February 1997
Previous guidelines recommended by the Centers for Disease Control and Prevention for Pneumocystis carinii pneumonia (PCP) prophylaxis in HIV-infected children, which were based on CD4 thresholds in the first year of life, were found to be unreliable predictors of which children with HIV were at risk, so new guidelines were adopted, according to George McSherry, MD.
"What was recommended was to go to across-the-board prophylaxis where all infants born to HIV-infected mothers would get prophylaxis, beginning at between 4 weeks and 6 weeks of age and out to about 4 months of age, during which time you would hopefully be doing HIV-specific diagnostic work-up, including PCR and/or culture," said McSherry, section chief of pediatric infectious diseases in the division of allergy, immunology and infectious disease at the Children's Hospital of New Jersey in Newark.
With older infants, where the infection status is undetermined, prophylaxis is recommended until infection is reasonably excluded by two negative HIV tests, one at 1 month of age and the other at 4 months of age or older. For infants older than 6 months of age, two negative immunoglobulin G antibody tests and no clinical evidence of HIV are required. For children older than 1 year, prophylaxis is based on CD4 thresholds.
Prophylactic medications for PCP include trimethoprim-sulfamethoxazole, dapsone (primarily in children), and IV pentamidine. In addition, atovaquone, which does not have a track record as a prophylactic agent, has been used anecdotally with good success, McSherry reported.
For CMV prevention, oral acycylovir has proven successful in transplant patients, while oral ganciclovir is available for adults and may hold some promise for children, he said.
Immunizations can also play an important role in effective prevention. "Haemophilus influenzae type b immunizations have decreased the amount of immunocompromised patients that we see with Hib disease. There are currently pneumococcal conjugate vaccines in trial that may reduce the numbers and amounts of pneumococcal disease that we see," McSherry said.
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