What is the role of antibiotic prophylaxis in the treatment of pediatric HIV infection and which drugs are used?

Updated: Mar 05, 2020
  • Author: Delia M Rivera, MD; Chief Editor: Russell W Steele, MD  more...
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Answer

Tables 2 and 3 below summarize the antibiotics used for primary and secondary prophylaxis of opportunistic infections and their appropriate dosages.

Antibiotic prophylaxis does not guarantee protection, and opportunistic infections should be appropriately included in the differential diagnosis for all HIV-infected patients.

Several antibiotics used for prophylaxis have clinically significant adverse interactions with antiretroviral agents. For example, rifampin and rifabutin reduce the effectiveness and increase the toxicity of protease inhibitors and nonnucleoside reverse transcriptase inhibitors (NNRTIs). Also, isoniazid is hepatotoxic and may interact poorly with protease inhibitors that are hepatotoxic.

Table 2. Antibiotics for Primary and Secondary Prophylaxis of Opportunistic Infections (Open Table in a new window)

Infection

Indication

First-Line Regimen

Alternative Regimen

TB

PPD test result >5 mm

Isoniazid and pyridoxine qd for 9 mo

Rifampin for 4 mo

Exposure

Isoniazid and pyridoxine 3 times/wk for 9 mo, rifampin and pyrazinamide qd for 2 mo

Consult an infectious diseases specialist if the pathogen is multidrug resistant

PCP

CD4+ finding*

Trimethoprim-sulfamethoxazole qd

Trimethoprim-sulfamethoxazole 3 times/wk

Fever of unknown origin for 2 wk, history of infection

Dapsone, pyrimethamine, and leucovorin

Dapsone or aerosolized pentamidine in children >5 y

---

Atovaquone

Atovaquone

Toxoplasmosis

CD4+ count < 100 cells/mL

Trimethoprim-sulfamethoxazole qd

Dapsone, pyrimethamine, and leucovorin

Positive immunoglobulin G finding

None

Atovaquone

Previous infection

Sulfadiazine, pyrimethamine, and leucovorin

Clindamycin, pyrimethamine, and leucovorin

MAC infection

CD4+ finding**

Azithromycin qwk

Rifabutin qd or clarithromycin bid

Previous infection

Clarithromycin or azithromycin qd and ethambutol

Clarithromycin or azithromycin qd and ethambutol

Abbreviations: bid = twice daily; PPD = purified protein derivative; qd = every day; qwk = every week.

* See Table 4

**See Table 5

Table 3. Drugs and Doses for Prophylaxis of Opportunistic Infections (Open Table in a new window)

Drug

Dose

Azithromycin

20 mg/kg/dose (1.2 g maximum) PO qwk or

5 mg/kg/dose (250 mg maximum) PO qd

Clarithromycin

7.5 mg/kg/dose (500 mg maximum) PO bid

Clindamycin

20-30 mg/kg/d PO qid

Dapsone

1-2 mg/kg/d (100 mg maximum) PO qd

Ethambutol

15 mg/kg/dose (900 mg maximum) PO qd

Isoniazid

10-15 mg/kg/dose (300 mg maximum) PO/IM qd

Leucovorin

5 mg PO 3 times/wk

Pentamidine

4 mg/kg/dose monthly

Pyrimethamine

15 mg/m2/dose (25 mg maximum) PO qd

Rifabutin

5 mg/kg/dose (300 mg maximum) PO qd

Rifampin

10-20 mg/kg (600 mg maximum) PO/IV qd

Sulfadiazine

85-120 mg/kg/d PO bid

Trimethoprim-sulfamethoxazole

150/750 mg/m2/d PO bid

Abbreviations: bid = twice daily; PO = by mouth; qd = every day; qwk = every week.

Table 4. CD4+ -Based Indications for Starting PCP Prophylaxis (Open Table in a new window)

Age or Status

CD4+ Count, cells/mL

CD4+ Percentage

6 wk to 1 y

Any

Any

1-2 y

< 750

< 15

2-5 y

< 500

< 15

>5 y

< 200

< 15

Previous PCP infection

Any

Any

Table 5. CD4+ -Based Indications for MAC Prophylaxis (Open Table in a new window)

Age or Status

CD4+ Count, Cells/mL

< 1y

< 750

1-2 y

< 500

2-6 y

< 75

> 6 y

< 50

Previous infection

Any


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