Page 901 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

632 PART 5: Infectious Disorders

■ MANAGEMENT with methemoglobinemia, thrombocytopenia, neutropenia, liver dys-

Trimethoprim-sulfamethoxazole (TMP-SMX) is effective against P function, rash, and gastrointestinal upset, which often interferes with
jirovecii, as well as various gram-negative and gram-positive bacte- oral drug administration. Dapsone-induced methemoglobinemia and
rial organisms. Intravenous trimethoprim-sulfamethoxazole (15 mg/kg hemolytic anemia are particularly severe among individuals with glucose-
6-phosphate dehydrogenase deficiency, so prescreening for this glucose-
of the trimethoprim component divided three times daily) is recom-
<70 mm Hg, A-a gradient 6-phosphate dehydrogenase deficiency should be considered. It is also
mended for severely ill patients (eg, Pa O 2 important to note that the hemolytic anemia will produce an increase in
>45 mm Hg). The optimal duration of therapy is 21 days (see 85
82
Table 69-4). Side effects of trimethoprim-sulfamethoxazole include LDH that should not be misinterpreted as a sign of worsening PJP.
If used for therapy, pentamidine is usually administered intravenously
rash (including severe mucocutaneous reactions), cytopenias, and renal
dysfunction. A number of reports have documented successful desensi- (4 mg/kg once daily diluted in 250 mL of 5% dextrose and water) for 14
to 21 days. Adverse reactions to pentamidine are common, occurring in
https://kat.cr/user/tahir99/
tization of TMP-SMX-allergic patients using progressively larger doses
of the drug. Hypersensitivity-type reactions such as fever or rash can up to 100% of patients in some series. Common adverse drug reactions
include renal and hepatic dysfunction, neutropenia, thrombocytopenia,
also be treated with diphenhydramine or corticosteroids. 83
Dapsone (100 mg by mouth daily), a sulfone, is effective against hyponatremia, rash, fever, and gastrointestinal upset. Hypotension
Pneumocystis in combination with trimethoprim (TMP) (15 mg/kg daily, is common with pentamidine infusion. Administering pentamidine
in three doses per day). This combination has similar efficacy and better slowly over several hours can minimize hypotension. If severe or long-
lasting hypotension occurs, this should be treated supportively with a
tolerability and safety compared to TMP-SMX. Nonetheless, adverse
84
reactions of this combination are common, including hemolytic anemia vasopressor because it is readily reversible. Occasionally, carbohydrate
TABLE 69-4 Antimicrobial Therapy of Common Infections in AIDS Patients
Infection Drug of Choice Total Daily Dose Dose Interval Route Usual Duration Alternative Therapy
Protozoa
Toxoplasmosis Pyrimethamine a 200 mg loading dose, then Daily PO ≥6 weeks b Pyrimethamine (leucovorin) plus
(Toxoplasma gondii) 50 mg (if <60 kg), or 75 mg (if clindamycin 600 mg IV or PO q6h,
c
>60 kg)
Or
TMP-SMX (TMP 5 mg/kg and SMX
25 mg/kg) IV or PO BID
plus
Sulfadiazine 4000 mg (if <60 kg), or 6000 mg 6 h PO >6 weeks
(if >60 kg)
plus 10-25 mg
Leucovorin Daily PO >6 weeks
Maintenance therapy:
Pyrimethamine a 25-50 mg Daily PO Indefinitely Pyrimethamine 25-50 mg/d PO
a
plus plus leucovorin 10-25 mg PO daily
plus clindamycin 600 mg PO q8h
Or
TMP-SMX DS 1 tablet BID
Sulfadiazine 2000-4000 mg 12 h PO Indefinitely
plus
Leucovorin 10-25 mg Daily PO Indefinitely
Cryptosporidiosis No proven effective therapy Nitazoxanide 500-1000 mg PO BID for
(Cryptosporidium) 14 d, or Paromomycin 500 mg PO QID
for 14-21 d (optimize antiretroviral
therapy, rehydrate)
Rehydration and electrolyte replacement
Optimize antiretroviral therapy
Isosporiasis (Isospora Trimethoprim-sulfamethoxazole 640 mg
belli) 3200 mg 6 h PO, IV 10 d d Pyrimethamine 50-75 mg PO daily plus
leucovorin 5-10 mg PO daily for 4 weeks;
or ciprofloxacin 500 mg PO BID × 7 d
Maintenance therapy:
Trimethoprim, 160 mg, 3 times per week PO Until CD4 >200 Pyrimethamine 25 mg PO daily plus
sulfamethoxazole, 800 mg for >6 months folinic acid 5 mg PO daily
(Continued)

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