First-Line Antibiotics for Common Bacterial Infections in HIV Patients
For HIV patients with common bacterial infections, the first-line antibiotic treatment is an oral beta-lactam plus an oral macrolide for outpatient management, with preferred beta-lactams being high-dose amoxicillin or amoxicillin-clavulanate, and preferred macrolides being azithromycin or clarithromycin. 1
Outpatient Treatment
- For HIV patients with bacterial respiratory infections treated as outpatients, administer an oral beta-lactam (high-dose amoxicillin, amoxicillin-clavulanate, cefpodoxime, or cefuroxime) plus an oral macrolide (azithromycin or clarithromycin) 2, 1
- Oral doxycycline is an alternative to macrolides if needed 2
- For penicillin-allergic patients or those who have received a beta-lactam within the previous 3 months, use an oral respiratory fluoroquinolone (moxifloxacin, levofloxacin 750 mg/day, or gemifloxacin) 2, 1
Inpatient Treatment
- For non-ICU inpatient treatment, administer an IV beta-lactam (ceftriaxone, cefotaxime, or ampicillin-sulbactam) plus a macrolide 2, 1
- For ICU patients, administer an IV beta-lactam plus either IV azithromycin or an IV respiratory fluoroquinolone 1, 3
- For patients with risk factors for Pseudomonas infection, meropenem (1g IV every 8 hours) can be combined with either ciprofloxacin or levofloxacin 3
Important Considerations
- Never use macrolide monotherapy due to increased risk of drug-resistant Streptococcus pneumoniae in HIV patients 2, 1
- Use fluoroquinolones with caution when tuberculosis is suspected, as they may mask TB symptoms and delay appropriate multi-drug TB therapy 2, 4
- For HIV patients with Salmonella septicemia, fluoroquinolones (primarily ciprofloxacin) are usually the drugs of choice for susceptible organisms to prevent recurrence 2
Prophylaxis Considerations
- Trimethoprim-sulfamethoxazole (TMP-SMZ), when administered daily for Pneumocystis jirovecii pneumonia (PCP) prophylaxis, also reduces the frequency of bacterial respiratory infections 2, 5
- TMP-SMZ should not be prescribed solely to prevent bacterial respiratory infections due to risk of developing resistant organisms 2
- Clarithromycin administered daily or azithromycin administered weekly for Mycobacterium avium complex (MAC) prophylaxis might also be effective in preventing bacterial respiratory infections 2
Special Populations
Children
- For HIV-infected children with recurrent serious bacterial infections, antibiotic chemoprophylaxis may be considered 2
- Intravenous immunoglobulin (IVIG) should be considered for HIV-infected children with hypogammaglobulinemia (IgG <400 mg/dL) or those with recurrent serious bacterial infections 2
- TMP-SMZ prophylaxis in children has been shown to be effective even at lower than standard doses 6
Pneumocystis Pneumonia (PCP)
- For PCP, which is a common opportunistic infection in HIV patients, TMP-SMX is the first-line treatment with standard dosing of TMP 15-20 mg/kg/day and SMX 75-100 mg/kg/day, divided into 3-4 doses 1, 7, 8
- Lower doses of TMP-SMX (TMP 10 mg/kg/day-SMX 50 mg/kg/day) may be equally efficacious with potentially fewer adverse effects 7
Treatment Monitoring
- Monitor clinical response to therapy, with expected improvement in symptoms within 48-72 hours 1
- Consider alternative diagnoses, especially tuberculosis, if a patient fails to respond to appropriate therapy 1, 9
- Collect specimens for microbiologic studies before initiating antibiotics, but do not delay antibiotic therapy while waiting for results 4
Remember that appropriate antibiotic selection and prompt initiation of therapy are crucial for reducing morbidity and mortality in HIV patients with bacterial infections.