                   AIDS INFORMATION NEWSLETTER
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     (415) 221-4810 ext 3305
                          July 28, 1995

                Opportunistic Infections (Part V)

           USPHS/IDSA GUIDELINES FOR THE PREVENTION OF
          OPPORTUNISTIC INFECTIONS IN PERSONS INFECTED
          WITH HUMAN IMMUNODEFICIENCY VIRUS: A SUMMARY

[Morbidity and Mortality Weekly Report, Centers for Disease Control
and Prevention, Recommendations and Reports, July 14, 1995, Vol.
44, No. RR-08.]

PREFACE

     In the United States, opportunistic infections reduce the
quality and duration of life for approximately 1 million persons
who have HIV infection (1), especially for the estimated 250,000
persons who are severely immunosuppressed, as measured by a CD4+
T-lymphocyte count below 200 cells/uL (2; CDC, unpublished data).
In the late 1980s and early 1990s, efforts to prevent opportunistic
infections focused first on chemoprophylaxis against Pneumocystis
carinii pneumonia (PCP) (3,4), and then on chemoprophylaxis against
disseminated Mycobacterium avium complex (MAC) disease (5).
     During the past decade, clinicians and researchers have
learned that, in addition to P. carinii and MAC, other pathogens
can cause disease in patients with HIV infection. Knowledge
regarding the reduction of risk of exposure to, and thus
acquisition of, opportunistic pathogens also has increased. During
this decade, the number of chemoprophylactic regimens available for
preventing disease also has increased. Information about preventing
exposure and preventing disease is often published in journals that
are not regularly reviewed by health-care providers; some of it has
not yet been published.
     In 1994, the U.S Public Health Service (USPHS)---primarily
through the efforts of CDC and the National Institutes of Health
(NIH) and the Infectious Diseases Society of America (IDSA)--
 -recognized the importance of preventing oportunistic infections
and the need to consolidate information for health-care providers.
In response, these organizations initiated an effort to develop
comprehensive recommendations for the prevention of opportunistic
infections in HIV-infected persons. Draft recommendations were
reviewed by consultants from CDC, NIH, and IDSA, as well as by
members of other Federal and non-Federal agencies, community
organizations, physicians caring for HIV-infected persons, and
HIV-infected persons themselves. These recommendations were
discussed at a 2-day meeting convened by CDC, NIH, and IDSA in
Atlanta in September 1994. Comments were solicited from the public,
and final recommendations were approved by USPHS and IDSA. These
recommendations were also endorsed by the American Academy of
Pediatrics, the Infectious Diseases Society of Obstetrics and
Gynecology, and the Society of Healthcare Epidemiologists of
America. The recommendations are designed for the use of
health-care providers, but they also can provide useful information
for HIV-infected patients.
     The full text of the USPHS/IDSA Guidelines for the Prevention
of Opportunistic Infections in Persons Infected with Human
Immunodeficiency Virus is being published in a supplement to
Clinical Infectious Diseases (6-8). This report excerpts the
disease-specific recommendations that form the basis for the
guidelines. These recommendations address 17 opportunistic
infections or groups of opportunistic infections by providing
guidelines on a) preventing exposure to the opportunistic
pathogens, b) preventing the first episode of disease (by
chemoprophylaxis or vaccination), and c) preventing disease
recurrence (by long-term maintenance drug therapy). This report
also includes the drug regimens used to prevent opportunistic
infections in HIV-infected adults and adolescents and infants and
children.
     Several factors were considered in developing these
recommendations, including a) the level of immunosuppression at
which opportunistic disease is most likely to occur; b) the
incidence of disease; c) the severity of disease in terms of
morbidity, cost of care (including hospitalization), and mortality;
d) the feasibility, efficacy, and cost of the prevention measure;
e) the impact of the prevention measure on the quality of life; and
f) (for chemoprophylaxis recommendations) drug toxicities, drug
interactions, and the potential for the development of drug
resistance.
     Recommendations are rated according to the strength of the
recommendation for or against use (letters A-E) and the quality of
the evidence supporting the recommendation (Roman numerals I-III)
(6) (Tables 1,2). When applying the letter ratings A-E to
recommendations involving chemoprophylaxis, the strength of
evidence and magnitude of clinical benefit were balanced against
the toxicity, drug interactions, and cost of the chemoprophylactic
regimen and the feasibility of alternative approaches such as early
diagnosis and treatment of the opportunistic infection.
Recommendations designated "A" are supported by evidence that is
both statistically and clinically persuasive, are strongly
recommended, should always be offered, and are considered standard
care. Those designated "B" are recommended for consideration; such
measures should generally be offered but should involve some
discussion of the pros and cons between the provider and the
patient. Measures designated "C" are considered optional, either
because evidence of benefit is insufficient or because any proven
benefit is minimal from the clinical standpoint and may not
outweigh either the toxicity, drug interactions, or cost of the
chemoprophylaxis or the feasibility of alternative approaches.
Measures designated "D" should generally not be offered; those
designated "E" are contraindicated. The Roman numeral ratings I-III
refer to the quality of evidence that forms the basis for the
recommendations regarding the use of a product or measure for
preventing opportunistic infections in HIV-infected persons.
     Applying this rating system to recommendations regarding
prevention of exposure was complicated by the lack of information
regarding the effectiveness of various counseling messages.
Therefore, few "prevention of exposure" recommendations are rated
"A"; many are considered optional (rating "C"). However, use of the
rating system should facilitate understanding of the relative
importance of the various prevention recommendations.
     The prevention recommendations presented here differ from
those previously published because they include strategies for
preventing many opportunistic infections not previously discussed,
particularly those associated with prevention of exposure. They
also modify earlier recommendations. For example, for PCP
prophylaxis for sulfa-intolerant patients, either dapsone or
dapsone plus pyrimethamine are now recommended in preference to
aerosolized pentamidine. For prophylaxis against initial episodes
of disseminated MAC disease, the threshold of treatment has been
lowered from 100 to 75 CD4+ T-lymphocytes/uL. Chemoprophylaxis
against toxoplasmic encephalitis is now recommended.
     In this report, the disease-specific recommendations are not
listed in priority order. Health-care providers who manage and
treat HIV-infected patients should consult the overview of the
USPHS/IDSA guidelines, which addresses both the initial and
follow-up evaluations of the HIV-infected patient (7). In addition
to opportunistic infections addressed in the disease-specific
recommendations, the overview of the guidelines briefly addresses
other infections that occur with increased frequency in
HIV-infected persons (e.g., syphilis, hepatitis B, and other
sexually transmitted diseases). Sections on preventing
opportunistic infections in children and in pregnant women are
included. In this report, only the tables concerning drugs and
doses in adults and children (Tables 3a, 3b and 4a, 4b) and the
summary of prevention of exposure recommendations (Table 5) have
been excerpted from the overview. The approach to preventing
opportunistic infections and other infections commonly encountered
in HIV-infected persons, as described in the overview, should be
integrated with other aspects of HIV care, as described elsewhere
(9).

