Can antibiotics be given to patients on Antiretroviral Therapy (ART)?

Antibiotics and Antiretroviral Therapy: Compatibility and Considerations

Yes, antibiotics can be given to patients on antiretroviral therapy (ART), but careful consideration of potential drug-drug interactions is essential to maintain HIV viral suppression and prevent adverse effects.

General Compatibility of Antibiotics with ART

• Antibiotics are commonly needed in HIV patients for both opportunistic infections and routine bacterial infections 1
• Most antibiotics can be safely administered with ART, but specific drug-drug interactions must be evaluated before prescribing 2
• Trimethoprim-sulfamethoxazole remains one of the most important and widely used antibiotics in HIV patients, with broad-spectrum activity against Pneumocystis jiroveci, toxoplasmosis, and bacterial infections 1

Key Antibiotic-ART Interactions to Consider

Rifamycin Antibiotics

• Rifampin significantly affects metabolism of many antiretrovirals and requires specific ART regimen adjustments 2:
  • With rifampin, recommended ART regimens include 2 NRTIs (excluding TAF) plus efavirenz (600 mg daily), raltegravir (800 mg twice daily), or dolutegravir (50 mg twice daily) 2
  • Coadministration of bictegravir with rifampin is not recommended due to significantly decreased drug levels 2
  • Boosted protease inhibitors should be avoided with rifampin; if necessary, rifabutin (150 mg daily) should be substituted 2

Other Antibiotics

• Doxycycline has minimal interactions with ART and can be safely used in HIV patients 2
• TMP-SMX (trimethoprim-sulfamethoxazole) offers mortality benefits and reduces severe bacterial infections in patients on ART 2
• Ciprofloxacin and other fluoroquinolones generally have minimal interactions with most modern ART regimens 2

ART Regimen-Specific Considerations

Integrase Inhibitor-Based Regimens

• Unboosted integrase strand transfer inhibitor (InSTI) regimens (dolutegravir, raltegravir) have fewer drug interactions with antibiotics and are recommended when antimicrobial therapy is needed 2
• Bictegravir/TAF/emtricitabine (Biktarvy) has minimal drug-drug interactions compared to other antiretroviral classes, making it a preferred option when co-administered with many antibiotics 3

Protease Inhibitor-Based Regimens

• Boosted protease inhibitors (darunavir/ritonavir, atazanavir/ritonavir) have more significant drug interactions with antibiotics 2
• When using boosted PIs, careful review of antibiotic interactions is essential, particularly with macrolides, rifamycins, and certain fluoroquinolones 4

Special Clinical Scenarios

Tuberculosis Co-infection

• For patients with TB co-infection requiring rifampin-based therapy 2:
  • Dolutegravir (50 mg twice daily) with TDF/FTC is recommended during rifampin treatment 5
  • Efavirenz (600 mg)-based regimens remain an option due to fewer drug interactions 5
  • Boosted PIs should be avoided with rifampin; if necessary, substitute rifabutin (150 mg daily) 2

Hepatitis B/C Co-infection

• For patients with HIV/HCV co-infection requiring HCV treatment 2:
  • Choose ART regimens with minimal drug interactions with HCV therapies, such as dolutegravir/abacavir/lamivudine, dolutegravir/TAF/emtricitabine, bictegravir/TAF/emtricitabine, or raltegravir plus TAF/emtricitabine 2
  • Consult current HCV treatment guidelines for specific antibiotic recommendations 2

Fungal Infections

• When treating fungal infections in HIV patients 6:
  • Fluconazole has relatively weak interaction potential with the CYP450 system and is often the preferred antifungal 6
  • High itraconazole doses (>200 mg/day) should be avoided in patients on boosted PI regimens 6
  • Voriconazole is contraindicated with high-dose ritonavir-boosted PI 6

Monitoring Recommendations

• Regular monitoring is essential when combining antibiotics with ART 4:
  • Monitor renal function when using nephrotoxic antibiotics (e.g., aminoglycosides) with tenofovir disoproxil fumarate 2
  • Monitor for signs of treatment failure or toxicity when antibiotics that may interact with ART are necessary 4
  • Consider therapeutic drug monitoring when using antibiotics with narrow therapeutic windows alongside ART 6

Common Pitfalls to Avoid

• Avoid assuming all antibiotics have similar interaction profiles with ART - each combination must be individually evaluated 4
• Be aware that polypharmacy in HIV patients increases the risk of potential drug-drug interactions - a study found 68.8% of HIV patients in ICU had at least one potential drug-drug interaction 4
• Don't forget to consider the impact of food interactions when prescribing both antibiotics and ART, as some medications have specific food requirements 7
• Remember that drug interactions may affect not only efficacy but also toxicity profiles of both antibiotics and antiretrovirals 6