Immunocompromised patients treatment

Indications PO - acute treatment of herpes zoster (shingles) Initial episodes and the management of genital herpes Treatment of chickenpox (varicella) IV - treatment of initial and recurrent mucosal and cutaneous herpes simplex (HSV-1 and HSV-2) in immunocompromised patients Treatment of herpes simplex encephalitis Treatment of neonatal herpes infections Treatment of varicella-zoster (shingles) infections in immunocompromised patients... 

Darouiche RO. Oropharyngeal and esophageal candidiasis in immunocompromised patients Treatment issues. Clin Infect Dis 1998 26 259-274. 

Acyclovir (Zovirax) and penciclovir (Denavir) are the only topical antiviral dragp currently available These dragp inhibit viral replication. Acyclovir is used in the treatment of initial episodes of genital herpes, as well as heqies simplex virus infections in immunocompromised patients (patients with an immune system incapable of fighting infection). Penciclovir is used for the treatment of recurrent herpes labialis (cold sores) in adults. 

Antiviral drugp interfere with viral reproduction by altering DNA synthesis. These drug are used in the treatment of herpes simplex infections of the eye, treatment in immunocompromised patients with cytomegalovirus (CMV) retinitis, and for the prevention of CMV retinitis in patients undergoing transplant. 

Follow-up is dependent on the CSF findings. If pleocytosis is present, re-examine the CSF every 6 months until the WBC count normalizes. Consider recommending a second course of treatment if the CSF white count does not decline after 6 months or completely normalize after 2 years.15 Failure to normalize may require retreatment most treatment failures occur in immunocompromised patients. 

Two to three weeks of fluconazole or itraconazole solution are highly effective and demonstrate similar clinical response rates.32 Doses of 100 to 200 mg are effective in immunocompetent patients but doses up to 400 mg are recommended for immunocompromised patients. Due to variable absorption, ketoconazole and itraconazole capsules should be considered second-line therapy. In severe cases, oral azoles may prove ineffective, warranting the use of amphotericin B for 10 days. Although echinocandins and voriconazole are effective in treatment of esophageal candidiasis, experience remains limited. 

If immunocompromised patients experience frequent or severe recurrences, particularly of esophageal candidiasis, chronic maintenance therapy with fluconazole 100 to 200 mg daily should be considered. In patients with infrequent or mild cases, secondary prophylaxis is not recommended. The rationale for not giving prophylaxis includes availability of effective treatments for acute episodes, risk of developing resistant organisms, potential for drug interactions, and the cost of therapy. 

Finally, while a nonabsorbable antimicrobial agent has theoretic advantages as a choice for the treatment of infectious diarrhea, such an agent should not be used to treat hosts thought to have or be at risk for bacteremic disease (e.g. seriously immunocompromised patients). 

Amphotericin B (AmB) is a broad-spectrum antifungal agent that is the antibiotic of choice for disseminated fungal infections, particularly in immunocompromised patients. AmB is also used for the treatment of Leishmaniasis as a second-line treatment. However, its toxicity toward mammalian cells is often dose limiting, whatever its indication. 

Pneumocystis carinii pneumonia occurs in immunocompromised patients and it hence is a common cause of pneumonia in AIDS. High doses of co-trimoxazole are indicated for treatment of mild-to-moderate pneumocystis pneumonia. This condition should be treated by those experienced in its management as it can be fatal. 

Blastomycosis (capsules and injection) Treatment of pulmonary and extrapulmonary blastomycosis in nonimmunocompromised or immunocompromised patients. 

Herpes simplex virus (HSV) /nfecf/ons Treatment of acyclovir-resistant mucocutaneous HSV infections in immunocompromised patients. 

Ganciclovir IV is indicated for use only in the treatment of cytomegalovirus (CMV) retinitis in immunocompromised patients and for the prevention of CMV disease in transplant patients at risk for CMV disease. 

Ganciclovir capsules are indicated only for prevention of CMV disease in patients with advanced HIV infection at risk for CMV disease and for maintenance treatment of CMV retinitis in immunocompromised patients. 

