Dr Henry Masur is a clinical expert in HIV from the National Institute of Health (NIH) who has published over > 300 peer reviewed publications related to infections and HIV. Â We were tremendously lucky to have hime come up to Baltimore and give a really nice review on the history of HIV as well as some major pearls and pitfalls to consider the next time your managing a patient with HIV patient in your ICU. Â You think you may know how to manage the sick patient with the classic opportunistic infection – but what about the trauma patient with HIV? Â How about that HIV patient who just had an MI? Â You can really make some big mistakes if you go at it alone.
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- We may not be making as much progress as we think in HIV care
- HOPS Study – while optimistic, is based on a sample of patients who are compliant with out-patient care.
- NHDS – based on discharge summaries, shows we may not be doing that well with treating HIV and preventing OI’s.
- For any HIV patient in the ICU – it should automatically trigger you to give your friendly Infectious Disease consultant a call. Â Medications are complex, have lots of interactions, and shouldn’t be managed alone.
- Pearl: Â When do opportunistic infections occur? The CD4 cut off may not be what you were actually taught!!
- HIV issues to be aware of:
- Absorption issues: Resistance to subtherapeutic levels (nearly all meds are oral) of HIV meds can happen within DAYS. Â Once a resistance is established, they will have forever lost the ability to take that antiretroviral ever again.
- Toxicities:
- Abacavir: Distributive shock (Sepsis mimic), desquamating rash, hypersensitivity syndrome.
- Dapsone: Methemoglobinemia
- Fluconazole, bactrim, INH, rifampin: hepatitis
- Drug Interactions: Â Often interact with many drugs used in the ICU
- Ritonavir, Rifampin – lots of interractions
- Immune Reconstitution Inflammatory Syndrome (IRIS)
- Important to ask your HIV patient when they started their anti-retroviral therapy (ARVs) – classic time line for IRIS is days to weeks.
- HIV & Pneumonia – Pneumococcus, Hemophilus, PCP, Tuberculosis, & Atypicals/Viral infections are the most common causes. Don’t for get about S. Aureus either!
- Refractory PCP: Clindaprimaquine is just as good as IV Pentamadine. Â Atovaquone is a BAD CHOICE due to the fact that it’s an oral drug and has the potential for erratic absorption and subtherapeutic levels.
- HIV + CNS Mass lesions: Â CD4 < 100 – think Toxoplasma or Lymphoma. Â If the CD4 > 100, it’s not Toxo, think lympoma, Tb, or something else.
References
- Fauci AS, Folkers GK. Toward an AIDS-free generation. JAMA. 2012;308(4):343-4.
- Steinbrook R. HIV/AIDS in 1990 and 2012: from San Francisco to Washington, DC. JAMA. 2012;308(4):345-6.