Disease-Specific Recommendations*

PNEUMOCYSTIS CARINII PNEUMONIA

Prevention of Exposure
     (1) Although some authorities recommend that HIV-infected
persons at risk for P. carinii pneumonia (PCP) not share a hospital
room with a patient with PCP, data are insufficient to support this
recommendation as standard practice (CIII).

Prevention of Disease
     (2) Adults and adolescents with HIV infection (including those
who are pregnant) should receive chemoprophylaxis against PCP if
they have a CD4+ lymphocyte count of less than 200/gmL (AI),
unexplained fever (greater than 100 F) for greater than or equal
to 2 weeks (AII), or a history of oropharyngeal candidiasis (AII).
     Trimethoprim-sulfamethoxazole (TMP-SMZ) is the preferred
prophylactic agent (AI). TMP-SMZ may confer cross-protection
against toxoplasmosis (AII) and many bacterial infections (AII).
For patients with an adverse reaction that is not life-threatening,
treatment with TMP-SMZ should be continued if clinically feasible;
for those who have discontinued such therapy, its reinstitution
should be strongly considered (AII). Whether it is best to
reintroduce the drug at the original dose or at a lower and
gradually increasing dose or to try a desensitization regimen is
unknown.
     If TMP-SMZ cannot be tolerated, alternative prophylactic
regimens include dapsone (AI), dapsone plus pyrimethamine plus
leucovorin (AI), and aerosolized pentamidine administered by the
Respirgard II nebulizer (Marquest, Englewood, CO) (AI). Regimens
including dapsone plus pyrimethamine are also protective against
toxoplasmosis (AI) but not against most bacterial infections.
Because data on their efficacy for PCP prophylaxis are
insufficient, the following regimens generally cannot be
recommended for this purpose: aerosolized pentamidine administered
by other nebulization devices currently available in the United
States, intermittently administered parenteral pentamidine, oral
pyrimethamine/sulfadoxine, oral clindamycin plus primaquine, oral
atovaquone, and intravenous trimetrexate. However, the use of these
agents may be considered in unusual situations in which the
recommended agents cannot be administered (CIII).

Prevention of Recurrence
     (3) Adults and adolescents with a history of PCP should
receive chemoprophylaxis with the regimens indicated above to
prevent recurrence (AI).

Notes

Pediatric Notes
     (4) Children born to HIV-infected mothers should receive
prophylaxis with TMP-SMZ beginning at 4-6 weeks of age (11) (AII).
Prophylaxis should be discontinued for children who are
subsequently found not to be infected with HIV. HIV-infected
children and children whose infection status remains unknown should
continue to receive prophylaxis for the first year of life. The
need for subsequent prophylaxis should be determined on the basis
of age-specific CD4+ lymphocyte count thresholds (11,12) (AII).
     (5) Children with a history of PCP should receive
chemoprophylaxis as indicated above to prevent recurrence (AI).
Note Regarding Pregnancy
     (6) Chemoprophylaxis for PCP should be administered to
pregnant women as to other adults and adolescents (AIII), although
some providers, because of a general concern about administering
drugs during the first trimester of pregnancy, may choose not to
initiate such therapy until after the first trimester. Because of
the increase in blood plasma volume and the reduced concentrations
of drugs during pregnancy, the double-strength (DS) dose of TMP-SMZ
(one DS tablet daily) should be used.

TOXOPLASMIC ENCEPHALITIS

Prevention of Exposure
     (1) HIV-infected persons should be tested for IgG antibody to
Toxoplasma soon after the diagnosis of HIV infection to detect
latent infection with Toxoplasma gondii (BIII).
     (2) All HIV-infected persons, but particularly those who lack
IgG antibody to Toxoplasma, should be counseled about the various
sources of toxoplasmic infection. They should be advised not to eat
raw or undercooked meat, particularly undercooked pork, lamb, or
venison (BIII). Specifically, meat should be cooked to an internal
temperature of 150 F; meat cooked until no longer pink inside
generally has an internal temperature of 165 F and therefore
satisfies this requirement. HIV-infected persons should wash their
hands after contact with raw meat and after gardening or other
contact with soil; in addition, they should wash fruits and
vegetables well before eating them raw (BIII). If the patient owns
a cat, the litter box should be changed daily, preferably by an
HIV-negative, nonpregnant person; alternatively, the patient should
wash the hands thoroughly after changing the litter box (BIII).
Patients should be encouraged to keep their cats inside and not to
adopt or handle stray cats (BIII). Cats should be fed only canned
or dried commercial food or well-cooked table food, not raw or
undercooked meats (BIII). Patients need not be advised to part with
their cats or to have their cats tested for toxoplasmosis (EII).

Prevention of Disease
     (3) Toxoplasma-seropositive patients with a CD4+ lymphocyte
count of less than 100/gmL should receive prophylaxis against
toxoplasmic encephalitis (TE) (AII). The doses of TMP-SMZ
recommended for PCP prophylaxis appear to be effective against TE
as well (AII). If patients cannot tolerate TMP-SMZ, the regimens
including dapsone plus pyrimethamine that are recommended for PCP
prophylaxis provide protection against TE (AI). Prophylactic
monotherapy with dapsone, pyrimethamine, azithromycin,
clarithromycin, or atovaquone cannot be recommended on the basis
of current data (DII). Aerosolized pentamidine does not afford
protection against TE (EI).
     (4) Toxoplasma-seronegative persons who are not taking a PCP
prophylactic regimen known to be active against TE should be
retested for IgG antibody to Toxoplasma when their CD4+ lymphocyte
count falls below 100/gmL to determine whether they have
seroconverted and are therefore at risk for TE (CIII). Patients who
have seroconverted should receive prophylaxis for TE as described
above (AII).

Prevention of Recurrence
     (5) Patients who have had TE should receive lifelong
suppressive therapy with drugs active against Toxoplasma to prevent
relapse (AI). The combination of pyrimethamine plus sulfadiazine
and leucovorin is highly effective for this purpose (AII). A
commonly used regimen for patients who cannot tolerate sulfa drugs
is pyrimethamine plus clindamycin (AII); however, only the
combination of pyrimethamine plus sulfadiazine appears to provide
protection against PCP as well (AII).

Notes

Pediatric Note
     (6) Current data are insufficient for the formulation of
specific guidelines for children. The provider should consider the
recommendations for adults; children greater than 12 months of age
who are seropositive for IgG antibody to Toxoplasma, have a CD4+
lymphocyte count of less than 100/uL, and are not already taking
medication effective against Toxoplasma may be considered as
candidates for chemoprophylaxis (CIII). Some providers would
consider opting for chemoprophylaxis for very young children with
higher CD4+ lymphocyte counts consistent with severe
immunosuppression (12) and with evidence of toxoplasmic infection.

