HIV
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| PrEP therapy | Truvada (emtricitabine/tenofovir) 300mg/200mg QD
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| what drug should be included in perinatal therapy for HIV prevention | zidovudine
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| normal CD4 count | 500-1300
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| what percent change in CD4 count is considered clinically relevant | 30%
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| percent change in CD4 counts to be expected in pts getting potent ART therapy | increase 50-100/mm^3 annually
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| CD4 count diagnostic of AIDS (stage 3 HIV) | <200/uL or <14%
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| other than CD4 count, what defines AIDS | documentation of an AIDS defining condition along with laboratory confirmation of HIV
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| symptoms of acute/primary HIV infection | lethargy, sweats, arthralgias, myalgias,fevers, headache, photophobia, sore throat, lymphadenopathy, diarrhea
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| when are live vaccines contraindicated in pts with HIV | if CD4 count <200
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| vaccines recommended in pts with HIV | flu, pneumococcal (once), Hep B (in all susceptible) and Hep A (if at high risk)
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| how long and with what should the baby be treated with post natally if mom has HIV | 6 weeks with zidovudine 4 mg/kg/dose Q12H. if mom didn't take ART during preggers add nevirapine at birth and repeat at 48 hours then 96 hours after the second dose, repeat.
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| what HIV drug should be avoided in women of childbearing age to avoid first trimester exposure | efavirenz
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| how long should post exposure prophylaxis continue and how soon after exposure should it start | continue therapy for 4 weeks. if non-occupational exposure start within 72 hours. if occupational try to start within hours and start treatment while status is evaluated
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| preferred post exposure prophylaxis | raltegravir PLUS Truvada (emtricitabine/tenofovir) [occupational]. no preference for ART if non-occupational other than that it be potent combination ART.
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| in a low risk HIV positive pt, when should ART be initiated | when CD4 counts drop below 350 FOR SURE. 350-500 and over 500 can consider. if pt likely to transmit HIV to sexual partners start as well. if pt preggers or AIDs defining condition or Hep B coinfection as well.
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| what are the principles of HIV opportunistic infections | severe and typically not curable, suppressive therapy is used; not contagious to others typically as usually reactivation of previous exposure; depends on local bugs; more B cell associated infections such as pneumococcal becoming more common
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| preferred treatment for PCP | bactrim x 21 days. if Aa gradient of 35 or more or Po2<70 indicating severe dz then do adjuvant corticosteroids
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| calculate Aa gradient | 150-PCO2-PO2
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| alternatives to Bactrim for PCP | clinda + primaquine; pentamidine; trimethoprim + dapsone; atovaquone
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| preferred follow up treatment for cryptococcus meningitis | fluconazole 200 mg QD
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| diagnostic tests for cryptococcus meningitis | positive CSF cultures, CSF india ink, CSF cryptococcal antigen titer, elevated opening pressure >20, serum cryptococcal antigen more than 1:8
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| preferred treatment for cryptococcus meningitis | amphotericin B and flucytosine for at least 2 weeks followed by fluconazole for at least 8 weeks. can also do amp B monotherapy or just fluconazole and flucytosine or amp B and fluconazole but this is the preferred treatment
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| treatment for CMV infections | same for all. valgancyclovir or gancyclovir [both interact with zidovudine, gancyclovir can do lower doses but not recommended]; foscarnet - no notable DDIs and has anti-HIV activity and decreased mortality,; cidofovir - can cause renal impairment.
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| what prophylaxis is recommended in CMV. primary or secondary or both. | secondary is required fo rall. can d/c when CD4 ct is >100 for 3-6 months or longer with ART. primary ppx not recommended but if cd4 ct is <50 recommend funduscopic exam regularly
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| standard therapy for toxoplasmosis | pyrimethamine and sulfasalazine and leucovorin to prevent bone marrow effects of pyrimethamine. if sulfa allergy can use clindamycin.
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| prophylaxis for toxoplasmosis | seropositive pts should get primary ppx if cd4 is less than 100. use bactrim. for secondary until cd4 greater than 200 for 6 months due to ART. use pyrimethamine and leucovorin or clinda or atovaquone
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| treatment for latent TB in pts NOT coinfected with HIV | isoniazid 300 mg daily or 900 mg twice weekly for 6-9 months. may also use rifampin 600 mg daily for 4 months. other options require DOT or are not CDC recommended regimens
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| treatment for latent TB in pts coinfected with HIV | isoniazid 300 mg daily for 9 months. may also do 900 mg twice weekly for 9 months but requires DOT
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| treatment for active TB infection in pts WITHOUT HIV coinfection | isoniazid, rifampin, pyrazinamide and ethambutol for 2 months followed by isoniazid and rifampin for 4 more months
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| treatment for active TB in pt coinfected with HIV | isoniazid, rifampin, pyrazinamide and ethambutol for 2 months followed by isoniazidand rifampin for 4 months (same as for non-HIV) may need to change to rifabutin due to DDI with PI and NNRTIs. decrease rifabutin dose with PIs. need HIV RNA conc. checked
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| prevention of renal toxicity with amphotericin B | 1 L NS for 24 hrs or 500 ml before and after dose. avoid diuretics and liberalize salt intake
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| prevention of thrombophlebitis with amphotericin B | dilute to 0.1 mg/ml and infuse over at least 4 hours. use a central site and may add heparin
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| treatment of fever/chills with amphotericin B and MOA | amp B induces PGE synthesis. hydrocortisone or ibuprofen may help. ASA/APAP/benadryl have not been shown to help but were also not specifically studied
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| treatment of rigors for amp B | meperidine 50 mg. can be used prophylactically if needed for recurrent reactions
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| why is there no renal adjustment dose for voriconazole? | crcl <50 should not get vori due to vehicle sulfobutyl ether-B-cyclodextrin
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| drugs contraindicated with voriconazole | rifampin, rifabutin, carbamazepine, barbituates, sirolimus
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| dose adjustments for voriconazole with tacrolimus and cyclosporine | tac decrease dose by 2/3. cyclosporine decrease dose by 1/2
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