5/14/2012 1 Challenges in Antibiotic Selection for Pediatric Patients: Issues and Answers Answers What a Pediatrician Needs to know in 2012!! Disclosure I have no financial or other arrangements with the companies who make the products presented. Some of the dosing recommendations are based on common use (e.g., guidelines, review articles, studies, and current practice). As is common in pediatric pharmacotherapy, this may differ from the manufacturers’ package inserts. Objectives Discuss the current issues related to antibiotic resistance in pediatric patients Suggested alternative methods and agents for select group of patients in both the outpatient and inpatient arena Discuss ways to minimize drug toxicity and adverse events in pediatric patients on long term antibiotic therapy Discuss recent “break point “ changes and implications on drug selection for pediatric infections Update you on HIV treatment in pediatric patients
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5/14/2012
1
Challenges in Antibiotic Selection for Pediatric Patients: Issues and
AnswersAnswersWhat a Pediatrician Needs to
know in 2012!!
Disclosure I have no financial or other arrangements with the
companies who make the products presented.
Some of the dosing recommendations are based on common use (e.g., guidelines, review articles, studies, and current practice). As is common in pediatric pharmacotherapy, this may differ from the manufacturers’ package inserts.
Objectives Discuss the current issues related to antibiotic
resistance in pediatric patients
Suggested alternative methods and agents for select group of patients in both the outpatient and inpatient arena
Discuss ways to minimize drug toxicity and adverse events in pediatric patients on long term antibiotic therapy
Discuss recent “break point “ changes and implications on drug selection for pediatric infections
Update you on HIV treatment in pediatric patients
5/14/2012
2
Expected Outcome What is the desired change/result following this
educational intervention? Refine strategies to help select antibiotics for selected
infections in children
Apply the principles of antibiotic killing to practical ways toApply the principles of antibiotic killing to practical ways to manage infection
Have a current reference for pediatric HIV infections available for your patients
The Antibiotic Rules Once a day is best
Give IV antibiotics over 30-60 minutes except vancomycin
Resistance is a problem but not for my patients Resistance is a problem but not for my patients
Vitamin R is still golden
Clindamycin suspension taste great and is less filling
Cedinir taste great and treats almost everything
Azithromycin is good for everything from inflammation to infection
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Why we do what we do? 1. Volumetric Infusion devices
2. Free flow protection of IV infusion
3. Many portable, small IV infusion with smart phone technologytechnology
4. Many drug safe to give over very short periods of time .e.g. gentamicin 3-4mg/kg push over 5-10 minutes
5. Convenience
6. Better analytical capacity to measure drugs
7. Better understanding of Pharmacokinetics
Is this the right thing to do Peak to MIC ratio
AUC to MIC ratio
Time above MIC
Special Populations
Critically Ill
CF
Immunocompromised
Rule 1 Once a day is best
Great data on once a day medication for chronic therapy improves adherence
Limited data that once a day for short term therapy is Limited data that once a day for short term therapy is really much better than two times a day. Some studies suggest no real difference.
No new studies in this area in the last 10 years
Taste does make a huge difference in completing therapy
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Rule 1 revisited Pharmacokinetics/pharmacodynamics plays a huge
role in treating moderate to severe infections
More frequent dosing may be important than convenience in dosing.
We have now technology to minimize the complexity of drug delivery in inpatient and outpatient settings
Show me
Rule 2 Give IV antibiotics over 30-60 minutes except
vancomycin
Why do we do that?
It was hard to administer many of these drugs when we It was hard to administer many of these drugs when we tested them and wanted to make sure they were safe but not allow patients to be hooked up for too long
What we have now!
The Breakpoint “Breakpoint”: MIC (in mcg/ml) at or below which organism
considered susceptible Unique for drug-organism-(infection)
Bradley JS, et al. Clinical Infectious Bradley JS, et al. Clinical Infectious Diseases Advance Access Published Diseases Advance Access Published August 30, 2011.August 30, 2011.