Notes Regarding Pregnancy
     (7) Because of the low incidence of TE during pregnancy and
the possible risk associated with pyrimethamine treatment,
chemoprophylaxis with pyrimethamine-containing regimens can
reasonably be deferred until after pregnancy for women who are
seropositive for IgG antibody to Toxoplasma (CIII). TMP-SMZ can be
administered as described for prophylaxis of PCP. For prophylaxis
of recurrent TE, pyrimethamine should be used with caution (CIII).
     (8) In rare cases, HIV-infected pregnant women with
serological evidence of remote toxoplasmic infection have
transmitted Toxoplasma to the fetus in utero. Pregnant HIV-infected
women who have evidence of primary toxoplasmic infection or active
toxoplasmosis (including TE) should be evaluated during pregnancy
in consultation with appropriate specialists (CIII). Infants born
to women with serological evidence of infections with HIV and
Toxoplasma should be evaluated for congenital toxoplasmosis (CIII).

CRYPTOSPORIDIOSIS

Prevention of Exposure
     (1) HIV-infected persons should be educated and counseled
about the many ways that Cryptosporidium can be transmitted. Modes
of transmission include contact with infected adults and diaper-age
children, contact with infected animals, consumption of
contaminated drinking water, and contact with contaminated water
during recreational activities (BIII).
     (2) HIV-infected persons should avoid contact with human and
animal feces. They should be advised to wash their hands after
contact with human feces (e.g., during diaper changing), after
handling of pets, and after gardening or other contact with soil.
HIV-infected persons should avoid sexual practices such as
oral-anal intercourse that may result in oral exposure to feces
(BIII).
     (3) HIV-infected persons should be advised that newborn and
very young pets may pose a small risk of cryptosporidial infection,
but they should not be advised to destroy or give away healthy
pets. Persons contemplating the acquisition of a new pet should
avoid bringing any animal with diarrhea into their households,
should avoid purchasing a dog or cat less than 6 months of age, and
should not adopt stray pets. HIV-infected persons who wish to
assume the small risk of acquiring a puppy or kitten less than 6
months of age should request that their veterinarian examine the
animal's stool for Cryptosporidium before they have contact with
the animal (BIII).
     (4) HIV-infected persons should avoid exposure to calves and
lambs and to premises where these animals are raised (BII).
     (5) HIV-infected persons should not drink water directly from
lakes or rivers. Because water can be accidentally ingested,
patients should be advised that swimming in lakes, rivers, or
public swimming pools may put them at increased risk for infection
(BII).
     (6) Several outbreaks of cryptosporidiosis have been linked
to municipal water supplies. During outbreaks or in other
situations in which a community "boil-water" advisory is issued,
boiling of water for 1 minute will eliminate the risk of
cryptosporidiosis (AI). Use of submicron personal-use water
filters* (i.e., home/office types) and/or bottled water** (2) may
reduce the risk (CIII). The magnitude of the risk of acquiring
cryptosporidiosis from drinking water in a nonoutbreak setting is
uncertain, and current data are inadequate to recommend that all
HIV-infected persons boil or avoid drinking tap water in
nonoutbreak settings. However, HIV-infected persons who wish to
take independent action to reduce the risk of waterborne
cryptosporidiosis may choose to take precautions similar to those
recommended during outbreaks. Such decisions should be made in
conjunction with health care providers. Persons who opt for a
personal-use filter or bottled water should be aware of the
complexities involved in selecting appropriate products, the lack
of enforceable standards for the destruction or removal of oocysts,
the cost of the products, and the logistic difficulty of using
these products consistently.

Prevention of Disease
     (7) No effective chemoprophylactic agents are available for
cryptosporidiosis.

Prevention of Recurrence
     (8) No drug regimens are known to be effective in preventing
the recurrence of cryptosporidiosis.

Note

Pediatric Note
     (9) At present, no data indicate that formula-preparation
practices for infants should be altered in an effort to prevent
cryptosporidiosis (CIII).

MICROSPORIDIOSIS

Prevention of Exposure
     (1) Other than general attention to hand washing and other
personal hygiene measures, no precautions to reduce exposure can
be recommended at this time.

Prevention of Disease
     (2) No chemoprophylactic regimens are known to be effective
in preventing microsporidiosis.

Prevention of Recurrence
     (3) No chemotherapeutic regimens are known to be effective in
preventing the recurrence of microsporidiosis.

TUBERCULOSIS

Prevention of Exposure
     (1) HIV-infected persons should be advised that certain
activities and occupations may increase the likelihood of exposure
to tuberculosis (BIII). These include volunteer work or employment
in health care facilities, correctional institutions, and shelters
for the homeless as well as in other settings identified as high
risk by local health authorities. Decisions about whether to
continue with activities in these settings should be made in
conjunction with the health care provider and should take into
account such factors as the patient's specific duties in the
workplace, the prevalence of tuberculosis in the community, and the
degree to which precautions are taken to prevent the transmission
of tuberculosis in the workplace (BIII). Whether or not the patient
continues with such activities may affect the frequency with which
screening for tuberculosis needs to be conducted.
Prevention of Disease
     (2) When HIV infection is first recognized, the patient should
be screened by the Mantoux method with intermediate-strength (5-TU)
PPD (AI). Routine evaluation for anergy is controversial; some
experts recommend anergy testing for persons in settings where
there is an increased risk of infection with Mycobacterium
tuberculosis (i.e., in areas where the prevalence of such infection
is greater than 10%) (CIII).
     (3) All HIV-infected persons with a positive result in the
tuberculin skin test (TST; greater than or equal to 5 mm of
induration) should undergo chest radiography and clinical
evaluation for the exclusion of active tuberculosis. HIV-infected
individuals who have symptoms suggestive of tuberculosis should
undergo chest radiography and clinical evaluation regardless of
their TST status (AII).
     (4) All HIV-infected persons with a positive TST result who
have no evidence of active tuberculosis and no history of treatment
or prophylaxis for tuberculosis should receive 12 months of
preventive chemotherapy with isoniazid (AI). Since HIV-infected
persons are at risk for peripheral neuropathy, those receiving
isoniazid should also receive pyridoxine (BIII). The decision to
use alternative antimycobacterial agents for chemoprophylaxis
should be based on the relative risk of exposure to resistant
organisms and may require consultation with public health
authorities (AII). The need for direct observation as a means of
documenting compliance with chemoprophylaxis should be considered
on an individual basis (BIII).
     (5) HIV-infected individuals who are close contacts of persons
with infectious tuberculosis (i.e., acid-fast bacillary
smear-positive pulmonary disease) should receive preventive
therapy--regardless of TST results or prior courses of
chemoprophylaxis--after active tuberculosis has been excluded
(AII). Such persons should be tested with 5-TU PPD. If the TST
result is initially negative, the individual should be evaluated
again 3 months after the discontinuation of contact with the
infectious source, and the information obtained should be
considered in the course of decisions about whether
chemoprophylaxis should continue (BIII).
     (6) TST-negative, HIV-infected persons from risk groups or
geographic areas with a high prevalence of M. tuberculosis
infection (greater than 10%) may be at increased risk of
tuberculosis. Some experts recommend preventive therapy for anergic
individuals or perhaps for all persons in this category (CIII).
However, the efficacy of preventive therapy in this group has not
been demonstrated, and decisions concerning the use of
chemoprophylaxis in these situations must be individualized.
     (7) Although the reliability of the TST may diminish as the
CD4+ lymphocyte count declines, testing should be repeated at least
annually for HIV-infected persons who are TST-negative on initial
evaluation (BIII). In addition to documenting tuberculous
infection, TST conversion in an HIV-infected person should alert
health care providers to the possibility of an infectious case in
the environment and lead to notification of public health officials
for investigation to identify a possible source case.
     (8) The administration of BCG vaccine to HIV-infected persons
is contraindicated because of its potential to cause disseminated
disease (EII).

