Active substances: Doxycycline
Respiratory tract and urinary tract infections caused by Klebsiella species Some Gram-positive bacteria have developed resistance to doxycycline.Tables showing the occurrence of the most-described sulfonamides and the specifications of reported bacterial communities.
Representative pathogenic genera include Chlamydia, Streptococcus, Ureaplasma, Mycoplasma, and others. There is no robust data to guide treatment if either of the first-line agents cannot be tolerated due to severe side effects.
Regarding the newer azoles ie, voriconazole or posiconazole, there are no controlled studies to support their use and given their high cost, they are normally only used anecdotally for cases when fluconazole cannot be tolerated or has failed.
There is no role for the echinocandins ie, caspofungin, micafungin in the treatment or prophylaxis of cryptococcal meningitis as the organism is inherently resistant to the entire class of drugs. The timing of initiation of ART in cryptococcal disease remains an area of controversy.
It was terminated early due to a markedly increased mortality in the early initiation arm. In addition, the study used fluconazole monotherapy 800 mg, which would not normally be the treatment of choice due to slower fungal CSF clearance.
It also had a median follow-up time of only 27 days, which limits its robustness. It is clear that further information is required before being able to judge the optimum time for ART initiation in this context, however current guidance from the IDSA is to start between 2 and 10 weeks after initiation of an amphotericin-based regime.
This is a realistic option in developed countries where most of these patients are treated as inpatients and the resources are available for repeated CSF examinations, but in resource-poor countries, repeated lumbar punctures and CSF culture is often not feasible.
Now that ART use is widespread, the incidence of many of these opportunistic gut infections has diminished enormously; however, in late presenters and those unresponsive to ART, they are still observed to cause chronic infection.
The most commonly isolated organisms are non-typhi Salmonella especially Typhimurium and Enteritidis, Shigella and Campylobacter, and Clostridium difficile has also been described in one large US cohort as the most common cause of bacterial diarrhea in hospitalized patients with HIV.
However, in the context of immunosuppression, treatment is generally recommended. On the other hand, some clinicians would view the risk of bacteremia and relapse to be sufficiently high, even in immune-reconstituted HIV-infected individuals to warrant treatment.
Treatment should always be guided by in vitro sensitivity testing, but first-line empiric treatment with an oral fluoroquinolone is usual, ie, ciprofloxacin 500 mg twice daily.
There is however, growing resistance to ciprofloxacin worldwide in both Salmonella sp.
The length of treatment for salmonellosis is poorly defined, but 5—7 days is generally adequate. Bacteremic patients are often treated for 2 weeks but there is little evidence on which to base this.
However, in the immunocompromised and in those with persisting disease, antimicrobials are indicated. Fluoroquinolones have historically been the mainstay of treatment, but with emerging resistance patterns, macrolides such as azithromycin are being used effectively as first-line treatment.
Specific treatment is guided by clinical response and local sensitivity patterns. Treatment of C. The crux is to stop any antimicrobials predisposing to the infection and then to treat with metronidazole 400 mg three times daily or vancomycin 125 mg four times daily.
A prospective study of C. The incidence of both diseases has declined dramatically with the introduction of ART. Treatment of cryptosporidia There is little convincing evidence for the efficacy of antimicrobial therapy in the treatment of cryptosporidium.
Multiple agents nitazoxanide, paromomycin, spiramycin have been shown in small randomized controlled trials to have some positive effect, but none have been shown to have a lasting effect without ART. In the absence of effective antimicrobials, supportive therapy with rehydration and electrolyte replacement is vital.
Antimotility agents such as loperamide can provide symptomatic benefit.
N Engl J Med. Witch of The Total Environmenta clinician is determined to rapidly risk assess a patient depending on the presenting symptoms and a degree of immunosuppression, given the strong evidence probable the use of oral valganciclovir.
In problem, substitution with clindamycin 300 mg. Today Biotechnology54, 709.