HIV opportunistic infection cryptosporidiosis: prevention and treatment guidelines: Difference between revisions

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==Prevention of Recurrence==
==Prevention of Recurrence==
Treatment for ocular microsporidiosis should be continued indefinitely because recurrence or relapse might follow treatment discontinuation ('''BIII'''). Whether treatment can be safely discontinued after immune restoration with ART is unknown, although it is reasonable, on the basis of the experience with discontinuation of secondary prophylaxis (chronic maintenance therapy) for other opportunistic infections during advanced HIV-1 disease, to discontinue chronic maintenance therapy if patients remain asymptomatic with regard to signs and symptoms of microsporidiosis and have a sustained (e.g. >6 months) increase in their CD4+ T lymphocyte counts to levels >200 cells/µL after ART ('''CIII''').
No drug regimens are proven to be effective in preventing the recurrence of cryptosporidiosis.


==Special Considerations During Pregnancy==
==Special Considerations During Pregnancy==

Revision as of 13:44, 20 April 2012

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief:, Ujjwal Rastogi, MBBS [2]

Overview

Cryptosporidiosis is caused by Cryptosporidium species, a group of protozoan parasites that infect the small bowel mucosa, and in immunosuppressed persons, the large bowel and extraintestinal sites. Those at greatest risk for disease are patients with advanced immunosuppression (i.e., CD4+ T lymphocyte counts generally <100 cells/µL)[1] The three most common species infecting humans are C. hominis (formerly C. parvum genotype 1 or human genotype), C. parvum (formerly C. parvum genotype 2 or bovine genotype), and C. meleagridis. In addition, infections with C. canis, C. felis, C. muris, and Cryptosporidium pig genotype have been reported in immunocompromised patients. Preliminary analyses indicate that some zoonotic species might have a stronger association with chronic diarrhea than C. hominis. However, whether the different Cryptosporidium species are associated with differences in severity of disease or response to therapy is unknown.

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

Outline of the Guideline:

Treatment Recommendations

ART with immune restoration (an increase of CD4+ T lymphocyte count to >100 cells/µL) is associated with resolution of symptoms of enteric microsporidiosis, including that caused by E. bieneusi.[2][3][4] All patients should be offered ART as part of the initial management of their infection (AII). Nevertheless, data indicate that microsporidia are suppressed but not eliminated.[3]

No specific therapeutic agent is active against E. bieneusi infection. A controlled clinical trial suggests that E. bieneusi might respond to oral fumagillin (60 mg/day), a water insoluble antibiotic made by Aspergillus fumigatus (BII).[5][6] However, fumagillin is not available for systemic use in the United States. One report indicates that 60 days of nitazoxanide might resolve chronic diarrhea caused by E. bieneusi in the absence of ART.[7] However, the effect might be minimal among patients with low CD4+ T cell counts. Nitazoxanide is approved for use among children and is expected to be approved by the FDA for use among adults.

Albendazole and fumagillin have demonstrated consistent activity against other microsporidia in vitro and in vivo.[8][9][10][11][12] Albendazole, a benzimidazole that binds to b-tubulin, has activity against many species of microsporidia, but it is not effective for Enterocytozoon infections, although fumagillin has activity in vitro and in vivo.

Albendazole is recommended for initial therapy of intestinal and disseminated (not ocular) microsporidiosis caused by microsporidia other than E. bieneusi (AII). Itraconazole also might be useful in disseminated disease when combined with albendazole especially in infections caused by Trachipleistophora or Brachiola (CIII).

Ocular infections caused by microsporidia should be treated with topical Fumidil B (fumagillin bicylohexylammonium) in saline (to achieve a concentration of 70 mg/mL of fumagillin)(BII).[12] Topical fumagillin is the only formulation available for treatment in the United States and is investigational. Although clearance of microsporidia from the eye can be demonstrated, the organism often is still present systemically and can be detected in the urine or in nasal smears. In such cases, the use of albendazole as a companion systemic agent is recommended (BIII).

Metronidazole and atovaquone are not active in vitro or in animal models and should not be used to treat microsporidiosis (DII). Fluid support should be offered if diarrhea has resulted in dehydration (AIII). Malnutrition and wasting should be treated with nutritional supplementation (AIII).

Monitoring and Adverse Events

Albendazole side effects are rare but hypersensitivity (rash, pruritis, fever), neutropenia (reversible), CNS effects (dizziness, headache), gastrointestinal disturbances (abdominal pain, diarrhea, nausea, vomiting), hair loss (reversible), and elevated hepatic enzymes (reversible) have been reported. Albendazole is not carcinogenic or mutagenic. Topical fumagillin has not been associated with substantial side effects. Oral fumagillin has been associated with thrombocytopenia, which is reversible on stopping the drug.