Prevention of Recurrence
     (9) Chronic suppressive therapy for a patient who has
successfully completed a recommended regimen of treatment for
tuberculosis is not necessary (EII).

Notes

Pediatric Note
     (10) All infants born to HIV-infected mothers should have a
TST (5-TU PPD) at 9-12 months of age (CIII). All children living
in households with M. tuberculosis-infected (TST-positive) persons
should be evaluated for tuberculosis (13) (CIII); those exposed to
a person with active tuberculosis should receive preventive therapy
after active tuberculosis has been excluded (AII).

Note Regarding Pregnancy
     (11) HIV-infected pregnant women who have a positive TST
result without evidence of active tuberculosis should receive
standard chemoprophylaxis (AII). When possible, chest radiography
should be undertaken and chemoprophylaxis should be initiated after
the first trimester in order to avoid the critical period of major
organogenesis. Preventive therapy with isoniazid should be
accompanied by treatment with pyridoxine so that peripheral
neuropathy does not develop. Alternative regimens (e.g., rifampin,
rifabutin) should be used with caution during pregnancy.

DISSEMINATED INFECTION WITH MYCOBACTERIUM AVIUM COMPLEX

Prevention of Exposure
     (1) Organisms of the M. avium complex (MAC) are common in
environmental sources such as food and water. Current information
does not support specific recommendations regarding avoidance of
exposure.

Prevention of Disease
     (2) Prophylaxis with rifabutin should be considered for
HIV-infected adults and adolescents who have a CD4+ lymphocyte
count of less than 75/uL, although some experts would wait until
the count is less than 50/uL (BII). Disseminated MAC disease should
be ruled out (by a negative blood culture) before prophylaxis is
initiated. Because treatment with rifabutin may result in the
development of resistance to rifampin in individuals with active
tuberculosis, the latter condition should be excluded before
rifabutin prophylaxis is begun. Drug interactions, partial
efficacy, and cost are among the other issues that should be
considered in decisions about whether to institute prophylaxis for
MAC disease. Data on the safety and efficacy of clarithromycin,
azithromycin, and combinations of clarithromycin or azithromycin
with rifabutin have not yet been reviewed sufficiently to warrant
recommendations concerning these regimens.
     (3) Although the detection of MAC organisms in the respiratory
or gastrointestinal tract may be predictive of the development of
disseminated MAC infection, no data are available on the efficacy
of prophylaxis with rifabutin or other drugs in patients with MAC
organisms at these sites and a negative blood culture. Therefore,
routine screening of respiratory or gastrointestinal specimens for
MAC cannot be recommended at this time (DIII).
Prevention of Recurrence
     (4) Patients who are treated for disseminated MAC infection
should continue to receive full therapeutic doses for life (BIII).
The use of a macrolide, usually clarithromycin, is generally
recommended in conjunction with at least one other drug, such as
ethambutol, clofazimine, ciprofloxacin, or rifabutin.

Notes

Pediatric Note
     (5) HIV-infected children less than 12 years of age also
develop disseminated MAC infections. Prophylaxis should be
considered similar to that recommended for adults and adolescents
(BI). For children 6-12 years of age, a CD4+ lymphocyte count of
less than 75/uL is a reasonable threshold for the initiation of
chemoprophylaxis. Some adjustment for age is necessary in the
interpretation of CD4+ lymphocyte counts of children less than 6
years of age (12). No pediatric formulation of rifabutin is
currently available, but a dosage of 5 mg/kg has been used in
pharmacokinetic studies.

Note Regarding Pregnancy
     (6) Information is insufficient for recommendations concerning
the use of rifabutin or clarithromycin during pregnancy.

BACTERIAL RESPIRATORY INFECTIONS

Prevention of Exposure
     (1) Because Streptococcus pneumoniae and Haemophilus
influenzae are common in the community, there is no effective way
to reduce exposure to these bacteria.

Prevention of Disease
     (2) As soon as possible after HIV infection is diagnosed,
adults should receive a single dose of 23-valent polysaccharide
pneumococcal vaccine (BIII). This recommendation is especially
pertinent in light of the increasing incidence of invasive
infections with drug-resistant strains of S. pneumoniae. Although
the administration of protein-polysaccharide conjugate H.
influenzae type b vaccine may be considered, data are insufficient
to recommend the use of this vaccine in HIV-infected adults at this
time.
     (3) TMP-SMZ, administered daily, may be effective in
preventing serious bacterial respiratory infections (although not
those caused by drug-resistant S. pneumoniae); this fact should be
considered in the selection of an agent for PCP prophylaxis (AII).
However, indiscriminate use of this drug (when not indicated for
PCP prophylaxis or other specific reasons) may promote the
development of resistant organisms.
     (4) An absolute neutrophil count that is depressed because of
HIV disease or drug therapy may be increased by granulocyte
colony-stimulating factor (G-CSF) or granulocyte-macrophage
colony-stimulating factor (GM-CSF). However, data are insufficient
for recommendations concerning the use of G-CSF or GM-CSF to
prevent bacterial infections in HIV-infected patients with
neutropenia.

Prevention of Recurrence
     (5) Some clinicians may choose to offer antibiotic
chemoprophylaxis to HIV-infected patients with recurrent serious
bacterial respiratory infections (BIII). TMP-SMZ, administered for
PCP prophylaxis, is appropriate for drug-sensitive organisms.
     (6) All invasive pneumococcal isolates from HIV-infected
patients should be tested for susceptibility to b-lactam
antibiotics, and local patterns of resistance should be considered
in the choice of regimens for empirical treatment (AII). Invasive
infections due to H. influenzae should be treated with regimens
effective against b-lactamase-producing strains until drug
susceptibilities are known (AII).

Notes

Pediatric Notes
     (7) Children with HIV infection should receive H. influenzae
type b vaccine in accordance with the guidelines of the Advisory
Committee for Immunization Practices (14) and the American Academy
of Pediatrics (13) (AII). Children greater than 2 years of age
should also receive 23-valent polysaccharide pneumococcal vaccine
(BII).
     (8) To prevent serious bacterial infections in HIV-infected
children with documented antibody deficiency, clinicians should use
intravenous immunoglobulin (IVIG) (AI). The administration of IVIG
should also be considered for HIV-infected children with recurrent
serious bacterial infections (AI), but such treatment may not
provide additional benefit to children receiving daily TMP-SMZ.