3 m/o to 5 y/o: Therapy Viral infection-no antibiotics
Coinfection known or suspected-use antibiotics If immunized & healthy: amoxicillin
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
Respiratory Syncytial Virus (RSV) Ineffective acute therapy for bronchiolitis Systemic corticosteroids Albuterol or racemic epinephrine Palivizumab (Synagis)
Supportive Care: nasal flush IV fluids Supportive Care: nasal flush, IV fluids
May be associated with coinfection
Prophylaxis Palivizumab (Synagis) 15 mg/kg IM monthly Season “October to February” High risk patients Cost: $1000-2,000/dose Outpatient requires prior approval
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Etiology: 5y/o - Adolescence Viral Infection Possible
Bacteria Streptococcus pneumoniae
Group A Streptococcusp p
Staphylococcus aureus
Chlamydia pneumoniae
Mycoplasma pneumoniae
S. pneumoniae PCN Susceptibility
IV Penicillin May increase dose and treat if MIC <= 2 mcg/mL
PO Penicillin Susceptible: <= 0.06 mcg/mLp g
Intermediate: 0.12-1 mcg/mL
Resistant: >= 2 mcg/mL
Weinstein MP, et al. Clin Infect Dis; 2009;48:1596-1600
Cross-susceptibility and cross-resistance analysis of MIC breakpoints of penicillin, compared with MIC breakpoints of ceftriaxone, involving 23,669 isolates of
Streptococcus pneumoniae.
Weinstein M P et al. Clin Infect Dis. 2009;48:1596-1600
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
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S. pneumoniae w PCN MIC<=2
(Step-Down or Mild Infection) Preferred
Amoxicillin 90 mg/kg/day ÷ Q12H
Amoxicillin 45 mg/kg/day ÷ Q8H
Oral AlternativesOral Alternatives
Cefpodoxime/cefuroxime/cefprozil
Levofloxacin 0.5-5 y/o: 16-20 mg/kg ÷ Q12H
>5 y/o: 10 mg/kg ÷ Q24H
Linezolid < 12 y/o: 30 mg/kg/day ÷ Q8H
>=12 y/o: 20 mg/kg ÷ Q12HBradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
S. pneumoniae w PCN MIC>=4 Preferred IV
Ceftriaxone 100 mg/kg/day ÷ Q12-24H
Alternate IV
Ampicillin 300-400 mg/kg/day ÷ Q6H
Levofloxacin
0.5-5 y/o: 16-20 mg/kg ÷ Q12H
>5 y/o: 10 mg/kg ÷ Q24H
Linezolid
< 12 y/o: 30 mg/kg/day ÷ Q8H
>=12 y/o: 20 mg/kg ÷ Q12H
Clindamycin 40 mg/kg/day ÷ Q6-8H
Vancomycin 40-60 mg/kg/day ÷ Q6-8H
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
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S. pneumoniae w PCN MIC>=4 (Step-
Down or Mild Infection) Preferred
Levofloxacin 0.5-5 y/o: 16-20 mg/kg ÷ Q12H
>5 y/o: 10 mg/kg ÷ Q24H
Li lid Linezolid < 12 y/o: 30 mg/kg/day ÷ Q8H
>=12 y/o: 20 mg/kg ÷ Q12H
Oral Alternative
Clindamycin 40 mg/kg/day ÷ Q8H
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
Cefdinir and Future Changes? N=37
Older infants and children
Desired % time>MIC > 40% for resistant S. pneumoniae strains (MIC
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
Group A Streptococcus: PO Preferred Amoxicillin 50-75 mg/kg/day÷ Q12H
Bradley JS, et al. Clinical Infectious Diseases Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Advance Access Published August 30, 2011.
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MSSA/OSSA: IV Preferred Cefazolin 150 mg/kg/day ÷ Q8H
Alternative Clindamycin* 40 mg/kg/day ÷ Q6-8Hy g g y
Vancomycin 40-60 mg/kg/day ÷ Q6-8H
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
MSSA/OSSA: PO Preferred Cephalexin 75-100 mg/kg/day ÷ Q6-8H
Alternative Clindamycin* 30-40 mg/kg/day ÷ Q8Hy g g y
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
MRSA/ORSA: IV then PO Preferred Vancomycin 40-60 mg/kg/day ÷ Q6-8H
(or dose to AUC/MIC ratio > 400)
Clindamycin* 40 mg/kg/day ÷ Q6-8H
Alternative Linezolid < 12 y/o: 30 mg/kg/day ÷ Q8H
> 12 y/o: 20 mg/kg/day ÷ Q12H
Bradley JS, et al. Clinical Infectious Diseases Advance Access Bradley JS, et al. Clinical Infectious Diseases Advance Access
Published August 30, 2011Published August 30, 2011..
