Transcript Treating Opportunistic Infections Among HIV

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected
Adults and Adolescents
Mycobacterium Tuberculosis 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
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out of date quickly.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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MTB: Epidemiology
 Worldwide, 10 million people coinfected
with HIV and MTB
 90% in developing countries
 Most common cause of death in AIDS
patients
 In the United States, decline in HIVrelated TB since 1992, likely related to
ART
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MTB: Epidemiology (2)
 Infection via inhalation of droplet nuclei with
MTB organisms
 Latent TB infection (LTBI): immune system
usually limits multiplication of TB bacilli, but
bacilli may persist
 Persons with LTBI are asymptomatic and are not
infectious
 Active TB disease: can develop immediately
after infection (primary TB) or with reactivation
of LTBI
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MTB: Epidemiology (3)
 Reactivation of latent TB:
 More likely in HIV-infected patients; risk increases
soon after HIV infection
 3-16% annual risk in HIV-infected patients; in HIV
uninfected, ~5% lifetime risk
 TB disease can occur at any CD4 count, but
risk increases with progression of
immunodeficiency
 TB coinfection increases HIV viral loads and
progression of HIV
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MTB: Preventing Exposure
 HIV-infected patients who travel or work in
high-prevalence settings should be
counseled about TB infection risk and
tested for LTBI
 Exposure risks in some health care and
correctional settings in the United States –
usual precautions
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MTB: Preventing Disease
 Diagnosis and treatment of LTBI is key
aspect of preventing active TB
 Treatment of LTBI lowers risk of TB
disease (by 62%) and death (by 26%)
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TB Disease: Diagnosis
Screening
 Test all for LTBI at time of HIV diagnosis
(regardless of TB risks)
 If CD4 count <200 cells/µL and no indications for
empiric LTBI treatment, retest for LTBI when count
rises to ≥200 cells/µL on ART
 Annual testing only for those at high risk or
repeated or ongoing exposure to active TB
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TB Disease: Diagnosis (2)
Testing methods
 Tuberculin skin test (TST):
 0.1 mL purified protein derivative (PPD)
 In HIV infection, positive is induration ≥5 mm at 48-72
hours
 Specificity 56-95%
 Requires 2 office visits; lower specificity in recipients of
BCG vaccination
 Interferon-gamma release assay (IGRA):
 IFN-γ release in response to MTB-specific peptides
 Higher specificity (92-97%); less cross-reactivity
resulting from BCG vaccination or other non-TB
mycobacterial exposure
 Advanced immunosuppression may cause
false-negative results to both tests, perhaps
less with IGRAs
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TB Disease: Diagnosis (3)
 In the U.S., only 47-65% complete TST
screening; use of IGRA may result in
better rates of screening
 Use of both TST and IGRA is not
recommended in the U.S.
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TB Disease: Diagnosis (4)
TST or IGRA test results
 If negative and CD4 count <200 cells/µL:
retest after ART initiation and increase in
CD4 count to >200 cells/µL
 If positive test: chest X ray and clinical
evaluation to screen for active TB
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TB Disease: Treatment
 Rule out active TB: chest X ray and clinical
evaluation
 All HIV-infected persons should be treated, if no
evidence of active TB and:
 Positive screening test for LTBI and no history of
treatment for active or latent TB
 Close contact with someone with infectious TB,
regardless of LTBI test results
 For HIV-infected persons who are anergic and
no recent contact with infectious TB: LTBI
treatment not recommended (no evidence of
clinical benefit)
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TB Disease: Treatment (2)
 Preferred (duration: 9 months):
 INH 300 mg PO QD (+ pyridoxine 25 mg PO QD, to reduce risk of
peripheral neuropathy)
 INH or 900 mg PO BIW (+ pyridoxine 25 mg PO QD)
 Alternative (duration: 4 months):
 Rifampin: 600 mg PO QD
 Rifabutin: dose adjusted according to concomitant ARVs
 Note: potential drug interactions between rifamycins and PIs,