CMV retinitis - Treatment of CMV retinitis in immunocompromised patients, including patients with AIDS. 

Chickenpox Although chickenpox in otherwise healthy children is usually a self-limited disease of mild to moderate severity, adolescents and adults tend to have more severe disease. Treatment was initiated within 24 hours of the typical chickenpox rash in the controlled studies, and there is no information regarding the effects of treatment begun later in the disease course. IV acyclovir is indicated for the treatment of varicella-zoster infections in immunocompromised patients. 

As an alternative therapy with concurrent leucovorin administration (leucovorin protection) for the treatment of moderate to severe Pneumocystis carinii pneumonia (PCP) in immunocompromised patients, including patients with acquired immunodeficiency syndrome (AIDS), who are intolerant of or refractory to TMP-SMZ therapy, or for whom TMP-SMZ is contraindicated. 

Infections Anakinra has been associated with an increased incidence of serious infections (2%) vs placebo (less than 1%). Discontinue administration if a patient develops a serious infection. Do not initiate treatment with anakinra in patients with active infections. The safety and efficacy of anakinra in immunocompromised patients or in patients with chronic infections have not been evaluated. Coadministration of anakinra and etanercept has not demonstrated increased clinical benefit. Carefully monitor patients when considering initiation of anakinra therapy concurrently with etanercept therapy. 

Owing to its inferior pharmacokinetic profile, voriconazole is dosed twice daily i.v. doses of 6 mg/kg are used on the first day, followed by 200 mg orally or continued i.v. dosing at 4 mg/kg. Voriconazole is recommended for the treatment of adults with invasive aspergillosis and can be used for rare infections caused by Fusarium spp. and Scedosporium apiospermum, where treatment with other agents has failed. Its primary use is in immunocompromised patients with progressive, life-threatening infections. 

Topical aciclovir has limited effectivity in the treatment of recurrent herpes genitalis or herpes febrilis infections in non-immunocompromised patients, although topical aciclovir may cause some reduction in the duration of viral shedding. Topical aciclovir has no role in the treatment of herpes zoster. 

In immunocompromised patients, crampy abdominal pain and prolonged severe watery diarrhoea occur. Fluid replacement and the use of an-tidiarrhoeals are the mainstay of treatment. In patients with acquired immunodeficiency syndrome... 

Oseltamivir may not be indicated for use in certain individuals. Its efficacy in patients with chronic cardiac or respiratory disease has not been established. In clinical trials, no difference in the incidence of complications was seen between treatment and control groups. The efficacy of oseltamivir has not been demonstrated in immunocompromised patients, patients who begin treatment after 40 hours of symptoms, or patients given repeated prophylactic courses of therapy. Dosage adjustment is recommended for individuals with renal insufficiency the drug s safety in patients with hepatic insufficiency is unknown. 

Khare MD and Sharland M. Cytomegalovirus treatment options in immunocompromised patients. Expert Opin Pharmacother 2001 2 1247-1257. 

B. Amphotericin B remains the drug of choice in the treatment of disseminated or invasive fungal infections in immunocompromised hosts bone marrow transplant recipients are the most heavily immunocompromised patients encountered in the hospital setting. 5-Flucytosine has no significant activity against Aspergillus spp., and it has bone marrow toxicity as a common adverse effect it should... 

Intravenous acyclovir is the treatment of choice for herpes simplex encephalitis, neonatal HSV infection, and serious HSV or VZV infections (Table 49-1). In immunocompromised patients with VZV infection, intravenous acyclovir reduces the incidence of cutaneous and visceral dissemination. 

Pyrimethamine, in combination with sulfadiazine, is first-line therapy in the treatment of toxoplasmosis, including acute infection, congenital infection, and disease in immunocompromised patients. For immunocompromised patients, high-dose therapy is required followed by chronic suppressive therapy. Folinic acid is included to limit myelosuppression. Toxicity from the combination is usually due primarily to sulfadiazine. The replacement of sulfadiazine with clindamycin provides an effective alternative regimen. 

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