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Mycoplasma or Chlamydia: IV Preferred Azithromycin 10 mg/kg/day ÷ Q24H x 2 days then change
to PO
Alternatives Erythromycin lactobionate
Levofloxacin
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
Mycoplasma or Chlamydia: PO Preferred Azithromycin 10 mg/kg then 5 mg/kg/day x 4 days
Alternative: Clarithromyciny
Erythromycin
Doxycycline
Levofloxacin or moxifloxacin
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
Alternative: Amoxicillin/Clavulanate 90 mg amox/ kg/day ÷Q12H* (up to 4 gm amox/day) Q ( p g y)
Atypical Preferred: Azithromycin 10 mg/kg (up to 500mg) then 5
mg/kg/day (up to 250mg)
Alternatives Clarithromycin 15 mg/kg ÷ Q12H
Erythromycin 40 mg/kg ÷ Q6H
Doxycycline Bradley JS, et al. Clinical Infectious Diseases Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Advance Access Published August 30, 2011.
Empiric Inpatient Bacterial Therapy for Immunized Patient with Low Local PCN Resistance
Preferred Ampicillin
Pen G
Alternatives C ft i f t i Ceftriaxone or cefotaxime
If CA-MRSA Suspected Vancomycin
Clindamycin
Bradley JS, et al. Clinical Infectious Diseases Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Advance Access Published August 30, 2011.
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Empiric Inpatient Atypical Therapy for Immunized Patient with Low Local PCN Resistance
Preferred Azithromycin
+/- Beta-lactam
Alternatives Clarithromycin
Erythromycin
Doxycycline (> 7 y/o)
Levofloxacin*
Bradley JS, et al. Clinical Infectious Diseases Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Advance Access Published August 30, 2011.
Empiric Inpatient Bacterial Therapy for Unimmunized Patient OR Significant Local Pneumococcal
Resistance
Preferred Ceftriaxone or cefotaxime
+/- Vancomycin or clindamycin
AlternativesAlternatives Levofloxacin
+/- Vancomycin or clindamycin
Bradley JS, et al. Clinical Infectious Diseases Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Advance Access Published August 30, 2011.
Empiric Inpatient Atypical Therapy for Unimmunized Patient OR Significant Local Pneumococcal Resistance
Preferred Azithromycin
+/- Beta-lactam
Alternatives Clarithromycin
Erythromycin
Doxycycline (> 7 y/o)
Levofloxacin*
Bradley JS, et al. Clinical Infectious Diseases Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Advance Access Published August 30, 2011.
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Amoxicillin Allergy? Possible non-serious reaction: Not well-defined,
individualize therapy Amoxicillin trial
Prepen and penicillin test (not in Guidelines)
Cephalosporin trial p p
Cefpodoxime—in future at higher doses?
Cefprozil
Cefuroxime
Levofloxacin
Linezolid
Clindamycin
Macrolide
Presumed Influenza Pneumonia
< 5 y/o Oseltamivir PO
Amantadine/Rimantadine PO (if susceptible)
>= 5 y/oy Oseltamivir PO
Zanamivir IH (if >= 7 y/o)
Alternatives
Peramivir
Oseltamivir and zanamivir
Amantadine /Rimantadine PO (if susceptible)
IV zanamivir (compassionate use study)
Bradley JS, et al. Clinical Infectious Diseases Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Advance Access Published August 30, 2011.
IV Agents: Ampicillin Narrow spectrum
Time-dependent killing
Q6H dosing for most patients
Oral alternative available (amoxicillin 45-90 mg/kg/day ÷ Q8-12H)
Relatively inexpensive*
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IV Agents: Cefotaxime & Ceftriaxone Covers many GNB and some gram positive
Time-dependent killing
Interval Cefotaxime typically Q6HCefotaxime typically Q6H Ceftriaxone Q12 or Q24H
Disposition Cefotaxime: renal by GFR Ceftriaxone: hepatobiliary Highest risk of sludging if < 1m/o or on IV Ca+2
Low Acquisition Cost Liu C, et al. Clin Infect Dis 2011;52(3):285Liu C, et al. Clin Infect Dis 2011;52(3):285--292.292.Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.30, 2011.
