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Acyclovir, 800 mg orally four or five times daily for 7 days Intravenous therapy at 10 mg/kg every 8 hours for ocular involvement, disseminated disease Famciclovir, 500 mg orally three times daily for 7 days Valacyclovir, 500 mg orally three times daily for 7 days Foscarnet, 40 mg/kg intravenously every 8 hours for acyclovirresistant cases (Adjust for changes in renal function)
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Observation, intralesional vinblastine Systemic chemotherapy (eg, liposomal doxorubicin) Interferon- (for patients with CD4 > 200 cells/mcL and no constitutional symptoms) Radiation (amelioration of edema) Combination chemotherapy (eg, daunorubicin, bleomycin, vinblastine)
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For treatment of Mycobacterium tuberculosis infection, see 9 For moderate to severe P jiroveci infection (oxygen saturation < 90%), corticosteroids should be given with specific treatment The dose of prednisone is 40 mg orally twice daily for 5 days, then 40 mg daily for 5 days, and then 20 mg daily until therapy is complete 3 When considering use of dapsone, check glucose-6-phosphate dehydrogenase (G6PD) level in black patients and those of Mediterranean origin CHOP, cyclophosphamide, doxorubicin (hydroxydaunomycin), vincristine (Oncovin), and prednisone; modified M-BACOD, methotrexate, bleomycin, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), and dexamethasone; G-CSF, granulocyte-colony stimulating factor (filgrastim); GM-CSF, granulocyte-macrophage colony-stimulating factor (sargramostim)
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with moderate to severe pneumocystosis (oxygen saturation < 90%, PO2 < 65 mm Hg) when administered within 72 hours after diagnosis The mechanism of action is presumed to be a decrease in alveolar inflammation
CMV infection can be discontinued in persons with durable suppression of viral load on HAART who have a CD4 count > 100 150 cells/mcL Similar results have been observed in patients with M avium complex bacteremia Prophylaxis for Pneumocystis pneumonia is also commonly discontinued in patients who have achieved and maintained a CD4 > 200 cells/mcL with good virologic control Treating patients with repeated episodes of the same opportunistic infection can pose difficult therapeutic challenges For example, patients with second or third episodes of Pneumocystis pneumonia may have developed allergic reactions to standard treatments with a prior episode Fortunately, there are several alternatives available for the treatment of Pneumocystis infection Trimethoprim with dapsone and primaquine with clindamycin are two combinations that often are tolerated in patients with a prior allergic reaction to trimethoprim-sulfamethoxazole and intravenous pentamidine On the positive side, patients in whom second episodes of Pneumocystis pneumonia develop while taking prophylaxis tend to have milder courses Well-established alternative regimens now also exist for most AIDS-related opportunistic infections: amphotericin B or fluconazole for cryptococcal meningitis; ganciclovir, cidofovir, or foscarnet for CMV infection; and sulfadiazine or clindamycin with pyrimethamine for toxoplasmosis Although conceptually it would seem that corticosteroid therapy should be avoided in HIV-infected patients, corticosteroid use has been shown to improve the course of patients
B Antiretroviral Therapy
The availability of agents that in combination suppress HIV replication (Table 31 5) has had a profound impact on the natural history of HIV infection Patients who achieve excellent suppression of HIV generally have stabilization or improvement of their clinical course that results from partial immunologic reconstitution and a subsequent decrease in AIDS-related complications The best time to initiate antiretroviral treatment remains controversial It is best to weigh the benefits of viral suppression against the side effects of the drugs for each patient In general, treatment should be initiated for asymptomatic HIV disease when the CD4 cell count drops below 350 cells/mcL or for symptomatic HIV disease Patients with rapidly dropping CD4 counts or very high viral loads (> 100,000/mcL) should be considered for earlier treatment For those patients who might have difficulty adhering to treatment or who are at higher risk for toxicity (eg, underlying liver disease), waiting until the CD4 count nears 200 cells/mcL may be a better strategy Patients who started receiving treatment at higher CD4 levels than are currently recommended for initiation of treatment are usually maintained on their regimens if they are doing well and are not
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