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About This Slide Set

• This presentation was prepared by Susa Coffey,
  MD, and Oliver Bacon, MD, for the AETC National
  Resource Center in May 2013
• See the AETC NRC website for the most current
  version of this presentation
• http//www.aidsetc.org