Persons with human immunodeficiency virus (HIV) have weakened immune systems and are at risk for opportunistic infections (OIs). OIs are caused by organisms that are common in the environment and may represent reactivation of a suppressed/hidden infection. OIs risk increases as CD4 counts decrease (Figure 28-1). The CD4 count serves as the basis for initiating or discontinuing OI therapy. In the antiretroviral era, the main principle in OI management is treating HIV with antiretrovirals to enable CD4 cell recovery. Additional OI management is classified based on the intended goal: (1) primary prophylaxis (reduces the likelihood for first occurrence), (2) treatment (resolves an active infection), and (3) secondary prophylaxis/chronic maintenance suppressive therapy (prevents a prior infection from returning). Importantly, the pathogen determines the therapy and the management goal determines the dose, frequency, and duration. An example treatment plan for select OIs in a person living with HIV includes (may vary pending the specific OI): (1) management of HIV with antiretrovirals (eg, dolutegravir, abacavir, and lamivudine); (2) prevent exposure to opportunistic pathogens; (3) use primary chemoprophylaxis at certain CD4 thresholds to prevent first-episode disease; (4) treat OI; (5) use secondary chemoprophylaxis to prevent disease recurrence; and (6) discontinue prophylaxis with sustained CD4 recovery from utilization of antiretrovirals.
History of opportunistic infections associated with human immunodeficiency virus. Reprinted with permission, © Courtney V. Fletcher, 2009.
Mucocutaneous candidiasis is a fungal infection caused by Candida species (primarily Candida albicans). The infection can be limited to the oropharyngeal area or extended to the esophagus. Oropharyngeal candidiasis presents as painless, creamy, white plaque-like lesions on the tongue, soft/hard palate, or buccal surface (thrush) that are easily scraped off/removed using a tongue depressor in persons with CD4 count more than 200 cells/mm3. A more severe presentation of this OI is termed esophageal candidiasis and can present as retrosternal pain, odynophagia, or dysphagia typically with concurrent thrush symptoms. A culture may be needed to confirm pathogen susceptibility if therapy proves ineffective.
Primary prophylaxis is not routinely recommended for Candidiasis, regardless of CD4 count, as this predisposes the patient to increased risk for drug interactions and may promote drug-resistant species. Secondary prophylaxis is rarely recommended and reserved for patients with severe, poorly responsive recurrences.
Topical agents may be used for the initial episode of oropharyngeal candidiasis and include clotrimazole, miconazole troches/buccal tablet, or nystatin suspension/pastilles. Systemic treatment with oral fluconazole is the therapy of choice for candidiasis and the recommendation is 100 to 200 mg daily for 7 to 14 days for oropharyngeal or 200 to 400 mg daily for 14 to 21 days for esophageal candidiasis. The azoles, echinocandins, and amphotericin products effectively treat esophageal candidiasis; however, fluconazole is ...