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See Table 31 4 It is appropriate to start empiric therapy for P jiroveci pneumonia if the disease is suspected clinically; however, in both AIDS patients and non-AIDS patients with mild to moderately severe disease, continued treatment should be based on a proved diagnosis because of the toxicity of therapy and the possible coexistence of other infections Both in AIDS patients and in non-AIDS patients with mild to moderately severe disease, oral trimethoprim-sulfamethoxazole (TMPSMZ) is the preferred agent because of its low cost and excellent bioavailability Patients suffering from nausea and vomiting or intractable diarrhea should be given intravenous TMP-SMZ until they can tolerate the oral formulation Other options include clindamycin/primaquine, dapsone/trimethoprim, pentamidine, and atovaquone Therapy should be continued with the selected drug for at least 5 10 days before considering changing agents, as fever, tachypnea, and pulmonary infiltrates persist for 4 6 days after starting treatment Some patients have a transient worsening of their disease during the first 3 5 days, which may be related to an inflammatory response secondary to the presence of dead or dying organisms Early addition of corticosteroids may attenuate this response (see 31) Some clinicians prefer to treat episodes of AIDS-associated Pneumocystis pneumonia for 21 days rather than the usual 14 days recommended for nonAIDS cases



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Clindamycin, 600 mg three times daily, plus primaquine, 15 mg/d; and dapsone, 100 mg/d, plus trimethoprim 15 mg/kg/ d, in three divided doses daily, are alternative oral regimens for mild to moderate disease or for continuation of therapy after intravenous therapy is no longer needed

(1-49)

In conjunction with antimicrobials, prednisone is given for moderate to severe pneumonia (when PaO2 on admission is < 70 mm Hg or oxygen saturation is < 90%); its use during the first 72 hours of therapy for severe Pneumocystis pneumonia prevents deterioration in oxygenation and improves survival The dosage of prednisone is 40 mg twice daily for 5 days, then 40 mg daily for 5 days, and then 20 mg daily until therapy is completed





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The dosage is TMP 20 mg/kg (12 15 mg/kg may decrease side effects without decreasing efficacy) and SMZ 100 mg/kg given orally or intravenously daily in three or four divided doses for 14 21 days Adverse reactions are generally those of the sulfonamide component Patients with AIDS have a high frequency of hypersensitivity reactions (approaching 50%), which may include fever, rashes (sometimes severe), malaise, neutropenia, hepatitis, nephritis, thrombocytopenia, hyperkalemia, and hyperbilirubinemia

Primary prophylaxis for Pneumocystis pneumonia in HIVinfected patients should be given to persons with CD4 counts < 200 cells/mcL, a CD4 percentage below 14%, or weight loss or oral candidiasis Development of P jiroveci pneumonia while on prophylaxis may be associated with development of resistance to TMP-SMZ Patients with a history of Pneumocystis pneumonia should receive secondary prophylaxis until they have had a durable virologic response to antiretroviral therapy for at least 3 6 months and maintain a CD4 count of > 250 cells/mcL

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On a Macintosh, you can go to System Preferences and use the Network utility (Figure 7-43) Sometimes you might find yourself in a situation where your computer gets confused and won t grab an IP address no matter what you try In these cases you should first force the computer to release its lease In Windows, get to a command prompt and type these two commands, each followed by pressing ENTER:

This drug is administered intravenously (preferred) or intramuscularly as a single dose of 3 mg (salt)/kg/d for 14 21 days To avoid injection site pain or sterile abscesses, most clinicians administer the drug only intravenously by diluting it in 250 mL of 5% dextrose in water and giving it slowly over 1 hour Pentamidine causes side effects in nearly 50% of patients Occasional reactions include rash, neutropenia, abnormal liver function tests, serum folate depression, hyperkalemia, and hypocalcemia Hypoglycemia (often clinically inapparent), hyperglycemia, hyponatremia, and delayed nephrotoxicity with azotemia may occur Rarely, a variety of other severe adverse reactions may occur, including anemia, thrombocytopenia, ventricular arrhythmias, and fatal pancreatitis Blood

In the absence of early and adequate treatment, the fatality rate for the endemic infantile form of Pneumocystis pneumonia is 20 50%; for the sporadic form in immunodeficient persons, the fatality rate is nearly 100% Early treatment reduces the mortality rate to about 3% in the former and 10 20% in AIDS patients The mortality rate in other immunodeficient patients is still 30 50%, probably because of failure to make a timely diagnosis In immunodeficient patients who

For suspected meningeal disease, lumbar puncture is the preferred diagnostic procedure A substantial proportion of individuals who have systemic disease without clinical signs of meningitis will have meningeal involvement, mandating examination of the cerebrospinal fluid Spinal fluid findings include increased opening pressure, variable pleocytosis, increased protein, and decreased glucose, though as many as 50% of AIDS patients have no pleocytosis India ink smear or Gram stain of the cerebrospinal fluid usually reveals budding, encapsulated fungal cells Cryptococcal capsular antigen in cerebrospinal fluid and culture together establish the diagnosis over 90% of the time Patients with AIDS often have the antigen in both cerebrospinal fluid and serum, and extrameningeal disease (lungs, blood, urinary tract) is common In patients with AIDS, the serum cryptococcal antigen is a sensitive screening test for meningitis, being positive in over 95% of cases CT or MRI scanning of the head should be performed if focal neurologic signs or papilledema are present to evaluate for mass lesions (eg, cryptococcoma) or hydrocephalus

p (t ) = v (t ) i (t ) = 2VI cos t cos ( t )

do not receive prophylaxis, recurrences are common (30% in AIDS)

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