Bacterial Respiratory Infections
Prevention of Exposure
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
As soon as feasible after HIV infection is diagnosed, adults and adolescents
who have a CD4+ T-lymphocyte count of >200 cells/µL should
be administered a single dose of 23-valent polysaccharide pneumococcal vaccine
if they have not had this vaccine during the previous 5 years. For
persons who have a CD4+ T-lymphocyte count of <200 cells/µL, vaccination
should be offered, although the humoral response and, therefore, clinical
efficacy are likely to be diminished. The recommendation to vaccinate
is increasingly pertinent because of the increasing incidence of invasive
infections with drug-resistant (including TMP-SMZresistant and
macrolide-resistant) strains of S. pneumoniae. Limited data suggest that
administration of certain bacterial vaccines may transiently increase HIV
replication and plasma HIV-1 RNA levels in HIV-infected persons who are not
being administered potent antiretroviral regimens. However, evidence that
adverse clinical outcomes are associated with this transient increase is
lacking. Most experts believe that the benefit of pneumococcal vaccination
outweighs the potential risk.
The duration of the protective effect afforded by primary pneumococcal vaccination is unknown. Revaccination once should be considered for HIV-infected persons, provided that at least 5 years have elapsed since administration of the first dose of pneumococcal vaccine.
The incidence of H. influenzae type B infection in adults is low. Therefore, H. influenzae type B vaccine is not generally recommended for adult use.
TMP-SMZ, administered daily, reduces the frequency of bacterial respiratory infections; this should be considered in the selection of an agent for PCP prophylaxis. However, indiscriminate use of this drug (when not indicated for PCP prophylaxis or other specific reasons) may promote the development of TMP-SMZresistant organisms. Thus, TMP-SMZ should not be prescribed solely to prevent bacterial respiratory infection. Similarly, clarithromycin administered daily and azithromycin administered weekly are effective in preventing bacterial respiratory infections. This should be considered in the selection of an agent for prophylaxis of MAC disease, although again, these drugs should not be prescribed solely for preventing bacterial respiratory infection.
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). The use of G-CSF or GM-CSF to prevent bacterial infections in HIV-infected patients with neutropenia can-not be recommended. However, preliminary data suggest that G-CSF can provide benefit for selected patients.
Prevention of Recurrence
Some clinicians may administer antibiotic chemoprophylaxis to HIV-infected
patients who have very frequent recurrences of serious bacterial respiratory
infections. TMP-SMZ, administered for PCP prophylaxis, and clarithromycin
or azithromycin, administered for MAC prophylaxis, are appropriate for
drug-sensitive organisms. However, providers should be cautious about use
of antibiotics for this purpose be-cause of the potential for development
of drug-resistant microorganisms.
All invasive pneumococcal isolates from HIV-infected patients should be tested for susceptibility to beta-lactam antibiotics, and local patterns of resistance should be considered in the choice of regimens for empirical treatment. Invasive infections caused by H. influenzae should be treated with regimens effective against beta-lactamaseproducing strains until drug susceptibilities are known.
Notes
Pediatric Notes
Children who have HIV infection should be administered H. influenzae
type b vaccine in accordance with the guidelines of the Advisory Committee
on Immunization Practices (18) and the American Academy of Pediatrics (17). Children aged >2 years also should be administered 23-valent
polysaccharide pneumococcal vaccine (AII). Revaccination with pneumococcal
vaccine generally should be offered after 35 years to children aged
<10 years and after 5 years to children aged >10 years.
To prevent serious bacterial infections in HIV-infected children who have hypogammaglobulinemia, clinicians should use intravenous immunoglobulin (IVIG) (AI). Respiratory syncytial virus (RSV) IVIG may be substituted for IVIG during the RSV season.
To prevent recurrence of serious bacterial respiratory infections, antibiotic chemoprophylaxis should be considered. However, providers should be cautious about use of antibiotics for this purpose because of the potential for development of drug-resistant microorganisms. The administration of IVIG should also be considered for HIV-infected children who have recurrent serious bacterial infections (BI), but such treatment may not provide additional benefit to children who are being administered daily TMP-SMZ.
Note Regarding Pregnancy
Pneumococcal vaccination is recommended during pregnancy for patients
who have not been vaccinated during the previous 5 years. In nonpregnant
adults, vaccination has been associated with a transient burst of HIV
replication. It is unknown whether the transient viremia can increase the
risk of perinatal HIV transmission. Because of this concern, when feasible,
vaccination may be deferred until after antiretroviral therapy has been initiated
for the prevention of perinatal HIV transmission.
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