June 2013 FAQs

What are the differences and similarities between the Medical Letter antimicrobial prophylaxis guidelines and the guidelines from ASHP/IDSA/SIS/SHEA?

The Medical Letter antimicrobial prophylaxis guidelines1 were released in October 2012 as an update to the June 2009 guidelines and were summarized in an FAQ from November 2012.2 In contrast, guidelines from the American Society of Health-System Pharmacists (ASHP), Infectious Disease Society of America (IDSA), Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA) released in February 20133 is an update to the 1999 ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery4 and other guidelines from IDSA and SIS.5,6 The major updates are discussed below with discussion of the differences between these most recent guidelines and the Medical Letter guidelines. The full guidelines should be consulted for additional information and are available at the IDSA website : http://www.idsociety.org/Antimicrobial_Agents/#Antimicrobial%20Prophylaxis%20for%20Surgery

Updates to the guidelines

Major updates to the guidelines include preoperative-dose timing, selection and dosing of antimicrobials, and duration of prophylaxis, as well as expanded and new recommendations for urology, cardiac, and thoracic procedures.3 There are also recommendations for prophylaxis when implantable devices are placed and information regarding the use of mupirocin and the role of vancomycin in surgical prophylaxis.

Preoperative-dose timing

A more specific recommendation for the optimal time for antimicrobial administration has been provided: within 60 minutes before incision (as opposed to the less specific “at induction of anesthesia”).3 Consideration is given for medications that have extended times of infusion (e.g. fluoroquinolones and vancomycin) and it is recommended that these agents should be started within 120 minutes before surgical incision.

Selection and dosing

Specific recommendations on which agents should be selected for different types of surgeries as well as initial dosing and interval of redosing is provided in the guidelines and is replicated below (Tables 1 and 2).3 Of note, there is a brief discussion of antibiotic dosing in obesity. Overall, there is little evidence to support one strategy over another for antimicrobial prophylaxis in obese patients although the pharmacokinetics of most, if not all, antimicrobials are effected by obesity.

Duration of prophylaxis

A more specific recommendation of limiting the postoperative course of antimicrobials is provided in these guidelines.3 The recommendations are to provide a single dose of an antimicrobial or continue for no more than 24 hours postoperatively. It is also discussed that postoperative antimicrobial prophylaxis based on the presence of indwelling drains and intravascular catheters is not needed.

Comparison of ASHP/IDSA/SIS/SHEA to the Medical Letter guidelines

Recommendations for preoperative-dose timing are identical between the 2 guidelines.1,3 Recommendations for redosing interval is similar as well, although redosing of vancomycin is not recommended in the ASHP/IDSA/SIS/SHEA guidelines due to its long half-life. Dosing recommendations differ between the guidelines as well. For example, the ASHP/IDSA/SIS/SHEA guidelines recommend cefazolin be given at a dose of 2 g for patients < 120 kg and 3 g for patients ≥ 120kg, whereas the Medical Letter guidelines recommend a dose of 1 g for patients < 80 kg and 2 g for patients ≥ 80 kg. The recommended dose of vancomycin also differs, with the ASHP/IDSA/SIS/SHEA guidelines recommending a weight-based dose of 15 mg/kg, and the Medical Letter guidelines recommend a flat dose of 1 g for all patients. Both guidelines contain tables summarizing the antimicrobial selection based on the procedure type as well as the dosing of these antimicrobials. The tables from the ASHP/IDSA/SIS/SHEA guidelines are summarized below in Tables 1 and 2.

There are other large differences between these guidelines but not in terms of recommendations.1,3 First, the ASHP/IDSA/SIS/SHEA guidelines contain recommendations for pediatric dosing of antimicrobials for surgical prophylaxis. While there is a lack of pediatric-specific evidence to support the use of antimicrobial surgical prophylaxis in pediatrics (most recommendations in the guidelines are based on expert opinion), children undergo many surgeries that are similar to those undergone but adults. Therefore, the recommendations for antimicrobial selection and timing of administration in pediatrics mimic that of adults. Dosing in pediatrics is weight-based but the dose should not exceed that of the recommended dose for adults. This usually happens when the child’s weight reaches 40 kg or above. The recommended dosing interval does not differ between children and adults.