Note Regarding Pregnancy
     (9) Pneumococcal vaccine is not contraindicated during
pregnancy.

BACTERIAL ENTERIC INFECTIONS

Prevention of Exposure

Food
     (1) Health care providers should advise HIV-infected persons
not to eat raw or undercooked eggs (including foods that may
contain raw eggs--e.g., some preparations of hollandaise sauce,
Caesar and other salad dressings, and mayonnaise); raw or
undercooked poultry, meat, or seafood; or unpasteurized dairy
products. Poultry and meat should be well cooked and should not be
pink in the middle (internal temperature, greater than 165 F).
Produce should be thoroughly washed before being eaten (BIII).
     (2) Health care providers should advise HIV-infected persons
to avoid cross-contamination of foods. For example, uncooked meats
should not come into contact with other foods, and hands, cutting
boards, counters, and knives and other utensils should be washed
thoroughly after contact with uncooked foods (BIII).
     (3) Health care providers should advise HIV-infected persons
that, although the incidence of listeriosis is low, it is a serious
disease that occurs with unusually high frequency among
HIV-infected persons who are severely immunosuppressed. Such
persons may choose to avoid soft cheeses because some studies have
shown an association between these foods and listeriosis. These
studies have also documented an association between ready-to-eat
foods (e.g., hot dogs and cold cuts from delicatessen counters) and
listeriosis. An immunosuppressed, HIV-infected person who wishes
to reduce the risk of food-borne disease as much as possible may
choose to re-heat such foods until they are steaming hot before
eating them (CIII).

Pets
     (4) When obtaining a new pet, HIV-infected persons should
avoid young animals (less than 6 months of age), especially those
with diarrhea (BIII).
     (5) HIV-infected persons should avoid contact with animals
that have diarrhea (BIII). HIV-infected pet owners should seek
veterinary care for animals with diarrheal illness, and a fecal
sample from such animals should be examined for Cryptosporidium,
Salmonella, and Campylobacter.
     (6) HIV-infected persons should wash their hands after
handling pets (especially before eating) and should avoid contact
with pets' feces (BIII).
     (7) HIV-infected persons should avoid contact with reptiles
(such as snakes, lizards, and turtles) because of the risk of
salmonellosis (BIII).

Travel
     (8) The risk of food- and waterborne infections among
immunosuppressed, HIV- infected persons is magnified during travel
to developing countries. Those who elect to travel to such
countries should avoid foods and beverages that may be
contaminated, particularly raw fruits and vegetables, raw or
undercooked seafood or meat, tap water, ice made with tap water,
unpasteurized milk and dairy products, and items sold by street
vendors (AII). Foods and beverages that are generally safe include
steaming-hot foods, fruits that are peeled by the traveler, bottled
(especially carbonated) beverages, hot coffee and tea, beer, wine,
and water brought to a rolling boil for 1 minute (AII). Treatment
of water with iodine or chlorine may not be as effective as boiling
but can be used when boiling is not practical (BIII).

Prevention of Disease
     (9) Prophylactic antimicrobial agents are not generally
recommended for travelers (DIII). The effectiveness of these agents
depends upon local antimicrobial-resistance patterns of
gastrointestinal pathogens, which are seldom known. Moreover, these
agents can elicit adverse reactions and can promote the emergence
of resistant organisms. However, for HIV-infected travelers,
antimicrobial prophylaxis may be considered, depending upon the
level of immunosuppression and the region and duration of travel
(CIII).
     The use of fluoroquinolones--such as ciprofloxacin (500 mg/d)-
 -can be considered when prophylaxis is deemed necessary (BIII).
As an alternative (e.g., for children, pregnant women, and persons
already taking TMP-SMZ for PCP prophylaxis), TMP-SMZ may offer some
protection against traveler's diarrhea (BIII). The risk of toxicity
should be considered before treatment with TMP-SMZ is initiated
solely because of travel.
     (10) Antimicrobial agents such as fluoroquinolones (e.g., 500
mg of ciprofloxacin b.i.d. for 3-7 days) should be given to
patients before their departure, to be taken empirically should
traveler's diarrhea develop (BIII). Alternative antibiotics for
children and pregnant women should be discussed (CIII). Travelers
should consult a physician if their diarrhea is severe and does not
respond to empirical therapy, if their stools contain blood, if
fever is accompanied by shaking chills, or if dehydration develops.
Antiperistaltic agents such as diphenoxylate and loperamide can be
used for the treatment of mild diarrhea. However, the use of these
drugs should be discontinued if symptoms persist beyond 48 hours.
Moreover, these agents should not be given to patients with high
fever or with blood in the stool (AII).
     (11) Some experts recommend that HIV-infected persons with
salmonella gastroenteritis receive antimicrobial therapy to prevent
extraintestinal spread. However, no controlled study has
demonstrated a beneficial effect of such treatment, and some
studies of immunocompetent persons have suggested that
antimicrobial therapy can lengthen the shedding period. The
fluoroquinolones--primarily ciprofloxacin (750 mg b.i.d. for 14
days)--can be used when antimicrobial therapy is opted for (CIII).

Prevention of Recurrence
     (12) HIV-infected persons with salmonella septicemia require
long-term therapy for the prevention of recurrence. The
fluoroquinolones, primarily ciprofloxacin, are usually the drugs
of choice for susceptible organisms (BII).
     (13) Household contacts of HIV-infected persons with
salmonellosis or shigellosis should be evaluated for asymptomatic
carriage of Salmonella or Shigella so that strict hygienic measures
and/or antimicrobial therapy can be instituted and recurrent
transmission to the HIV-infected person can be prevented (CIII).

Notes

Pediatric Notes
     (14) Like HIV-infected adults, HIV-infected children should
wash their hands after handling pets (especially before eating) and
should avoid contact with pets' feces. Hand washing should be
supervised (BIII).
     (15) HIV-exposed infants less than 3 months of age and all
HIV-infected children with severe immunosuppression should receive
treatment for salmonella gastroenteritis to prevent extraintestinal
spread. Possible choices of antibiotics include TMP-SMZ,
ampicillin, cefotaxime, ceftriaxone, or chloramphenicol;
ciprofloxacin may be considered for the treatment of children
greater than 6 years of age (CIII).
     (16) HIV-infected children with salmonella septicemia require
long-term therapy for the prevention of recurrence. TMP-SMZ is the
drug of choice; ampicillin or chloramphenicol can be used if the
organism is susceptible. Ciprofloxacin may be considered for the
treatment of children greater than 6 years of age (CIII).
(17) Antiperistaltic drugs are not recommended for children (DIII).
Notes Regarding Pregnancy
     (18) Since both pregnancy and HIV infection confer a risk for
listeriosis, pregnant HIV-infected women should pay particular
attention to recommendations concerned with this disease (BII).
     (19) Fluoroquinolones should not be used during pregnancy.
TMP-SMZ may offer some protection against traveler's diarrhea.

