Question 7 - Opportunistic Infections: Treatment Question Bank

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Opportunistic Infections: TreatmentQuestion 7/20

A 42-year-old cisgender woman with HIV who has been lost to follow-up for several years is seen in the emergency room with fever, weight loss, and abdominal pain. The most recent laboratory studies showed a CD4 count of 38 cells/mm³ and HIV RNA level of 215,200 copies/mL. She undergoes an extensive work-up, and after 11 days, the blood cultures grow Mycobacterium avium complex.

Which one of the following is recommended for the treatment of disseminated Mycobacterium avium complex infection?

Clarithromycin plus pyrazinamide

Azithromycin plus isoniazid plus rifabutin

Azithromycin plus ethambutol

Ethambutol plus rifabutin plus ciprofloxacin

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Question Last Updated
September 28th, 2023

Table 1. **Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV**

Treating Disseminated MAC Disease
Preferred Therapy: At least two drugs as initial therapy to prevent or delay emergence of resistance (AI) Clarithromycin 500 mg PO twice daily (AI) plus ethambutol 15 mg/kg PO daily (AI), or Azithromycin 500–600 mg (AII) plus ethambutol 15 mg/kg PO daily (AI) when drug interactions or intolerance precludes the use of clarithromycin (AII) Note: Testing of susceptibility to clarithromycin or azithromycin is recommended. Some experts would add rifabutin when more severe disease manifestations are present. Rifabutin 300 mg PO daily (CI). Dose adjustment of rifabutin may be necessary based on drug interactions. Some experts would also add a fourth drug if more severe disease is present, the risk of mortality is high, emergence of drug resistance is likely (e.g., after failure of MAC prophylaxis), CD4 count is <50 cells/mm³, mycobacterial loads are high (>2 log₁₀ CFU/mL of blood), or effective antiretroviral therapy is absent (CIII). Fourth drug options may include: A fluoroquinolone (CIII) (e.g., levofloxacin 500 mg PO daily or moxifloxacin 400 mg PO daily), or An injectable aminoglycoside (CIII) (e.g., amikacin 10–15 mg/kg IV daily or streptomycin 1 g IV or IM daily) (generally avoided unless in the setting of refractory disease when other alternatives are not available or tolerated) Bedaquiline, tedizolid, linezolid, and omadacycline have demonstrated in vitro activity against clinical isolates of MAC; these might also be considered in people with refractory MAC disease.
Other Considerations Nonsteroidal anti-‍inflammatory drugs (NSAIDs) may be used for people with HIV who experience moderate-to-severe symptoms attributed to immune reconstitution inflammatory syndrome (IRIS) (BIII). If IRIS symptoms persist, a short-term course (4–8 weeks) of systemic corticosteroid therapy (equivalent to prednisone 20–‍40 mg/day) can be used (BII).
Abbreviations: MAC = Mycobacterium avium complex; PO = orally; CFU = colony-forming units; IV = intravenous; IM = intramuscular Rating System for Prevention and Treatment Recommendations Strength of Recommendation: A = Strong; B = Moderate; C = Weak Quality of Evidence for the Recommendation: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, non-randomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Source:

Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Mycobacterium avium complex disease. Updated: August 15, 2024. [HIV.gov]

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Opportunistic Infections: TreatmentQuestion 7/20

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Which one of the following is recommended for the treatment of disseminated Mycobacterium avium complex infection?

Treating Disseminated MAC Disease

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