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Antimicrobial Prophylaxis per CD4 Counts

Rachel Pellegrino

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CD4 counts Opportunistic Infection Indication for Prophylaxis Medication Special Notes
<200 cells/mm3 Pneumocystis Pneumonia (PJP) CD4 < 200, or CD4 < 14%, or CD4 200-250 w/ delayed init. ART & poor f/u TMP-SMX: 1 DS daily (qd), or TMP-SMX: 1SS qd TMP-SMX: 1 DS TIW If intolerant of TMP-SMX: dapsone*, or pentamidine, or atovaquone
<200 cells/mm3 Toxoplasma gondii encephalitis Toxoplasma IgG + and CD4 < 100 TMP-SMX 1 DS tab daily Alternative regimens: Dapsone, or Atovaquone (all regimens effect. for PJP )
<200 cells/mm3 Mycobacterium avium- intracellulare (MAC, MAI) Only if not on fully suppressive ART and active disseminated MAC is ruled out - Azithromycin 1200 mg weekly, or -Clarithromycin 500 mg BID, or - Rifabutin 300 mg daily NOT indicated for those initiating ART
Infection Screening Indication Intervention
Hepatitis A Virus (HAV) Non-immune w/ ↑ risk for HAV infection (MSM, IVDU) or chronic liver disease HAV vaccine
Hepatitis B Virus (HBV) Pts w/o chronic HBV or non-immune HBV vaccine. Ideally admin. before CD4 < 350
Human Papilloma virus (HPV) Age 13-45 HPV vaccine series
Influenza A and B Virus All patients Yearly inactivated influenza vaccine
Latent Mycobacterium tuberculosis infection (LTBI) -Pts with positive screening test for LTBI w/ no evidence of active disease. -Pts w/ known exposure (INH 300mg + pyridoxine 25-50mg) PO daily for 9 months
Streptococcus pneumoniae All patients PCV13 and PPV23 (order and timing depends on previous vaccination history and CD4)
Syphilis All pts exposed to sex partner with syphilis diagnosis Screening for syphilis and gonorrhea/chlamydia with treatment if indicated.
Varicella Zoster Virus (VZV) Pre-exposure: CD4 >200, no previous vaccine.Shingrix (recombinant vaccine) is not live virus, only Zostavax (live virus) is contraindicated for CD4 <200). Post-exposure: Close contact, particularly if CD4 <200 Pre-exposure: Consider vaccination Post-exposure: Varicella-zoster immune globulin

Last update: 2022-10-15 17:31:10