INFECTION WITH BARTONELLA (FORMERLY ROCHALIMAEA)

Prevention of Exposure
     (1) HIV-infected persons, particularly those who are severely
immunosuppressed, are at unusually high risk of developing
relatively severe disease due to Bartonella species. These
individuals should consider the potential risks of cat ownership
(CIII). Those who elect to acquire a cat should adopt or purchase
an older animal (greater than 1 year of age) that is in good health
(BII).
     (2) Although declawing is not generally advised, HIV-infected
persons should avoid rough play with cats and situations in which
scratches are likely (BII). Any cat-associated wound should be
washed promptly (CIII). HIV-infected persons should not allow cats
to lick open cuts or wounds (BIII).
     (3) Care of cats should include flea control (CIII).
     (4) There is no evidence of benefit to cat or owner from
routine culture or serological testing of the pet for Bartonella
infection (DII).

Prevention of Disease
     (5) No data currently support chemoprophylaxis for
Bartonella-associated disease (CIII).
Prevention of Recurrence
     (6) Relapse or reinfection with Bartonella has sometimes
followed a course of primary treatment. Although no firm
recommendation can be made regarding prophylaxis in this situation,
long-term suppression of infection with erythromycin or doxycycline
should be considered (CIII).

Note

Pediatric Note
     (7) The risks of cat ownership for HIV-infected children who
are severely immunocompromised should be discussed with
parents/caretakers (CIII).

CANDIDIASIS

Prevention of Exposure
     (1) Candida organisms are common on mucosal surfaces and skin.
No measures are available to reduce exposure to these fungi.

Prevention of Disease
     (2) Although data from a prospective controlled trial indicate
that fluconazole can reduce the risk of mucosal (oropharyngeal,
esophageal, and vaginal) candidiasis in patients with advanced HIV
disease, routine primary prophylaxis is not recommended because of
the effectiveness of therapy for acute disease, the low mortality
associated with mucosal candidiasis, the potential for resistant
Candida organisms to develop, the possibility of drug interactions,
and the cost of prophylaxis (DII).

Prevention of Recurrence
     (3) Many experts do not recommend chronic prophylaxis of
recurrent oropharyngeal or vulvovaginal candidiasis for the same
reasons that they do not recommend primary prophylaxis. However,
if recurrences are frequent or severe, intermittent or chronic
administration of topical nystatin, topical clotrimazole, or an
oral azole (ketoconazole, fluconazole, or itraconazole) may be
considered (BI). Other factors that influence choices about such
therapy include the impact of the recurrences on the patient's
well-being and quality of life, the need for prophylaxis for other
fungal infections, cost, toxicities, and drug interactions.
     (4) Adults or adolescents with a history of documented
esophageal candidiasis, particularly multiple episodes, should be
considered candidates for chronic suppressive therapy with
fluconazole (BI).

Notes

Pediatric Notes
     (5) Primary prophylaxis of candidiasis in HIV-infected infants
is not indicated (DII).
     (6) Suppressive therapy with systemic azoles should be
considered for infants with severe recurrent mucocutaneous
candidiasis (BIII) and particularly for those with esophageal
candidiasis (BI).

CRYPTOCOCCOSIS

Prevention of Exposure
     (1) Although HIV-infected persons cannot avoid exposure to
Cryptococcus neoformans completely, avoiding sites that are likely
to be heavily contaminated with C. neoformans (e.g., areas heavily
contaminated with pigeon droppings) may reduce the risk of
infection.

Prevention of Disease
     (2) Because of the low probability that the results will
affect clinical decisions, routine testing of asymptomatic persons
for serum cryptococcal antigen is not recommended (DIII).
     (3) Data from a prospective controlled trial indicate that
fluconazole can reduce the frequency of cryptococcal disease among
patients with advanced HIV disease; thus, physicians may wish to
consider chemoprophylaxis for adult and adolescent patients with
a CD4+ lymphocyte count of less than 50/uL (BI). However, such
prophylaxis should not be offered routinely because of the relative
infrequency of cryptococcal disease, the possibility of drug
interactions, the potential for development of resistance, and the
cost of prophylaxis (DII). The need for prophylaxis or suppressive
therapy for other fungal infections (e.g., candidiasis) should be
considered in the course of decisions about prophylaxis for
cryptococcosis.

Prevention of Recurrence
     (4) Patients who complete initial therapy for cryptococcosis
should receive lifelong suppressive treatment with fluconazole
(AI).

Notes

Pediatric Note
     (5) There are no data on which to base specific
recommendations for children, but lifelong suppressive therapy with
fluconazole after an episode of cryptococcosis is appropriate
(CIII).

Note Regarding Pregnancy
     (6) Although treatment with fluconazole is indicated to
prevent the recurrence of cryptococcosis, this drug should be used
with caution in pregnant women (CIII). At high doses, fluconazole
has been associated with both fetal death and increased rates of
fetal abnormalities in rats.

HISTOPLASMOSIS

Prevention of Exposure
     (1) Although HIV-infected persons living in or visiting
histoplasmosis-endemic areas cannot completely avoid exposure to
Histoplasma capsulatum, they should avoid activities known to be
associated with increased risk (e.g., cleaning chicken coops,
disturbing soil beneath bird-roosting sites, and exploring caves)
(CIII).

Prevention of Disease
     (2) Routine skin testing with histoplasmin in
histoplasmosis-endemic areas is not predictive of disease and
should not be performed (EII).
     (3) No recommendation can be made regarding chemoprophylaxis
for HIV-infected persons in histoplasmosis-endemic areas or for
histoplasmin-positive persons in nonendemic areas.
Prevention of Recurrence
     (4) Patients who complete initial therapy should receive
lifelong suppressive treatment with itraconazole (AII).

Note

Pediatric Note
     (5) Because primary histoplasmosis can lead to disseminated
infection in children, HIV-infected children with histoplasmosis
should receive suppressive therapy for life (CIII).

COCCIDIOIDOMYCOSIS

Prevention of Exposure
     (1) Although HIV-infected persons living in or visiting areas
in which coccidioidomycosis is endemic cannot completely avoid
exposure to Coccidioides immitis, they should, when possible, avoid
activities associated with increased risk (e.g., those involving
extensive exposure to disturbed soil as occurs at building
excavation sites, on farms, or during dust storms) (CIII).

Prevention of Disease
     (2) Routine skin testing with coccidioidin (spherulin) in
coccidioidomycosis-endemic areas is not predictive of disease and
should not be performed (EII).
     (3) No recommendation can be made regarding routine
chemoprophylaxis for HIV-infected individuals who live in
coccidioidomycosis-endemic areas or for skin test-positive persons
in nonendemic areas.

