CDC releases new guidelines for OI exposures

Here’s help in knowing what to teach patients

AIDS Guide for Health Care Workers

The revised Guidelines for Preventing Opportunistic Infections Among HIV-Infected Persons-2002 contain several changes from the 1999 guidelines, as well as an appendix with recommendations for helping patients to avoid opportunistic infections (OIs). Recently published by the Centers for Disease Control and Prevention, here is a summary of what the guidelines contain and what health care workers need to know about OIs and teaching HIV/AIDS patients about limiting exposure to OIs and avoiding infection.

Major changes in OI treatment recommendations:

• The new recommendation is to discontinue primary toxoplasmosis prophylaxis when the CD4 t-cell count has increased to greater than 200 cells for three or more months.

• Prophylaxis for Pneumocystis carinii pneumonia (PCP) may be discontinued when the CD4 t-cells have increased to greater than 200 cells for three or more months after initiation of highly active antiretroviral therapy (HAART).

• Prophylaxis for Mycobacterium avium complex (MAC) may be discontinued when CD4 t-cells have increased to more than 100 cells for three or more months. Secondary prophylaxis for disseminated MAC can be discontinued after a six month or greater increase in CD4 t-cells count to greater than 100 cells in response to HAART, if the patient has completed 12 months of MAC therapy and has no signs or symptoms of MAC.

• Clinicians may discontinue secondary prophylaxis for toxoplasmosis and cryptococcosis when patients have had a CD4 t-cell count of greater than 200 cells and greater than 100 cells, respectively, in response to HAART, for six months or greater. This is dependent upon their having completed their initial therapy and having demonstrated no signs or symptoms.

• Screen all HIV-infected patients for hepatitis C.

Advice to give HIV-infected patients about preventing OIs:

• Use a latex condom during every act of sexual intercourse to reduce the risk for acquiring cytomegalovirus, herpes simplex virus, and human papilloma-virus as well as other sexually transmitted pathogens. Using a condom also will reduce the risk for acquiring human herpes/ virus 8, as well as superinfection with a strain of HIV that has become resistant to antiretroviral drugs and will prevent transmission of HIV and other sexually transmitted pathogens to others. Female condoms are recommended to reduce risk strategy.

• Avoid sexual practices that might result in oral exposure to feces (e.g., oral-anal contact) to reduce the risk for intestinal infections (e.g., cryptosporidiosis, shigellosis, campylobacteriosis, amebiasis, giardiasis, and hepatitis A). Even using a latex condom might not be enough to reduce the risk for acquiring these fecal-orally transmitted pathogens, chiefly those that have low infectious doses. Other risk-reduction strategies include using dental dams or similar barrier methods for oral-anal and oral-genital contact, changing condoms after anal intercourse, wearing latex gloves during digital-anal contact, and washing hands frequently with warm soapy water during and after activities that might bring these body parts in contact with feces.

• All HIV-positive people who are susceptible should be vaccinated for hepatitis B, using the antihepatitis B core antigen-negative. Some, including those who inject drugs, also may need to be vaccinated for hepatitis A.

• Patients who inject drugs and are not ready to change their behavior should be advised to never reuse or share syringes, needles, water, or drug-preparation equipment, or to at least clean equipment with bleach and water.

• Injection-drug using patients also should obtain their syringes from pharmacies or needle-exchange programs, and they should use boiled or sterile water to prepare their drugs, clean the injection site with a new alcohol swab before injection, and safely dispose of syringes after one use.

• HIV-infected patients who work or volunteer in certain settings may place themselves at greater risk for exposure to tuberculosis. These settings include health care facilities, correctional institutions, homeless shelters, among others identified by local health authorities.

• HIV-infected patients who live with children in child care or work in child-care settings are at greater risk of acquiring cytomegalovirus infection, cryptosporidiosis, and other infections (e.g., hepatitis A and giardiasis) from children. This risk can be reduced through vigilant hand washing after contact with diapers, urine, or saliva.

• Another occupational risk factor is veterinary work and employment in pet stores, farms, or slaughterhouses, where HIV-infected persons may be exposed to cryptosporidiosis, toxoplasmosis, salmonellosis, campylobacteriosis, or Bartonella infection.

Patients should wash hands after contact with young farm animals and after gardening. Avoid exposure to surface soil dust, chicken coops, bird-roosting sites, old buildings with remodeling or cleaning projects underway, and cave exploring, particularly in areas endemic for histoplasmosis. The same advice regarding exposure to native soil, excavation sites, and dust storms, applies in areas endemic for coccidioidomycosis.

• Be aware of potential problems from pets and avoid contact with animals that have diarrhea. It’s also wise to avoid stray animals, dogs less than six months old, and cats less than a year old. Use caution when buying pets to make certain the pet-breeding facility, pet store, or animal shelter is hygienic and sanitary. Also, wash hands after handling pets and before eating and avoid contact with their feces to reduce risk for cryptosporidiosis, salmonellosis, and campylobacteriosis (BIII).

• Cat ownership increases an HIV-infected person’s risk for toxoplasmosis and Bartonella infection, as well as enteric infections. So it’s a good idea to clean litter boxes daily and thoroughly wash hands afterwards. Also, keep cats indoor and do not allow them to hunt or eat raw or undercooked meat. Avoid cat scratches and bites and, if one should occur, wash the site promptly. Do not allow cats to lick open cuts or wounds. Flea control is necessary, as well.

• Contact with reptiles (e.g., snakes, lizards, iguanas, and turtles) as well as chicks and ducklings could place an HIV-infected person at greater risk for salmonellosis. Use gloves when cleaning an aquarium to reduce the risk for infection with Mycobacterium marinum. Avoid contact with exotic pets.

• Avoid certain foods, including all that might contain raw eggs, such as nonprocessed hollandaise sauce, Caesar and some other salad dressings, mayonnaise, uncooked cookie and cake batter, and egg nog. Abstain from raw or undercooked poultry, meat, seafood (raw shellfish in particular ); and unpasteurized dairy products; unpasteurized fruit juice; and raw seed sprouts (e.g., alfalfa sprouts or mung bean sprouts).

For more information: Contact the CDC, which is the source of this information, at the Web site: AIDS Guide for Health Care Workers is written especially for the person working in the health care setting. It explains important issues concerning AIDS in a thorough, yet easy-to-understand style. Although the material is copyrighted, the publisher grants you permission to photocopy AIDS Guide for Health Care Workers and distribute it throughout your facility. We encourage dissemination of this information.