Another large difference between the ASHP/IDSA/SIS/SHEA guidelines and the Medical Letter guidelines is the depth of review of the literature. 1,3 While the Medical Letter guidelines are brief regarding the recommendations made, the ASHP/IDSA/SIS/SHEA guidelines delve into a large amount of literature specific to each type of procedure. It is, therefore, possible to better understand the rationale for the recommendations made in the ASHP/IDSA/SIS/SHEA guidelines and refer to the referenced literature to form a more patient-specific antimicrobial strategy.

Table 1. Recommended Doses and Redosing Intervals for Antimicrobials for Surgical Prophylaxis in Adults and Pediatrics.3

Adapted from Am J Health-Syst Pharm. 2013;70(3):195-283.

a. Maximum pediatric dose should not exceed usual adult dose
b. For intervals marked as NA (not applicable), redosing may be needed for unusually long procedures.
c. Fluoroquinolones should not be used routinely in pediatric patients due to the risk of toxicity (e.g. tendonitis/tendon rupture). However, single-dose prophylaxis is generally safe.
d. Limited to a single dose preoperatively. Dosing weight is actual body weight (ABW) unless ABW is more than 20% above ideal body weight (IBW); then dosing weight = IBW + 0.4(actual weight – IBW).

Table 2. Recommendations for Surgical Antimicrobial Prophylaxis.3

Adapted from Am J Health-Syst Pharm. 2013;70(3):195-283.

a. Addition of a single preoperative dose of vancomycin may be done for patients colonized with methicillin-resistant Staphylococcus aureus
b. Evidence for prophylaxis is graded as A (well-conducted randomized, controlled trials or well-conducted cohort trials); levels I-III), B (well-conducted case-control trials or uncontrolled studies that were not well conducted) or C (expert opinion)
c. Susceptibility profiles should be reviewed prior to use of fluoroquinolones and ampicillin-sulbactam due to increasing resistance of Escherichia coli
d. Gentamicin or tobramycin
e. Ciprofloxacin or levofloxacin
f. Fluoroquinolones are not drugs of first choice in children due increased adverse events
g. A mechanical bowel preparation combined with oral neomycin plus either oral erythromycin base or oral metronidazole should be given in addition to intravenous agents for most patients
h. For perioperative antimicrobial prophylaxis only; not for prevention of opportunistic infections in immunocompromised transplant recipients

References

1. The Medical Letter. Antimicrobial prophylaxis for surgery. Treat Guide Med Lett. 2012; 10(122):73-78.

2. Martinez M. What are the most recent antimicrobial prophylaxis guidelines from the Medical Letter? University of Illinois at Chicago Drug Information Group Web site. http://dig.pharm.uic.edu/faq/2012/Nov/faq2.aspx. Accessed April 16, 2013.

3. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70(3):195-283.

4. American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 1999;56(18):1839-1888.

5. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis. 1994;18(3):422-427.

6. Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds: guidelines for clinical care. Arch Surg. 1993(1);128:79-88.

Prepared by:

Johnathan Voss, PharmD

PGY-1

University of Illinois at Chicago

May 2013

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Should zolpidem use be minimized due to increased risk of falls in hospitalized patients?

Introduction

In the United States, insomnia, or the inability to fall and/or stay asleep, is recognized as a public health concern.1 Between 50 and 70 million adults in the United States have a sleep or wakefulness disorder. According to research from the National Institutes of Health (NIH), 30% to 40% of adults report having insomnia symptoms within any given year.2 A majority of these individuals have acute insomnia which lasts one or several nights, whereas 10% to 15% complain of chronic insomnia which can last from months to years. Pharmacotherapy, as well as interventions such as behavioral strategies, are often required to manage insomnia.3 Zolpidem, an oral nonbenzodiazepine hypnotic drug indicated for insomnia, may have several advantages over the use of benzodiazepines for insomnia, including a lower risk of dependence, abuse, and withdrawal.4 Zolpidem is selective for the α1 subunit of the gamma-aminobutyric acid (GABAA)receptor, which is responsible for the desired sedative-hypnotic effect.5 Benzodiazepines are nonselective at the GABAA receptor and consequently may cause anterograde amnesia, ataxia, and muscle relaxation.3 Additionally, zolpidem does not adversely affect sleep architecture as do benzodiazepines. Multiple formulations of zolpidem exist, including immediate-release (IR) formulations (Ambien, generic zolpidem), an extended-release (Ambien CR, generic zolpidem CR) tablet, IR sublingual tablets (Intermezzo, Edluar), and an IR oral spray (Zolpimist).6