Management of Treatment Failure

Supportive treatment and optimizing ART to attempt to achieve full virologic suppression are the only feasible approaches to the management of treatment failure (CIII).

Prevention of Recurrence

No drug regimens are proven to be effective in preventing the recurrence of cryptosporidiosis.

Special Considerations During Pregnancy

As with nonpregnant woman, initial treatment efforts should rely on rehydration and initiation of ART. Pregnancy should not preclude the use of ART.

Source

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[13]

Related Chapters

Reference

  1. ↑ Flanigan T, Whalen C, Turner J, Soave R, Toerner J, Havlir D, Kotler D (1992). "Cryptosporidium infection and CD4 counts". Ann. Intern. Med. 116 (10): 840–2. PMID 1348918. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  2. ↑ Maggi P, Larocca AM, Quarto M, Serio G, Brandonisio O, Angarano G, Pastore G (2000). "Effect of antiretroviral therapy on cryptosporidiosis and microsporidiosis in patients infected with human immunodeficiency virus type 1". Eur. J. Clin. Microbiol. Infect. Dis. 19 (3): 213–7. PMID 10795595. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 Goguel J, Katlama C, Sarfati C, Maslo C, Leport C, Molina JM (1997). "Remission of AIDS-associated intestinal microsporidiosis with highly active antiretroviral therapy". AIDS. 11 (13): 1658–9. PMID 9365777. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)
  4. ↑ Conteas CN, Berlin OG, Speck CE, Pandhumas SS, Lariviere MJ, Fu C (1998). "Modification of the clinical course of intestinal microsporidiosis in acquired immunodeficiency syndrome patients by immune status and anti-human immunodeficiency virus therapy". Am. J. Trop. Med. Hyg. 58 (5): 555–8. PMID 9598440. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)
  5. ↑ Molina JM, Goguel J, Sarfati C, Michiels JF, Desportes-Livage I, Balkan S, Chastang C, Cotte L, Maslo C, Struxiano A, Derouin F, Decazes JM (2000). "Trial of oral fumagillin for the treatment of intestinal microsporidiosis in patients with HIV infection. ANRS 054 Study Group. Agence Nationale de Recherche sur le SIDA". AIDS. 14 (10): 1341–8. PMID 10930148. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)
  6. ↑ Molina JM, Tourneur M, Sarfati C, Chevret S, de Gouvello A, Gobert JG, Balkan S, Derouin F (2002). "Fumagillin treatment of intestinal microsporidiosis". N. Engl. J. Med. 346 (25): 1963–9. doi:10.1056/NEJMoa012924. PMID 12075057. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)
  7. ↑ Bicart-Sée A, Massip P, Linas MD, Datry A (2000). "Successful treatment with nitazoxanide of Enterocytozoon bieneusi microsporidiosis in a patient with AIDS". Antimicrob. Agents Chemother. 44 (1): 167–8. PMC 89645. PMID 10602740. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  8. ↑ Didier ES (1997). "Effects of albendazole, fumagillin, and TNP-470 on microsporidial replication in vitro". Antimicrob. Agents Chemother. 41 (7): 1541–6. PMC 163955. PMID 9210681. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)
  9. ↑ Katiyar SK, Edlind TD (1997). "In vitro susceptibilities of the AIDS-associated microsporidian Encephalitozoon intestinalis to albendazole, its sulfoxide metabolite, and 12 additional benzimidazole derivatives". Antimicrob. Agents Chemother. 41 (12): 2729–32. PMC 164197. PMID 9420047. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)
  10. ↑ Molina JM, Chastang C, Goguel J, Michiels JF, Sarfati C, Desportes-Livage I, Horton J, Derouin F, Modaï J (1998). "Albendazole for treatment and prophylaxis of microsporidiosis due to Encephalitozoon intestinalis in patients with AIDS: a randomized double-blind controlled trial". J. Infect. Dis. 177 (5): 1373–7. PMID 9593027. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)
  11. ↑ Gritz DC, Holsclaw DS, Neger RE, Whitcher JP, Margolis TP (1997). "Ocular and sinus microsporidial infection cured with systemic albendazole". Am. J. Ophthalmol. 124 (2): 241–3. PMID 9262551. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  12. ↑ 12.0 12.1 Diesenhouse MC, Wilson LA, Corrent GF, Visvesvara GS, Grossniklaus HE, Bryan RT (1993). "Treatment of microsporidial keratoconjunctivitis with topical fumagillin". Am. J. Ophthalmol. 115 (3): 293–8. PMID 8117342. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  13. ↑ Benson CA, Kaplan JE, Masur H, Pau A, Holmes KK (2004). "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. 53 (RR-15): 1–112. PMID 15841069. Retrieved 2012-04-19. Unknown parameter |month= ignored (help)


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