NNRTIs, integrase inhibitors; dosage adjustments may be
required; some combinations are contraindicated
 For persons exposed to drug-resistant TB:
consult with experts
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TB Disease: Treatment (3)
 Regimens duration less than 9 months may
enhance adherence
 3-month regimen of once weekly INH + rifapentine as
effective as 9-month INH regimen; not recommended
for HIV-infected persons on ART because of potential
interactions between some ARVs and rifapentine
 2-month regimen of rifampin + pyrazinamide not
recommended: risk of severe hepatotoxicity
 ART decreases risk of TB disease; use of
both ART and LTBI treatment is
recommended
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TB Disease: Monitoring
 Monitor monthly for adherence and drug toxicity
 Directly observed therapy (DOT) should be used
with intermittent dosing regimens
 INH: liver toxicity possible, check baseline AST
or ALT, bilirubin; repeat if abnormal; monitor
closely if viral hepatitis
 Asymptomatic patients: discontinue INH if AST
increases >5 times upper limit of normal (ULN)
 Symptomatic patients: discontinue INH if AST
increases >3 times ULN
 Baseline elevated transaminases: discontinue INH if
AST increases >2 times ULN
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TB Disease: Clinical Manifestations
 Common symptoms included cough, fever,
sweats, weight loss, fatigue
 May be subclinical or have few symptoms, even
if culture positive
 Immune reconstitution following ART initiation
can unmask subclinical TB, with inflammatory
reactions at site of infection
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TB Disease: Clinical Manifestations (2)
 Degree of immunosuppression influences clinical,
radiographic, and histopathologic presentation of
active TB
 CD4 count >350 cells/µL: as in HIV uninfected
 TB usually limited to lungs
 Chest X ray: upper lobe infiltrates, +/− cavitation
 Extrapulmonary disease (pleuritis, pericarditis,
meningitis, lymphadenitis), more common in HIV
infection, regardless of CD4 count
 More common in advanced immunosuppression
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TB Disease: Clinical Manifestations (3)
 Advanced HIV
 TB may be systemic disease: high fevers, rapid
progression, sepsis syndrome
 Extrapulmonary TB, with or without pulmonary disease,
in most TB patients with CD4 count <200 cells/µL
 TB may be subclinical or with few symptoms
 Chest X ray: lower lobe, middle lobe, interstitial, and
miliary infiltrates are common; cavitation less common
 Intrathoracic lymphadenopathy is common
 Granulomas may be poorly formed or absent
 Sputum smear and culture may be positive even with
normal chest X ray
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TB Disease: Clinical Manifestations (4)
Chest X ray: TB manifesting as a
focal opacity in the right lung
Credit: L. Huang, MD; HIV InSite
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Chest X ray: TB with bilateral hilar
lymphadenopathy and diffuse interstitial
and airspace opacities
Credit: L. Goozé, MD; C. Daley, MD;
HIV InSite
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TB Disease: Clinical Manifestations (5)
Chest X ray: miliary pattern of TB in an HIV-infected patient
with advanced immunosuppression
Credit: HIV Web Study (www.hivwebstudy.org) © 2006, University of Washington
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TB Disease: Diagnosis
 Direct initial testing at site of symptoms or signs
 Chest X ray
 Perform in all with HIV+ with suspected TB, even if no
pulmonary symptoms – pulmonary involvement is
common
 Normal chest X ray does not rule out active pulmonary
TB
 Sputum samples for AFB smear and culture
 3 samples recommended
 Sputum smear negativity is common in HIV, especially
in severe immunodeficiency and noncavitary disease
 AFB culture sensitivity not affected by HIV or
immunodeficiency
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TB Disease: Diagnosis (2)
 Extrapulmonary TB: sample suspected
tissue or fluid
 Lymph nodes: histopathology, smear, and
culture
 Pleural or pericardial fluid, ascites, CSF
 Urine and blood cultures: sensitivity relatively
high in advanced immunodeficiency
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TB Disease: Diagnosis (3)
 Nucleic acid amplification (NAA)
 May rapidly identify M tuberculosis
 NAA recommended on at least 1 specimen from
all patients with suspected pulmonary TB