Zolpidem and the Risk of Falls Among Hospitalized Patients

Earlier this year, a retrospective cohort study from the Mayo Clinic Center for Sleep Medicine was published with the aim of determining if zolpidem administration was associated with increased fall rates in the hospital setting. At this institution, zolpidem was the most commonly prescribed sleep aid. 7 Patients who were prescribed scheduled or “as-needed” zolpidem were identified in the pharmacy database, and an electronic medical record (EMR) was used to collect information on demographics, diagnoses, medications, and zolpidem dispensing. Hospital length of stay, Charlson comorbidity index scores, and Hendrich’s fall risk scores were also collected from the EMR. Records of inpatient falls were collected from the hospital’s central event reporting system. Patients who were in the intensive care unit or who were pregnant were not eligible. A multivariate logistic regression analysis was used to calculate the odds ratios for falls in patients who received zolpidem after accounting for significant confounding factors.

There were 609 patients with falls out of 41947 eligible admissions in 2010, for a fall rate of 1.45%.7 Zolpidem was ordered for 16320 (38.9%) of these admissions, but 4962 (30.4%) of these patients actually received a dose of zolpidem during the admission. Of these 4962 patients who were given zolpidem, 151 falls were recorded for a rate of 3.04%. Conversely, in the nearly 70% of patients for which zolpidem was ordered but not administered, only 81 patients fell, for a fall rate of 0.71% for an odds ratio (OR) of 4.37 (95% confidence interval [CI] 3.33-5.74). Compared to all patients that did not receive zolpidem (either not administered or not ordered), a higher risk of falling was found for patients who received zolpidem (3.04 falls/100 patients vs. 1.24 falls/100 patients; OR 2.50, 95% CI 2.08-3.02). Multivariate logistic regression analysis subsequently showed that zolpidem remained significantly associated with falls; other significant factors in the risk of falls included insomnia, delirium, age, Hendrich’s fall risk score, and Charlson index. The authors concluded that hospitalized, nonelderly patients’ use of zolpidem caused the greatest increase in fall risk (OR 6.39). In the largest inpatient cohort study to date on this topic, the data showed that the administration of zolpidem was associated with an increased risk of falling, leading to this institution’s decision to remove zolpidem from their inpatient order sets. The authors concluded that nonpharmacological therapies should be implemented for inpatients since current data are lacking to support the use of other hypnotic agents.

Alternative Therapies for Acute Insomnia

Because of this recent data with zolpidem some institutions may be eager to replace zolpidem with other available therapies for insomnia. However, these other therapies are not necessarily a safer or efficacious alternative. Whatever therapies are chosen, it is important to try to implement non-pharmacologic options as well, and certain considerations should be taken into account while choosing an alternative agent. These considerations are summarized below.

Nonpharmacologic Options

Nonpharmacological methods, such as cognitive behavior therapy and sleep hygiene practices, are evidence-based approaches for sustaining sleep improvement over the long-term, without the safety concerns that accompany pharmacologic therapies.3 However, in acute insomnia, or in patients with chronic insomnia who are hospitalized for a short time, cognitive therapies alone likely will not produce a meaningful effect. Sleep disruption in the acute care setting is caused by many factors, and a multifactorial approach involving both pharmacological therapies and nonpharmacological interventions such as relaxing music, noise reduction, decreased interruptions, and exposure to daylight and nighttime darkness may be effective and safe.8,9

Pharmacologic Options

Clinicians must be aware of issues with other pharmacologic agents that may be possible alternatives to zolpidem for sleep. Many pharmacologic agents for treatment of acute or chronic insomnia either have limited data for efficacy or are associated with significant safety concerns.3

Trazodone is a widely used antidepressant prescribed at lower doses for its sedating effects, but evidence for efficacy is lacking.3 Although it has shown to have some effect in the first week of administration, loss of efficacy over time, rebound insomnia, and side effects limit its use.