Prevention of Recurrence
     (4) Patients who complete initial therapy for
coccidioidomycosis should receive lifelong systemic suppressive
treatment (AII). Fluconazole is the preferred agent; alternative
drugs include itraconazole, ketoconazole, and amphotericin B.

Note

Pediatric Note
     (5) Although no specific data are available on
coccidioidomycosis in HIV-infected children, it is reasonable to
administer lifelong suppressive therapy after an acute episode of
the disease (CIII).

CYTOMEGALOVIRUS DISEASE

Prevention of Exposure
     (1) HIV-infected persons who belong to risk groups with
relatively low rates of seropositivity for cytomegalovirus (CMV)
and who anticipate possible exposure to CMV (e.g., through blood
transfusion or employment in a child-care facility) should be
tested for antibody to CMV (BIII). These groups include patients
who have not had male homosexual contact and those who are not
injection drug users.
     (2) HIV-infected adolescents and adults should be advised that
CMV is shed in semen, cervical secretions, and saliva and that
latex condoms must always be used during sexual contact to reduce
the risk of exposure to this virus and to other sexually
transmitted pathogens (AII).
     (3) HIV-infected adults and adolescents who are child-care
providers or parents of children in child-care facilities should
be informed that they--like all children at these facilities--are
at increased risk of acquiring CMV infection (BI). Parents and
other caretakers of HIV-infected children should be advised of the
increased risk to children at these centers (BIII). The risk of
acquiring CMV infection can be diminished by good hygienic
practices, such as hand washing (AII).
     (4) HIV-exposed infants and HIV-infected children,
adolescents, and adults who are seronegative for CMV and require
blood transfusion should receive only CMV antibody-negative or
leukocyte-reduced cellular blood products in nonemergency
situations (15) (BIII).
Prevention of Disease
     (5) Data on the efficacy and safety of oral ganciclovir have
not yet been adequately reviewed; thus no recommendation concerning
this drug can be made at this time. Acyclovir is not effective in
preventing CMV disease (EII). Since no chemoprophylactic agent is
currently available, the most important method for preventing
severe CMV disease is recognition of the early manifestations of
the disease. Early recognition of CMV retinitis is most likely when
the patient has been educated on this topic and undergoes regular
funduscopic examinations performed by a health care provider
(CIII). Patients should be made aware of the significance of
increased "floaters" in the eye and should be advised to assess
their visual acuity regularly by simple techniques such as reading
newsprint (BIII).

Prevention of Recurrence
     (6) CMV disease is not cured with courses of the currently
available antiviral agents ganciclovir and foscarnet. Chronic
suppressive or maintenance therapy is indicated. The presently
approved regimens include parenteral or oral ganciclovir or
parenteral foscarnet (AI). In spite of maintenance therapy,
recurrences develop routinely and require reinstitution of
high-dose induction therapy.

Note

Pediatric Note
     (7) The recommendations for the prevention of CMV disease and
of its recurrence apply to children as well as to adolescents and
adults. However, oral ganciclovir has not been studied in children.

HERPES SIMPLEX VIRUS DISEASE

Prevention of Exposure
     (1) HIV-infected persons should use latex condoms during every
act of sexual intercourse to reduce the risk of exposure to herpes
simplex virus (HSV) and to other sexually transmitted pathogens
(AII). They should specifically avoid sexual contact when herpetic
lesions (genital or orolabial) are evident (AII).

Prevention of Disease
     (2) Prophylaxis of initial episodes of HSV disease is not
recommended (DIII)*.

Prevention of Recurrence
     (3) Because acute episodes of HSV infection can be treated
successfully, chronic therapy with acyclovir is not required after
lesions resolve. However, persons with frequent or severe
recurrences can be given daily suppressive therapy with oral
acyclovir (AI). Intravenous foscarnet can be used for the treatment
of infection due to acyclovir-resistant isolates of HSV, which are
routinely resistant to ganciclovir as well (AI).

Notes

Pediatric Note
     (4) The recommendations for the prevention of initial disease
and recurrence apply to children as well as to adolescents and
adults.

Note Regarding Pregnancy
     (5) The effectiveness of suppressive treatment with acyclovir
in reducing the risk of perinatal HSV transmission has not been
studied. Therefore, no relevant recommendation can be made.

VARICELLA-ZOSTER VIRUS INFECTION

Prevention of Exposure
     (1) HIV-infected children and adults who are susceptible to
varicella-zoster virus (VZV)--i.e., those who have no history of
chickenpox or are seronegative for VZV--should avoid exposure to
persons with chickenpox or shingles (AII).
Prevention of Disease
     (2) For the prophylaxis of chickenpox, HIV-infected children
and adults who are susceptible to VZV should be given zoster immune
globulin within 96 hours after close contact with a patient with
chickenpox or shingles (AI). Data are lacking on the effectiveness
of acyclovir for preventing chickenpox in HIV-infected children or
adults.
     (3) No preventive measures are currently available for
shingles.

Prevention of Recurrence
     (4) Recurrence of shingles is unusual, and no drug has been
proven to prevent recurrence.

Note

Note Regarding Pregnancy
     (5) Zoster immune globulin is not contraindicated during
pregnancy and should be given to VZV-susceptible pregnant women
after exposure to VZV (AI).

HUMAN PAPILLOMAVIRUS INFECTION

Prevention of Exposure
     (1) HIV-infected persons should use latex condoms during every
act of sexual intercourse to reduce the risk of exposure to human
papillomavirus (HPV) as well as to other sexually transmitted
pathogens (AII).
Prevention of Disease
HPV-Associated Genital Epithelial Cancers in HIV-Infected Women
     (2) HIV-infected women should have annual cervical Pap smears
as part of their initial and routine gynecologic care. In
accordance with the recommendation of the Agency for Health Care
Policy and Research (9), a Pap smear should be obtained twice in
the first year after diagnosis of HIV infection and, if the results
are normal, annually thereafter (AII).
     (3) If an HIV-infected woman has a history of abnormal Pap
smears, the caregiver may choose to monitor this individual with
Pap smears every 6 months (BIII).
     (4) If the initial or follow-up Pap smear indicates
inflammation with reactive squamous cellular changes, further
management should be guided by diagnosis of the cause of the
inflammation, and another Pap smear should be collected within 3
months (BIII). HIV-infected women with Pap smears showing only
atypical cells of undetermined significance can be monitored with
annual Pap smears (BIII).
     (5) Controversy exists concerning the management of
HIV-infected women with low-grade squamous intraepithelial lesions
(SIL) evident on the cervical Pap smear; the natural history of
this finding in this population has not yet been well defined. Some
experts would collect another Pap smear within 3 months. If
subsequent Pap smears again showed low-grade SIL, some of these
authorities would refer the patient for colposcopic evaluation and
biopsy (if indicated); while others would monitor compliant
patients with repeat Pap smears at frequent intervals (e.g., every
3-6 months) (BIII). Other experts would refer all HIV-infected
patients with low-grade SIL for colposcopy (BIII).
     (6) If a Pap smear indicates high-grade SIL or squamous cell
carcinoma, the woman should be referred for colposcopic examination
and, if indicated, colposcopically directed biopsy (AI).
HPV-Associated Anal Intraepithelial Neoplasia and Anal Cancer in
HIV-Infected Men Who Have Sex with Men
     (7) Although the risks for anal intraepithelial neoplasia
(AIN) and anal cancer are increased among HIV-infected men who have
sex with men, the role of anal cytological screening and treatment
of AIN in preventing anal cancer in these men is not well defined.
Therefore, no recommendations can be made for periodic anal
cytological screening for the detection and treatment of AIN.
Prevention of Recurrence
     (8) The risks for recurrence of SIL and cervical cancer after
conventional therapy are increased among HIV-infected women. The
prevention of illness associated with recurrence depends on careful
follow-up of patients after treatment. Patients should be monitored
with frequent cytological screening and, when indicated, with
colposcopic examination for recurrent lesions (AI).