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Azithromycin Covers atypicals and some gram positive organisms
Unique dosing 10mg/kg then 5mg/kg daily for 4 days 10mg/kg daily x3 (not in Guidelines) 30-60mg/kg (max 2,000 mg) x1 (not in Guidelines)
Disposition Intracellular Oral = IV
Caution: slow IV infusion (QT Syndrome possible)
Preferred over erythromycin (hypertrophic pyloric stenosis in neonates and infants)
More palatable than clarithromycin
Duration of Therapy Patients 2 m/o to 5 y/o with non-severe CAP
4 trials
3 vs. 5 days y
No difference in clinical cure (RR 0.99, 95% confidence interval 0.97-1.01)
No difference in treatment failure (RR 1.07, 95% confidence interval 0.92-1.25)
Haider BA, et al. Cochrane Database of Systematic Reviews 2008; Issue 2. Art. No. CD005976, DOI:10.1002/14651858. CD005976.pub2.
Typical Therapy Duration “10 days” for most patients
Varies based on Disease severity > if empyema or abscess
> if CA-MRSA
Disease response
Medication
Liu C, et al. Clin Infect Dis 2011;52(3):285Liu C, et al. Clin Infect Dis 2011;52(3):285--292.292.Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
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Case 7 y/o male admitted for CAP
H/O URI starting 10 days ago, saw PMD 8 days ago. No prior lower RTIs before
Got better with Azithromycin 300mg po, then 150mg po daily x 4 daysp y y
Over the last 48hr, pt had new cough, fever to 103.1
What is true about your patient’s antibiotic therapy?
A. Typically duration is 10 days
B. May change to comparable PO therapy if responds well in 2 days
C. All of the above
But what if your hospitalized patient is really ill?
Requiring increased oxygen requirement
Necrosis
Abscess
Multilobar effusion
WBC increase to 50K with continued left shift
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Complications Associated With CAP
Pulmonary Pleural effusion or
empyema
Pneumothorax
Lung abscess
Metastatic Meningitis Central nervous system
abscess Pericarditis
E d ditig
Bronchopleural fistula
Necrotizing pneumonia
Acute respiratory failure
Endocarditis Osteomyelitis Septic arthritis
Systemic SIRS or sepsis Hemolytic uremic
syndrome
Bradley JS, et al. Clinical Infectious Diseases Advance Bradley JS, et al. Clinical Infectious Diseases Advance Access Published August 30, 2011.Access Published August 30, 2011.
Necrotizing Pneumonia Liquification and necrosis of lung tissue
Virulent organisms with toxins
Obtain blood cx
Tap and get cultures
Total antibiotic therapy 2-4 weeks
Lung Abscess Often follow aspiration or related to seizure or
neuromuscular disease
Mouth microbes Streptococcus species St h l Staphylococcus aureus GNR Anaerobes
Tuberculosis
Rare
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Purulent Effusions: Empyema Imaging needed to determine if free-flowing or
– Persons living with HIV (≥ 13 years): 1.2 million
– Women: ~290,000
Children < 13 years of age: ~3 000– Children < 13 years of age: ~3,000
• 2009 Perinatal infections: 131
• Pediatric Deaths from HIV in 2009‐28
CDC. MMWR. 2011;60:689-693.CDC. HIV Surveillance Report 2009. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. Updated 2011.
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Mother‐to‐Child Transmission (MTCT)
• Accounts for ~90% of all pediatric HIV cases in the US between 1985‐2005
– Intrauterine 25‐40% cases
Intra partum 60 75% cases– Intra‐partum 60‐75% cases
– Postpartum related to breast feeding
MMWR. 2006;55:592-7.
MTCT of HIV Infection
• Mother‐to‐child transmission rate ~25% without antiretroviral treatment
– ACTG076: pregnant women treated with zidovudine during antepartum period decreasedzidovudine during antepartum period decreased transmission to 8%
• In HAART era, transmission rate is < 2%
– Perinatal HIV infection in US is considered a “sentinel event”
DHHS. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. 2011;1-207.
Perinatal HIV Infection: Risk Factors
Maternal Factors
• High serum viral load
• Breastfeeding
• Sexually transmitted co‐
Obstetrical factors
• Preterm delivery
• Low birth weight
• Prolonged rupture of yinfections
• Advanced maternal HIV disease
• Maternal age > 30 years
• Drug abuse
• No HAART
g pmembranes
• Vaginal delivery
• Chorioamnionitis
• Breastfeeding
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Prevention of MTCT
• Early identification and treatment of HIV infection is key to prevention of perinatal HIV infection
– If HAART is not indicated, treatment can be postponed until the 2nd trimester
• Zidovudine + lamivudine + lopinavir/ritonavir is the preferred antiretroviral (ARV) combination in pregnant women naïve to HAART
– Nevirapine can used if CD4 count < 250 cells/mm3
DHHS. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. 2011;1-207.