Antihistamines, such as diphenhydramine and doxylamine, are available without a prescription.3 A major concern with this class are the side effects, which result from their action on many receptor types, their ability to cross the blood-brain barrier, and their long elimination half-life of 9 hours or more. Available evidence is sparse and does not support the use of these agents for insomnia.

Although benzodiazepines have many concerning side effects, this class of drugs, unlike the other alternatives, has ample data to support their safety and efficacy when used appropriately in the short-term.3 However, their use should be avoided in elderly patients, due to increased sensitivity to their effects.10 Triazolam is Food and Drug Administration (FDA)-approved for sleep onset, while estazolam, quazepam, flurazepam, and temazepam are approved for sleep maintenance.11

When pharmacologic therapy is selected, the American Academy for Sleep Medicine (AASM) guideline for chronic insomnia recommends selecting an agent based on symptoms, treatment goals, patient preference, cost, comorbidities, contraindications, drug interactions, and side effects.11 Currently, there is no guideline recommendation for selection of agents for insomnia related to sleep interruption or fragmentation as commonly occurs in the inpatient setting.

Recent Food and Drug Administration Safety Communication

Around the same time the Mayo Clinic study was published, an FDA Drug Safety Communication issued in January 2013 described the risk of next-morning impairment associated with the use of zolpidem.12 New data showed that for some patients, blood levels of the drug remained high the next morning, which may impair daytime activities requiring alertness. This risk was highest in those taking extended-release formulations. Women appear to be more susceptible to this effect due to slower elimination of the drug compared to men. The recent FDA alert suggests all patients – both men and women – be cautioned about the risk of next-morning drowsiness and recommends the starting dose be halved for female patients to 5 mg (IR) or 6.25 mg (extended-release). Intermezzo, a low-dose zolpidem product approved for middle-of-the-night awakenings, does not require this dosing change.

Summary

Although data from the largest inpatient cohort at Mayo Clinic led to that institution’s decision to remove zolpidem from their order sets due to the risk of patient falls and implement more nonpharmacologic therapies for acute insomnia, there may be other methods that can reduce the safety concerns with this drug. It is important to note the difficulty in the identification of a single cause of falls, since medications compose only one aspect of fall risk. Falls can be caused by factors related to care of the patient, such as slippery floors and poor lighting, as well as patient factors, such as muscular weakness, gait abnormalities, visual impairment, and cognitive impairment.13 Although studies try to control for these confounding factors, each case of a fall is likely to be more complex than the results suggest.

Additionally, the recent FDA safety communication highlights the need for education on the proper dosing and monitoring of zolpidem.12 Many patients will require a lower starting dose, as many of the side effects are dose-related. Furthermore, it is important to understand the risks of alternative agents that may consequently be used in the absence of zolpidem.3 Therefore, a comprehensive approach involving appropriately dosed and monitored zolpidem with nonpharmacologic therapy for sleep is likely a safe and effective strategy for managing patients with acute insomnia in the hospital.

Key Considerations for Safe Use of Zolpidem

· According to the prescribing information, zolpidem should not be used more than 7 to 10 days without re-evaluation.5

· Doses should be reduced when given in combination with other central nervous system depressants, or in patients who are elderly, debilitated, or have hepatic impairment. 5

· Although its mechanism lends to less side effects compared to benzodiazepines, zolpidem can still have similar safety concerns if dosed inappropriately or in susceptible patients.3 Studies have shown that withdrawal symptoms and rebound insomnia can occur after 4 weeks of nightly use, and effects may diminish over time.

· Some patients experience abnormal thinking and behavioral changes, including sleepwalking and hallucinating.5

· Drowsiness, dizziness, and diarrhea are the most common side effects of zolpidem and are dose-dependent. 5

· Postmarketing data have also shown respiratory insufficiency in patients with obstructive sleep apnea in association with zolpidem use. 5

References

1. Insufficient Sleep is a Public Health Epidemic. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/features/dssleep/. Accessed March 7, 2013.

2. Can’t Sleep? What To Know About Insomnia. National Sleep Foundation Web site. http://www.sleepfoundation.org/article/sleep-related-problems/insomnia-and-sleep. Accessed March 7, 2013.