Note

Pediatric Note
     (9) Newborns have been known to acquire laryngeal HPV from
their mothers. No recommendations can currently be made to prevent
such acquisition.

References

1. CDC. Estimates of HIV prevalence and projected AIDS cases:
summary of a workshop, October 31--November 1, 1989. MMWR
1990;39:110-2,117-9.
2. CDC. Projections of the number of persons diagnosed with AIDS
and the number of immunosuppressed HIV-infected persons--United
States, 1992-1994. MMWR 1992;41(No. RR-18):1-29.
3. CDC. Guidelines for prophylaxis against Pneumocystis carinii
pneumonia for persons infected with human immunodeficiency virus.
MMWR 1989;38(No. S-5):1-9.
4. CDC. Recommendations for prophylaxis against Pneumocystis
carinii pneumonia for adults and adolescents infected with human
immunodeficiency virus. MMWR 1992;41(No. RR- 4):1-11.
5. Masur H. Recommendations on prophylaxis and therapy for
disseminated Mycobacterium avium complex disease in patients
infected with the human immunodeficiency virus. N Engl J Med
1993;329:898-904.
6. Kaplan JE, Masur H, Holmes KK, et al. USPHS/IDSA guidelines for
the prevention of opportunistic infections in persons infected with
human immunodeficiency virus: Introduction. Clin Infect Dis
1995;21(suppl 1):1-11.
7. Kaplan JE, Masur H, Holmes KK, et al. USPHS/IDSA guidelines for
the prevention of opportunistic infections in persons infected with
human immunodeficiency virus: an overview. Clin Infect Dis
1995;21(suppl 1):12-31.
8. USPHS/IDSA Prevention of Opportunistic Infections Working Group.
USPHS/IDSA guidelines for the prevention of opportunistic
infections in persons infected with human immunodeficiency virus:
disease-specific recommendations. Clin Infect Dis 1995;21(suppl
1):32-43.
9. El-Sadr W, Oleske JM, Agins BD, et al. Evaluation and management
of early HIV infection. Clinical practice guidelines no. 7.
Rockville, MD: U.S. Department of Health and Human Services, 1994;
AHCPR publication No. 94-0572.
10. Gross PA, Barrett TL, Dellinger P, et al. Purpose of quality
standards for infectious diseases. Clin Infect Dis 1994;18:421.
11. CDC. 1995 revised guidelines for prophylaxis against
Pneumocystis carinii pneumonia for children infected with or
perinatally exposed to human immunodeficiency virus. MMWR
1995;44(No. RR-4):1-11.
12. CDC. 1994 revised classification system for human
immunodeficiency virus infection in children less than 13 years of
age. MMWR 1994;43(No. RR-12):1-10.
13. American Academy of Pediatrics. 1994 Red Book: report of the
Committee on Infectious Diseases. 23rd ed. Elk Grove Village, IL:
American Academy of Pediatrics, 1994:264,279-80,375,496-7.
14. CDC. Recommendations of the Advisory Committee on Immunization
Practices (ACIP): use of vaccines and immune globulins in persons
with altered immunocompetence. MMWR 1993;42(No. RR-4):1-18.
15. D2.400 Standards for blood banks and transfusion services. 16th
ed. Bethesda, MD: American Association of Blood Banks, 1994:12.
16. Castro, KG. Tuberculosis as an opportunistic disease in persons
infected with human immunodeficiency virus. Clin Infect Dis
1995;21(suppl 1):S66-S71.
17. CDC. Hepatitis B virus: a comprehensive strategy for
eliminating transmission in the United States through universal
childhood vaccination. MMWR 1991;40(No. RR-13):1-25.
18. CDC. Prevention and control of influenza: part I, vaccines.
MMWR 1994;43(No. RR-9):1-13.
19. CDC. Prevention and control of influenza: part 2, antiviral
agents. MMWR 1994;43(No. RR-15):1-10.
20. CDC. Recommended childhood immunization schedule--United
States, January 1995. MMWR 1995;43:959-60.
21. Hall CB. The recommended childhood immunization schedule of the
United States. American Academy of Pediatrics. Pediatrics
1995;95:135-7.

* These recommendations address 17 opportunistic infections or
groups of opportunistic infections and cover prevention of
exposure, prevention of the first episode of disease, and
prevention of recurrence (including relapse and reinfection). The
recommendations are not presented in order of priority; the
priorities in preventing opportunistic infections in HIV-infected
persons are presented in ``USPHS/IDSA Guidelines for the Prevention
of Opportunistic Infections in Persons Infected with Human
Immunodeficiency Virus: An Overview'' (7).

* Only filters capable of removing particles 1 um in diameter and
larger should be considered. Filters that provide the greatest
assurance of oocyst removal include those that operate by reverse
osmosis, those labeled as "absolute" 1-um filters, and those
labeled as meeting NSF (National Sanitation Foundation) standard
no. 53 for "cyst removal." The "nominal" 1-um filter rating is not
standardized, and many filters in this category may not be capable
of removing greater than or equal to 99% of oocysts.

** Sources of bottled water (wells, springs, municipal tap-water
supplies, rivers, lakes) and methods for its disinfection vary;
therefore, all brands should not be presumed to be free of
cryptosporidial oocysts. Water from wells and springs is much less
likely to be contaminated by oocysts than water from rivers or
lakes. Treatment of bottled water by distillation or reverse
osmosis ensures oocyst removal. Water passed through an "absolute"
1-um filter or a filter labeled as meeting NSF standard no. 53 for
"cyst removal" before bottling will provide nearly the same level
of protection. Use of "nominal" 1-um filters by bottlers as the
only barrier to cryptosporidia may not result in the removal of
greater than or equal to 99% of oocysts.

* Controversy exists over the possible association of acyclovir
therapy with prolonged survival of HIV-infected persons. Current
data suggest that chronic acyclovir therapy may be considered but
should not be standard practice (CIII).
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