 In AFB smear-positive specimens, highly
predictive of TB
 Can be used to direct therapy and make clinical
decisions
 More sensitive than AFB smear
 Positive in 50%-80% of smear-negative, culturepositive specimens
 Licensed only for sputum samples
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TB Disease: Diagnosis (4)
 TST or IGRA may be useful in unusual
circumstances (eg, if definitive culture
evidence for active TB cannot be obtained)
 Evidence of previous infection increases
likelihood of TB
 Negative test result does not rule out TB
disease
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TB Disease: Diagnosis (5)
 Drug susceptibility testing on initial isolates
from all patients with suspected TB
 Test first-line TB drugs
 Repeat if sputum cultures remain positive
for MTB at/after 4 months of treatment, or
become positive again after ≥1 month of
negative cultures
 Second-line drug susceptibility testing:
 Only in reference laboratories, only on
specimens with resistance to first-line TB
medications
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TB Disease: Diagnosis (6)
 Conventional susceptibility testing is well
validated by requires culture of M
tuberculosis; may take 6 weeks
 Genotypic testing allows rapid detection of
resistance (24 hrs)
 Commercial tests available for RIF and INH
resistance
 Commercial tests for other TB drugs are in
development
 CDC can provide rapid molecular testing for
patients who do not have local access to
this testing
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TB Disease: Diagnosis (7)
 Consider drug resistance testing:
 Known exposure to drug-resistant TB
 Country or area with high rates of drugresistant TB
 Persistently positive smear or culture results
at/after 4 months of treatment
 Previous TB treatment, particularly if no DOT
of if interrupted
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TB Disease: Diagnosis (8)
 Multidrug resistant (MDR): resistance to at
least INH and RIF
 Extensively drug resistant (XDR): resistance to
MDR TB plus resistance to a fluoroquinolone
and either kanamycin, amikacin, or
capreomycin
 High risk of treatment failure and relapse;
consult with specialist
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TB Disease: Treatment
 For patients with clinical and radiographic
presentation suggestive of TB, start empiric
treatment for TB, after collection of specimens
for culture and molecular diagnostic tests
 Early diagnosis and treatment are critical – TB
can progress rapidly in advanced
immunodeficiency
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TB Disease: Treatment (2)
General principles
 2 phases: intensive (2 months) and continuation
(4+ months)
 If TB is suspected, empiric treatment should be
started and continued until diagnostic workup is
complete
 DOT is recommended for all
 Addition of case management, other social support,
and linkage to HIV care further increases likelihood of
successful treatment (enhanced DOT)
 Treatment duration based on total number of
doses ingested, rather than on duration of
treatment administration
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TB Disease: Treatment (3)
For drug-susceptible pulmonary TB
 Intensive phase: 2 months
 Isoniazid (INH), rifampin (RIF) or rifabutin
(RFB), pyrazinamide (PZA), ethambutol
(EMB)
 If concern about resistance to RIF, use
expanded regimen (consult with expert)
 If organism is susceptible to INH and RIF,
may discontinue EMB
 Continuation phase: ≥4 months
 INH + RIF (or RFB)
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TB Disease: Treatment (4)
Frequency of dosing for HIV-infected patients:
 Intensive phase
 Daily therapy by DOT recommended (7 days/week for
56 doses or 5 days/week for 40 doses)
 2-3 times weekly dosing: increased risk of treatment
failure or relapse, with rifamycin resistance
 Continuation phase
 Daily (5-7 days/week) or TIW dosing recommended
 Less-frequent dosing: increased risk of treatment
failure, relapse, and rifamycin resistance
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TB Disease: Treatment (5)
 Duration of treatment for HIV-infected patients
(drug-susceptible TB):
 Optimal duration unknown; some data in
high-burden settings show higher rates of
recurrence if treated 6 months vs 9 or 12
months
 In the U.S., 6 months recommended for
most with drug-susceptible TB
 9 months if sputum culture positive at 2 months
 9-12 months if CNS involvement
