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Antimicrobial Prophylaxis per CD4 Counts

Rachel Pellegrino

CD4 counts Opportunistic Infection Indication for Prophylaxis Medication Special Notes
<200 cells/mm3 Pneumocystis Pneumonia (PJP) CD4 < 200, or CD4 < 14%, may consider discontinuation if CD4 100-200 in setting of viral suppression TMP-SMX: 1 DS daily (qd), or TMP-SMX: 1SS qd TMP-SMX: 1 DS TIW If intolerant of TMP-SMX: dapsone*, or inhaled pentamidine, or atovaquone
<200 cells/mm3 Toxoplasma gondii encephalitis Toxoplasma IgG + and CD4 < 100 TMP-SMX 1 DS tab daily Alternative regimens: dapsone + pyrimethamine + leucovorin, or atovaquone (all regimens also effective for PJP)
<50 cells/mm3 Mycobacterium avium-intracellulare (MAC, MAI) Only if not on fully suppressive ART and active disseminated MAC is ruled out Azithromycin 1200 mg weekly, or Clarithromycin 500 mg BID, or Rifabutin 300 mg daily NOT indicated for those initiating ART
Infection Screening Indication Prevention or Intervention
Hepatitis A Virus (HAV) Non-immune with ↑ risk for HAV infection (MSM, IVDU) or chronic liver disease HAV vaccine series
Hepatitis B Virus (HBV) Pts without chronic HBV or non-immune HBV vaccine series
Human Papilloma virus (HPV) Age 13-45 HPV vaccine series
Influenza A and B Virus All pts Yearly inactivated influenza vaccine
Latent Mycobacterium tuberculosis infection (LTBI) Pts with positive screening test for LTBI with no evidence of active disease.
Pts with known exposure
(INH 300mg + pyridoxine 25-50mg) PO daily for 9 months
Streptococcus pneumoniae All pts Pts without any previous pneumococcal vaccines: Give PCV15 or PCV20. If PCV15 is used, also give PPSV23 in 1 year.

Pts who have already received PPSV23: Give PCV15 or PCV20 one year after most recent PPSV23 vaccine

Pts who have already received PCV13: Give PPSV23
Syphilis All sexually active pts Screening for syphilis and gonorrhea/chlamydia with treatment if indicated.
Herpes zoster (shingles) Pts > age 50 Shingrix (recombinant zoster) vaccine series