Empiric syndrome based therapy
›Sepsis in advanced HIV
›Broad spectrum antibiotics per source suspicion
›If pneumonia source, ceftriaxone plus azithromycin pathway
›If healthcare exposure, antipseudomonal beta lactam pathway
›Early antifungal consideration when high risk
›If severe immunosuppression plus shock plus travel or exposure risk, amphotericin pathway after ID input
›Class I recommendation alignment for early sepsis management based on major sepsis guidelines
›Suspected Pneumocystis jirovecii pneumonia
›TMP SMX therapy
›TMP component 15 to 20 mg/kg/day divided q6 to q8 hours
›Renal adjustment per creatinine clearance
›Monitor potassium mmol/L
›Monitor creatinine
›Adjunct corticosteroids
›If PaO2 < 70 mmHg on room air, prednisone 40 mg twice daily days 1 to 5
›Prednisone 40 mg daily days 6 to 10
›Prednisone 20 mg daily days 11 to 21
›If IV needed, methylprednisolone 75% of prednisone dose
›Alternatives if TMP SMX intolerance
›Clindamycin plus primaquine
›G6PD deficiency exclusion before primaquine
›IV pentamidine
›Monitor glucose
›Monitor QT interval
›Atovaquone for mild disease
›Class I recommendation alignment for steroids in moderate to severe PJP based on major HIV OI guidelines
›Suspected cryptococcal meningitis
›Induction antifungal therapy
›Amphotericin B formulation per local protocol
›Flucytosine dosing per weight and renal function
›Monitor CBC for cytopenias
›Monitor creatinine and electrolytes
›Intracranial pressure management
›If opening pressure ≥ 25 cmH2O, therapeutic CSF drainage
›Repeat drainage daily if symptoms persist
›ART timing
›Delay ART initiation to reduce mortality risk from IRIS in cryptococcal meningitis per guideline consensus
›Class I recommendation alignment for amphotericin plus flucytosine induction in cryptococcal meningitis based on major HIV OI guidelines
›Suspected toxoplasma encephalitis
›Initial therapy options
›Pyrimethamine plus sulfadiazine plus leucovorin regimen pathway
›TMP SMX high dose alternative pathway
›Seizure management
›If active seizures, antiseizure medication initiation
›Steroids
›If significant mass effect with herniation risk, dexamethasone limited course
›Response assessment
›If no improvement by day 10 to 14, alternate diagnosis evaluation
›Suspected tuberculosis
›Isolation
›Airborne precautions
›Diagnostic confirmation before RIPE when feasible
›Sputum AFB and NAAT pathway
›If severe disease and high suspicion, RIPE initiation after ID and public health alignment
›Drug interaction management
›Rifampin interaction with many ART regimens
›Esophageal candidiasis
›Fluconazole therapy
›Oral dosing per local protocol
›IV option if unable to swallow
›If refractory, echinocandin pathway after ID input
Antiretroviral therapy and IRIS
›ART status decisions in acute illness
›If already on ART, continuation favored unless severe toxicity or critical interaction
›If newly diagnosed HIV with most OIs, early ART initiation favored after stabilization
›ART deferral scenarios
›Cryptococcal meningitis
›TB meningitis
›IRIS management
›Clinical suspicion features
›Worsening inflammation after ART initiation
›Improving HIV viral load with paradoxical clinical decline
›Management principles
›Treat underlying infection adequately
›If severe IRIS, corticosteroids after excluding uncontrolled infection
›Class I recommendation alignment for early ART in most settings based on major HIV treatment guidelines
Medication interaction and safety
›Interaction screening
›Boosted protease inhibitors and cobicistat
›CYP3A4 inhibition increases levels of many sedatives and antiarrhythmics
›Integrase inhibitors
›Polyvalent cation interaction with antacids and supplements
›Renal and electrolyte monitoring during therapy
›Amphotericin nephrotoxicity
›TMP SMX hyperkalemia
›Tenofovir renal effects
›Anaphylaxis and severe rash
›If severe cutaneous adverse reaction suspected, immediate culprit discontinuation
›If mucosal involvement, burn unit or dermatology pathway