 6-9 months if bone and joint TB
 6-9 months if extrapulmonary TB at other sites
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TB Disease: Treatment (Drug Sensitive) (6)
 Intensive phase (8 weeks), QD dosing (5-7
days/week):
 INH 5 mg/kg (usual dose 300 mg) PO QD +
 RIF* 10 mg/kg (usual dose 600 mg) PO QD (or
RFB** 5 mg/kg (usual dose 300 mg) PO QD) +
 PZA 40-55 kg, 1,000 mg PO QD; 56-75 kg, 1,500
mg PO QD; >75 kg, 2,000 mg PO QD +
 EMB 40-55 kg, 800 mg PO QD; 56-75 kg, 1,200 mg
PO QD; >75 kg, 1,600 mg PO QD
 For TIW regimens, see Guidelines
* Rifampin interacts with many ARVs and other drugs; consult
information on contraindicated combinations
** Adjust dosage for interacting ARVs
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TB Disease: Treatment (Drug Sensitive) (7)
 Continuation phase (≥16 weeks)
 QD regimen (5-7 days/week):
 INH 5 mg/kg (usual dose 300 mg) PO QD + RIF*
10 mg/kg (usual dose 600 mg) PO QD (or RFB** 5
mg/kg [usual dose 300 mg] PO QD)
OR
 TIW regimens:
 INH 15 mg/kg (usual dose 900 mg) PO TIW + RIF*
10 mg/kg (usual dose 600 mg) PO TIW (or RFB** 5
mg/kg [usual dose 300 mg] PO TIW)
* Rifampin
interacts with many ARVs and other drugs; consult
information on contraindicated combinations
** Adjust dosage for interacting ARVs
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TB Disease: Treatment (8)
Other therapies
 Pyridoxine (25-50 mg QD) for all on INH (to
decrease risk of neuropathy)
 Corticosteroids improve survival for CNS or
pericardial disease
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TB Disease: Starting ART
 For optimal management of HIV-related
TB, treat both infections
 Sequential treatment of TB followed by HIV
treatment is not recommended
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TB Disease: Starting ART (2)
 Cotreatment :
 Improves survival, particularly if CD4 count
<50 cells/µL
 Decreases risk of other OIs
 Can achieve high rates of HIV suppression
 May improve TB treatment outcomes
 Risks of early ART:
 Multidrug therapy for 2 infections, drug-drug
interactions, overlapping side effects, IRIS
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TB Disease: Starting ART (3)
 ART-naive patients:
 CD4 <50 cells/µL: start ART within 2 weeks
 CD4 ≥50 cells/µL: start ART by 8-12 weeks
 TB meningitis and low CD4: optimal timing of
ART is not clear; risk of severe adverse events
with early ART; consult with experts
 Patients on ART:
 Start TB treatment immediately
 Optimize ART if needed to suppress HIV
 Modify ART to reduce risk of drug interactions
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TB Disease: Starting ART (4)
Drug-drug interactions
 Rifamycins (especially RIF)
 Induce CYP3A metabolism of many drugs, including
most protease inhibitors (PIs) and nonnucleoside reverse
transcriptase inhibitors (NNRTIs)
 Have other complex interactions with some ARVs
 Dosage adjustments may be required, and some
combinations cannot be used
 Considerable interpatient variations: consider therapeutic
drug monitoring for RFB and/or PIs or NNRTIs
 Despite these issues, rifamycins should be used for
treatment of TB, if possible
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TB Disease: Starting ART (5)
 NRTIs: no significant interactions with
rifamycins
 NNRTIs:
 Efavirenz 600 mg QD + 2 NRTIs is preferred ART
regimen for patients taking RIF
 Dosage adjustments for weight >60 kg appears not supported by
good data
 Nevirapine- more significant interactions with RIF.
 Can be used for patients unable to take efavirenz
 Nevirapine + didanosine + lamivudine inferior to efavirenz
with the same NRTIs
 Monitor HIV RNA closely
 If on RIF for ≥2 weeks, omit lead-in dose of nevirapine
 RFB: increased dosage of RFB needed if used with
efavirenz
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TB Disease: Starting ART (6)
 PIs:
 RIF lowers serum levels of most PIs, including
ritonavir-boosted PIs: contraindicated
 RFB has little effect on levels of ritonavirboosted PIs but all PIs markedly increase RFB
concentrations
 Dosage reduction of RFB is needed, though optimal
dosing is not clear
 150 mg QD recommended for those on boosted PI, at
least during first 2 months of TB treatment
 Some reports of acquired rifamycin resistance with 150
mg TIW dosing of RFB + a boosted PI
 Consider therapeutic drug monitoring for RFB
 Closely monitor ART adherence (need to increase
RFB dosage if PI is stopped)
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TB Disease: Starting ART (7)