3. Morin AK, Jarvis CI, Lynch AM. Therapeutic options for sleep-maintenance and sleep-onset insomnia. Pharmacotherapy. 2007;27(1):90-110.

4. Harrison TS, Keating GM. Zolpidem: a review of its use in the management of insomnia. CNS Drugs. 2005;19(1):65-89.

5. Zolpidem [package insert]. Bridgewater, NJ. Sanofi-Aventis U.S. LLC; 2012.

6. Wickersham RM, ed. Drug Facts and Comparisons. St. Louis, MO. Wolters Kluwer Health; 2013. http://www.online.factsandcomparisons.com. Accessed April 19, 2013.

7. Kolla BK, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med. 2013;8(1):1-6.

8. Faraklas I, Holt B, Tran S, Lin H, Saffle J, Cochran A. Impact of a Nursing-Driven Sleep Hygiene Protocol on Sleep Quality. J Burn Care Res. 2013;34(2):249-254.

9. LeReau R, Benson L, Watcharotone K, Manguba G. Examining the feasibility of implementing specific nursing interventions to promote sleep in hospitalized elderly patients. Geriatr Nurs. 2008;29(3):197-206.

10. American Geriatrics Society 2012 Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631.

11. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487-504.

12. Zolpidem Containing Products: Drug Safety Communication – FDA Requires Lower Recommended Doses. U.S. Food and Drug Administration Web site: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/
ucm334738.htm.
Accessed March 7, 2013.

13. Chang CM, Chen MJ, Tsai CY, et al. Medical conditions and medications as risk factors of falls in the inpatient older people: a case-control study. Int J Geriatr Psychiatry. 2011;26(6):602-607.

Prepared by:

Michelle Bryson, PharmD

PGY-2 Drug Information Resident

University of Illinois at Chicago

May 2013

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What are the updated guideline recommendations for management of opportunistic infections in patients with HIV?

Introduction

Opportunistic infections (OI) are a common cause of morbidity and mortality in patients with human immunodeficiency virus (HIV) infection.1 Although the widespread use of effective antiretroviral therapy (ART) has substantially decreased OI prevalence and severity, these infections continue to occur in individuals who are not receiving ART for reasons such as undiagnosed disease, lack of access to care, or medication noncompliance. Guidelines for the prevention and treatment of OI in adults and adolescents have been published. In May 2013 an update to these guidelines was released by the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Disease Society of America. This article summarizes the major changes to the guideline since the prior edition was released in 2009, including recommendations for timing of ART initiation in the setting of an acute OI, treatment of hepatitis B and C virus co-infection, and notable changes to vaccination recommendations.

Initiating antiretroviral therapy in the setting of an acute opportunistic infection

When the 2009 OI guidelines were released there was no consensus regarding the optimal time to start ART after the diagnosis of an acute OI in treatment-naive patients, but preliminary data suggested that early initiation may be beneficial.2 These statements have been expanded in the 2013 guideline, which provides specific comments regarding ART initiation for each OI as summarized in the Table.1 Where applicable, the recommendation strength and quality rating is noted. In general, the guideline endorses starting ART as soon as possible to maximize immune function while minimizing the risk of immune reconstitution inflammatory syndrome (IRIS).

Table. Recommendations for initiating ART in the setting of an acute OI in treatment-naïve patients.1

a Recommendation rating system: A=strong, B=moderate, C=optional, I=one or more randomized trials with clinical outcomes and/or validated laboratory endpoints, II=one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes, III=expert opinion.

ART=antiretroviral therapy; HBV=hepatitis B virus; CMV=cytomegalovirus; CNS=central nervous system; HIV=human immunodeficiency virus; HPV=human papillomavirus; HSV=herpes simplex virus; MAC=Mycobacterium avium complex; OI=opportunistic infection; PI=protease inhibitor; PML=progressive multifocal leukoencephalopathy.

