When do HIV patients require different treatment for infections like pneumonia compared to non-immunocompromised patients?

From the Guidelines

Patients with HIV require different treatment approaches for infections like pneumonia when their CD4 count falls below 200 cells/mm³ or they have an AIDS-defining illness. This is based on the most recent evidence from the 2018 recommendations of the International Antiviral Society-USA panel 1. The key considerations in treating HIV patients with pneumonia include:

• Broader antimicrobial coverage to consider opportunistic pathogens like Pneumocystis jirovecii pneumonia (PJP)
• Use of trimethoprim-sulfamethoxazole (TMP-SMX) at 15-20 mg/kg/day of the trimethoprim component, divided into three or four doses for 21 days for PJP
• Addition of adjunctive corticosteroids for moderate to severe PJP (PaO2 <70 mmHg or A-a gradient >35 mmHg): prednisone 40 mg twice daily for 5 days, then 40 mg daily for 5 days, followed by 20 mg daily for 11 days
• Coverage for fungal infections like cryptococcosis or histoplasmosis, mycobacterial infections including tuberculosis, and viral infections such as cytomegalovirus
• Longer treatment duration and careful monitoring of drug interactions between antimicrobials and antiretroviral therapy The need for a different approach is due to HIV compromising cell-mediated immunity, making patients susceptible to a wider range of pathogens and more severe disease progression, with higher risks of treatment failure and antimicrobial resistance, as noted in the guidelines for using antiretroviral agents among HIV-infected adults and adolescents 1. Additionally, the 2016 recommendations of the International Antiviral Society-USA panel also emphasize the importance of considering CD4 cell counts in determining the need for primary prophylaxis for opportunistic infections, including Pneumocystis pneumonia 1. It is also worth noting that the initial diagnostic algorithm for patients with acute, subacute, and chronic cough is the same as that for immunocompetent persons, taking into account an expanded list of differential diagnoses that considers the type and severity of immune defect and geographic factors, as stated in the cough in the immunocompromised host: ACCP evidence-based clinical practice guidelines 1.

From the FDA Drug Label

AIDS patients may not tolerate or respond to sulfamethoxazole and trimethoprim in the same manner as non-AIDS patients The incidence of adverse reactions, particularly rash, fever, leukopenia, and elevated aminotransferase (transaminase) values, with sulfamethoxazole and trimethoprim therapy in AIDS patients who are being treated for P. jirovecii pneumonia has been reported to be increased compared with the incidence normally associated with the use of sulfamethoxazole and trimethoprim in non-AIDS patients

HIV patients, specifically those with Acquired Immunodeficiency Syndrome (AIDS), may require different treatment for infections like pneumonia compared to non-immunocompromised patients due to:

• Potential for increased adverse reactions
• Altered tolerance and response to sulfamethoxazole and trimethoprim therapy Key considerations for AIDS patients include:
• Close monitoring of serum potassium and other electrolytes
• Frequent laboratory tests to assess for adverse reactions and electrolyte abnormalities
• Adjustment of treatment as needed to minimize risks and optimize outcomes 2 3

From the Research

Treatment Requirements for HIV Patients with Infections like Pneumonia

HIV patients may require different treatment for infections like pneumonia compared to non-immunocompromised patients due to their compromised immune system. The following points highlight the differences in treatment requirements:

• HIV patients usually have mild-to-severe symptoms, while non-HIV patients present with a rapidly progressing disease 4, 5.
• Trimethoprim-sulfamethoxazole is considered the first-line drug for treatment and has proven to be highly effective for Pneumocystis jirovecii pneumonia prophylaxis in both HIV and non-HIV patients 4, 5, 6.
• Alternative treatment regimens include dapsone with trimethoprim, clindamycin with primaquine, atovaquone, or pentamidine 5, 6.
• Patients with moderate to severe disease should receive adjunctive corticosteroids 5.
• In newly diagnosed HIV-infected patients with Pneumocystis jirovecii pneumonia, antiretroviral therapy (ART) should be initiated as soon as possible 5.
• In non-HIV-infected immunocompromised patients, improvement of the immune status should be discussed (e.g., temporary reduction of immunosuppressive agents) 5.
• Special consideration is needed for patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency, as trimethoprim-sulfamethoxazole can cause hemolysis in these patients 7.
• Anidulafungin can be used as an alternative regimen for the treatment of Pneumocystis jirovecii pneumonia in patients with G6PD deficiency 7.

Extrapulmonary Pneumocystosis

Extrapulmonary Pneumocystis jirovecii infections are extremely rare, but can occur in HIV-positive patients 8. The treatment of extrapulmonary pneumocystosis (EPC) is not standardized, but trimethoprim-sulfamethoxazole is commonly used 8. Antiretroviral treatment (ART) may become the key to EPC treatment in individuals with HIV infection 8.