 Integrase inhibitors:
 Raltegravir: RIF decreases raltegravir levels
 Raltegravir 800 mg BID recommended but not studied in
clinical trials
 Elvitegravir + cobicistat: no data; drug
interactions expected to be similar to those
with boosted PIs
 Use only when required for ARV potency;
consult with an expert
 CCR5 antagonist: RIF and possibly RFB
decrease maraviroc levels; few data; consult with
expert
 Fusion inhibitor: enfuvirtide not affected by
rifamycins
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TB Disease: Monitoring
 Close follow-up is essential to ensure treatment
success
 Pulmonary TB: monthly sputum smear and
culture until 2 consecutive negative cultures
 Sputum cultures usually convert to negative with 2
months of TB therapy; may be longer if high burden of
disease (eg, cavitary TB)
 Positive cultures after 4 months: evaluate for possible
treatment failure and acquired drug resistance
 Extrapulmonary TB: follow-up evaluation
depends on sites involved
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TB Disease: Monitoring (2)
 Clinical and laboratory assessments at least
monthly (liver and renal function tests, CBC,
platelets, CD4)
 At each visit, screen for lapses in adherence,
possible adverse effects
 Patient on EMB: ask about blurred vision or scotomata;
test for visual acuity and color discrimination
 Routine drug level monitoring is not
recommended (consider if slow response to
treatment)
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TB Disease: Adverse Events
 First-line TB medications should not be
stopped permanently without strong
evidence that a TB drug was the cause of
a reaction
 Consult with experts
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TB Disease: Adverse Events (2)
 GI reactions: common with most TB drugs;
usually can be managed symptomatically; check
AST and bilirubin
 Rash: common with all TB drugs; if minor, use
antihistamines for symptomatic relief; if severe,
stop all TB drugs until rash is substantially better;
restart TB drugs one by one at intervals of 2-3
days; if recurrence: stop the last drug added
 If generalized rash + fever or mucous membrane
involvement, stop all drugs, switch to alternative TB
medications; consult with expert
 Fever after several weeks of TB treatment:
exclude worsening TB, superinfection, IRIS; if
drug fever suspected, stop all TB drugs; after
resolution of fever, restart as above
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TB Disease: Adverse Events (3)
 AST elevation: common, may be caused by INH,
RIF/RFB, or PZA; risk higher in patients taking
other hepatotoxic drugs and in those with liver
disease
 If no symptoms and AST <3 times ULN, continue TB
therapy but increase frequency of monitoring
 If AST ≥5 times ULN, or ≥3 times ULN with symptoms,
or if significant increase in bilirubin or alkaline
phosphatase, stop hepatotoxic drugs and evaluate
patient (eg, for symptoms, viral hepatitis, hepatotoxins)
 Substitute nonhepatotoxic drugs, until alternative longer-term
regimen is designed
 After AST decreases to <2 times ULN, may restart suspected
TB meds one at a time; if hepatotoxicity recurs, stop the last
drug added
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TB Disease: Adverse Events (4)
 EMB may cause visual disturbances
 Monthly review of symptoms
 Monthly visual acuity and color discrimination
testing for all patients on dosages that are
higher than recommended and all patients on
EMB >2 months
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TB Disease: IRIS
 Paradoxical TB IRIS: temporary exacerbation of
symptoms, signs, or radiographic manifestations
of TB after initial improvement on TB treatment;
may include:






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High fever
Worsening respiratory status
New or worsening lymphadenopathy
Worsening CNS lesions or symptoms
Worsening pulmonary infiltrates
Increasing pleural effusions
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TB Disease: IRIS (2)
 Symptoms usually begin in the first 1-4 weeks
after starting ART, usually last 2-3 months
 Risk factors: low CD4 count at start of ART
(especially <100 cells/µL), disseminated or
extrapulmonary TB, ART started shortly after start
of TB therapy (particularly within first 2 months of
TB therapy)
 No definitive tests; may be difficult to distinguish
IRS from worsening of TB, treatment failure, new
infection, adverse drug reaction, etc.