Treatment of hepatitis B virus in patients co-infected with HIV

For patients co-infected with hepatitis B virus (HBV) and HIV, ART should include 2 agents active against both viruses.1 The preferred agents are the nucleoside reverse transcriptase inhibitors (NRTIs), tenofovir and emtricitabine, which are co-formulated and are also the preferred NRTI backbone for ART-naïve patients. Lamivudine may be used instead of emtricitabine, but high rates of HBV resistance to lamivudine in co-infected individuals limit its use. Entecavir is also active against both viruses but is only recommended as add-on therapy to a fully suppressive ART regimen when the risk of nephrotoxicity with tenofovir outweighs its benefits. Therapy for both infections should be continued indefinitely. The previous guidelines listed all of the above agents as treatment options in co-infected individuals, but did not list tenofovir/emtricitabine as the preferred backbone agent due to lack of data at the time of publication.2

Patients who are co-infected but defer initiation of ART should be assessed as HBV mono-infected patients to determine if HBV treatment is indicated.3 If HBV treatment is indicated, agents with any activity against HIV should not be used in order to avoid development of ART resistance. 1 The preferred HBV treatment agent in patients not receiving ART is peginterferon alfa-2a or -2b alone. Adefovir is no longer recommended.

Treatment of hepatitis C virus in patients co-infected with HIV

Patients with HIV and either acute or chronic hepatitis C virus (HCV) should be considered for HCV treatment.1 The guidelines now recommend against treating HCV in co-infected individuals when the CD4 count is <200 cells/mm3.1 Prior to this, HCV treatment was recommended in patients with CD4 count <200 cells/mm3 as long as HIV viral replication was controlled with ART.2 For patients with CD4 count between 200 and 350 cells/mm3, the recommendation is that patients receive at least 6 months of ART before HCV treatment is initiated. 1

The recent approval of the HCV protease inhibitors (PIs) boceprevir and telaprevir have changed treatment recommendations for patients mono-infected with HCV, but it is unclear what role these agents play in the treatment of HCV in patients co-infected with HIV. Because of the rapidly-evolving development of HCV drugs, patients with minimal chronic HCV disease may benefit from waiting to initiate HCV treatment.1 Use of peginterferon alfa and ribavirin are still the recommended standard treatment of acute or chronic HCV in co-infected individuals, but enrollment of these individuals into clinical trials that assess the safety and efficacy of the HCV PIs and other novel direct-acting antiviral agents is another option. If considering use of PIs, potential drug-drug interactions with ART should also be considered.

Vaccine recommendations

In the updated guidelines, vaccine recommendations are categorized based on CD4 count <200 cells/mm3 and >200 cells/mm3. 1 Changes from the 2009 guidelines include different recommendations for the human papilloma virus (HPV) and the pneumococcal vaccine. It is currently recommended that both women and men receive 3 doses of the HPV vaccine through the age of 26 years, as the vaccine is effective in the prevention of HPV-related disease and cancer. Prior to this change, the HPV vaccine was only listed as an option for women because of limited data in women and no data in men.2

The pneumococcal vaccination recommendations in patients with HIV incorporate the recently approved pneumococcal 13-valent conjugate vaccine (PCV13). 1 It is now recommended that patients who have never received any pneumococcal vaccination or those who have had 1 year pass since their pneumococcal polysaccharide (PPV23) vaccination receive 1 dose of PCV13. If it is a patient’s first pneumococcal vaccination, the dose of PCV13 should be followed with a dose of PPV23 after 8 weeks. Re-vaccination with PPV23 in individuals who previously received PPV23 should occur after 5 years have elapsed since the initial dose. These recommendations echo those of the Advisory Committee on Immunization Practices for pneumococcal vaccination in immunocompromised adults.4

Conclusion

Effective treatment of OI in the setting of HIV infection continues to evolve. The 2013 OI treatment guidelines provide clinicians with further insight into timing of ART initiation in the setting of an acute OI and update recommendations for individuals with HBV/HIV and HCV/HIV co-infection. Ultimately, prevention with appropriate ART and optimal vaccination techniques is the most effective strategy for minimizing OI-related morbidity and mortality in the HIV-infected population.

References

1. Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: 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. Aidsinfo website. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed May 17, 2013.

2. Kaplan JE, Benson C, Holmes KH, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009;58(RR-4):1-207.

3. Lok AS, McMahon BJ. Chronic hepatitis B: update 2009. Hepatology. 2009;50(3):661-662.

4. Centers for Disease Control and Prevention. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61(40):816-819.

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