Intrapartum Care
• Consider cesarean section if VL > 1,000 copies/mcL
• Continue PO HAART (if on ARVs)( )
• IV zidovudine should be initiated in all women at the start of labor, regardless of resistance or absence of zidovudine in current HAART regimen– 2 mg/kg IV over 1 hour then 1 mg/kg IV per hour
Care of a HIV‐Exposed Neonate
• Neonates born to an HIV‐infected mother on HAART should be initiated on zidovudine and continued for 6 weeks
Gestational Age Standard Regimen
Term Zidovudine 4 mg/kg PO q12h
30‐34 weeks Zidovudine 2 mg/kg PO q12h, then q8h after 2 weeks
< 30 weeks Zidovudine 2 mg/kg PO q12h, then q8h after 4 weeks
DHHS. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. 2011;1-207.
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Care of a HIV‐Exposed Neonate
• Neonates born to an HIV‐infected mother who was not taking HAART should receive zidovudine and 3 doses of nevirapine
– Dose:– Dose:
• 1.5 – 2 kg: 8 mg/kg/dose
• > 2 kg: 12 mg/kg/dose
– Timing:
• Birth, 48 hours, and 96 hours after the 2nd dose
DHHS. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. 2011;1-207.
Care of a HIV‐Exposed Neonate
• HIV‐infected infants at risk for developing Pneumocystis jiroveci Pneumonia (PCP)
– Highest incidence in 1st year of life
In addition to respiratory/pneumonia symptoms:– In addition to respiratory/pneumonia symptoms:
• Age < 6 months, RR > 59 breath/min, PaO2 < 92%, absence of vomiting, high HIV RNA level
DHHS. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. 2011;1-207.
Care of a HIV‐Exposed Neonate
• Prophylaxis with TMP/SMX following completion of zidovudine recommended until definitive HIV infection exclusion
– Do not need to start PCP prophylaxis if– Do not need to start PCP prophylaxis if “presumptively” HIV‐negative
• “Low risk” pregnancy and delivery
• Infant not being breastfed
• 2 negative virological tests at 2 weeks and ≥ 4 weeks
• 1 negative virological test at ≥ 8 weeks
DHHS. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. 2011;1-207.
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MTCT Prevention: Summary
Patient On HAART Not On HAART
Mother
Antepartum Continue or Initiate HAART
N/A
Intrapartum AZT IV + HAARTCesarean delivery if HIV VL > 1000 copies/mL
AZT IVCesarean delivery if HIV VL > 1000 copies/mL
Postpartum Continue therapy if needed
Evaluate need for HAART
Neonate AZT for 6 weeks AZT for 6 weeks + 3 doses of NVP
Case 2: Pediatric HIV Infection
The infant born to the HIV‐infected mother presents for follow‐up in li iclinic.
What kind of methods can be used to diagnose HIV infection in this infant?
Diagnostic Tests for HIV Infection
Useful in infants• HIV DNA PCR
Not As Useful• Enzyme immunoassay
(ELISA)
• Western blot
• Rapid antibody test
• HIV RNA PCR
• Viral culture
• HIV p24 Antigen
DHHS. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. 2011;1-268.
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Diagnosis of Perinatal HIV
• Qualitative HIV DNA PCR preferred– Test at 2 weeks, 4‐6 weeks, and 2‐4 months of age
• Not enough information to use in children:– ABC + ddI, ABC + TdF, ddI + TdF
Monitoring Parameters
Parameter Initial Visit1st 1‐2 months
Q3‐4 months
Q6‐12 Months
ARV Switch
Physical Exam X X X X
CD4 Count/% X X X
HIV RNA X X X X
CBC/diff X X XCBC/diff X X X
Electrolytes X X X
Glucose X X X
AST/ALT/Bili X X X X
BUN/Scr X X X
Alb./Prot. X X X
Lipid Panel X X
Urinalysis X X
Resistance Test X X
Adherence Evaluation X X X
Case 4: Non‐Occupational PEP (nPEP)
• An 12 year‐old male is abducted on his way home and is found 36 hours later. He reports being attacked by 2‐3 men and was raped several timesseveral times.
• Would you give him non‐occupational post‐exposure prophylaxis (nPEP)?
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Summary
• New ways to use old antibiotics
• New breakpoints‐ a changing fence with the source in mind
di i h• Pediatric HIV‐ what a success story
• CAP‐ guidelines are not commandments
• We must be willing to adapt as the microbes do!!