 Evaluate thoroughly for other causes
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TB Disease: IRIS (3)
Management
 Usually self-limited; can be prolonged and severe
 Mild IRIS
 Symptomatic treatment, NSAIDs
 Aspiration of fluid collections, if indicated for symptomatic relief
 Moderate-to-severe IRIS
 Consider corticosteroids:
 Some data show more rapid improvement, though no mortality benefit in nonCNS TB IRIS
 CNS TB IRIS: corticosteroids decreased mortality
 Taper corticosteroids over 4 weeks or longer, based on clinical assessment
 Avoid in patients with Kaposi sarcoma
 Continue TB therapy
 Continue ART if possible (unless IRIS is life threatening)
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TB Disease: IRIS (4)
 Unmasking TB IRIS: patients with unrecognized
TB when they start ART; may develop accelerated
and inflammatory presentation of TB in the first
weeks of ART
 May have rapid onset of symptoms, features similar to
bacterial pneumonia, and/or abscesses and
lymphadenitis
 Treatment: standard TB treatment; corticosteroids if lifethreatening manifestations
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TB Disease: Treatment Failure
 Causes include
 Undetected primary drug resistance, inadequate
adherence to therapy, incorrect or inadequate
regimen, subtherapeutic drug levels (malabsorption,
drug interactions), superinfection with resistant MTB,
acquired drug resistance
 Evaluate with history, physical exam, chest X ray
 Review initial test results, therapy regimen,
adherence
 Repeat culture and susceptibility testing; sample
all available sites
 Perform rapid resistance testing on direct specimens
or positive cultures
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TB Disease: Treatment Failure (2)
 Pending repeat culture and resistance test
results, broaden treatment using second-line TB
drugs (consult with expert)
 Drug-resistant TB: optimal management not
established
 Resistance to INH:
 Evidence of increased risk of treatment failure with
baseline INH resistance
 Substitute fluoroquinolone for INH, at least for first 2
months of therapy and perhaps for continuation
phase, with RIF and EMB; total duration 9 months
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TB Disease: Treatment Failure (3)
 Resistance to RIF:
 Treatment is more complex, less effective,
and of longer duration
 Second- and third-line TB medications should
be used, based on drug susceptibility results
 New drugs are in development
 Consult with expert
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TB Disease: Management of Drug Resistance
 Resistance to INH:
 (RIF or RFB) + EMB + PZA + (moxifloxacin or
levofloxacin) for 2 months, followed by RIF or RFB) +
EMB + (moxifloxacin or levofloxacin) for 7 months
 Empiric therapy for suspected resistance to
rifamycin +/− resistance to other drugs:
 INH + RIF or RFB + PZA + EMB + moxifloxacin or levofloxacin
+ (an aminoglycoside or capreomycin)
 Suspected resistance to rifamycins +/−
resistance to other drugs:
 Individualize treatment and duration based on
susceptibility, clinical and microbiological responses
 Manage with specialist
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TB Disease: Preventing Recurrence
 Recurrence risk somewhat higher in HIV
infection, especially in TB-endemic settings,
usually via reinfection
 In U.S., reinfection is uncommon
 In high-burden settings (high risk of reexposure), treatment with INH for 6-9
months after completion of standard TB
therapy can decrease risk of reinfection
 Not recommended in low-burden settings
 ART probably decreases risk of reinfection
with TB
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TB Disease: Considerations in Pregnancy
 All pregnant women should be tested (TST),
unless documented negative TST result
 All at high risk of repeated or ongoing exposure
should be tested
 Limited data on IGRAs in pregnant women
 Diagnosis as in nonpregnant adults
(minimize fetal radiation exposure)
 TB (pulmonary or extrapulmonary) may
increase complications, including preterm
birth, low birthweight, intrauterine growth
retardation
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TB Disease: Considerations in Pregnancy (2)
 LTBI: consider treatment during pregnancy
(after ruling out active TB)
 Weigh risk of INH toxicity against
consequences of active TB
 High risk of maternal and infant mortality in HIVinfected pregnant women with TB
 ART decreases risk of progression from LTBI
to active TB
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TB Disease: Considerations in Pregnancy (3)
 TB disease:
 Treat as in nonpregnant adults
 Therapy should not be withheld because of
pregnancy
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TB Disease: Considerations in Pregnancy (4)
 Treatment considerations (1)
 INH: not teratogenic; hepatotoxicity may be
more frequent; monitor transaminases
monthly through postpartum period
 RIF: not teratogenic
 PZA: limited experience in human pregnancy
(not teratogenic in animals); WHO
recommends routine use, but limited data and
not recommended in United States; if PZA not
used in initial treatment, minimum duration of
therapy is 9 months
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TB Disease: Considerations in Pregnancy (5)
 Treatment considerations (2)
 EMB: teratogenic in animals at high doses;
no evidence of teratogenicity in humans; no
evidence of ocular toxicity in exposed infants
 Second-line drugs: limited experience; some
should be avoided; consult with experts
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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, 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
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