Bacterial Respiratory Infections

Prevention of Exposure
(1) 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
(2) As soon as feasible after HIV infection is diagnosed, adults and adolescents who have a CD4+ T-lymphocyte count of >200 cells/uL should be administered a single dose of 23-valent polysaccharide pneumococcal vaccine if they have not had this vaccine during the previous 5 years (BII) (45, 46). For persons who have a CD4+ T-lymphocyte count of <200 cells/uL, vaccination can be offered, although the humoral response and, therefore, clinical efficacy are likely to be diminished (CIII). The recommendation to vaccinate is increasingly pertinent because of the increasing incidence of invasive infections with drug-resistant (including TMP-SMZ-resistant 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 a minority of HIV-infected persons. 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.

(3) The duration of the protective effect afforded by primary pneumococcal vaccination is unknown. Periodic revaccination may be considered; an interval of 5 years has been recommended for non-HIV-infected persons (47). In addition, revaccination one time should also be considered if the initial immunization was given when the CD4+ T-lymphocyte count was < 200 cells/uL and if the CD4+ T-lymphocyte count has increased to > 200 cells/uL on HAART. (CIII).

(4) 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 (DIII).

(5) TMP-SMZ, administered daily, reduces the frequency of bacterial respiratory infections; this should be considered in the selection of an agent for PCP prophylaxis (AII). However, indiscriminate use of this drug (when not indicated for PCP prophylaxis or other specific reasons) may promote the development of TMP-SMZ-resistant organisms. Thus, TMP-SMZ should not be prescribed solely to prevent bacterial respiratory infection (DIII). Similarly, clarithromycin administered daily and azithromycin administered weekly for MAC prophylaxis may be effective in preventing bacterial respiratory infections; this should be considered in the selection of an agent for prophylaxis of MAC disease (BII). However, these drugs should not be prescribed solely for preventing bacterial respiratory infection (DIII).

(6) An absolute neutrophil count that is depressed due to HIV disease or drug therapy is associated with an increased risk of bacterial infections, including pneumonia. Reversal of neutropenia, either by cessation of myelosuppressive drugs (CII) or use of granulocyte colony-stimulating factor (G-CSF) (CII) may be considered to reduce the risk of bacterial infections.

Prevention of Recurrence
(7) Some clinicians may administer antibiotic chemoprophylaxis to HIV-infected patients who have very frequent recurrences of serious bacterial respiratory infections (CIII). 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 solely for this purpose because of the potential for development of drug-resistant microorganisms and drug toxicity.

Notes

Pediatric Notes
(8) 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) (AII). Children aged >2 years also should be administered 23-valent polysaccharide pneumococcal vaccine (BII). Revaccination with pneumococcal vaccine generally should be offered after 3-5 years to children aged < 10 years and after 5 years to children aged >10 years (BIII).

(9) To prevent serious bacterial infections in HIV-infected children who have hypogammaglobulinemia (IgG < 400 mg/dl), clinicians should use intravenous immunoglobulin (IVIG) (AI). Respiratory syncytial virus (RSV) IVIG (750 mg/kg), not monoclonal RSV antibody, may be substituted for IVIG during the RSV season to provide broad anti-infective protection, if this product is available.

(10) To prevent recurrence of serious bacterial respiratory infections, antibiotic chemoprophylaxis should be considered (BI). However, providers should be cautious about use of antibiotics for this purpose because of the potential for development of drug-resistant microorganisms and drug toxicity. The administration of IVIG should also be considered for HIV-infected children who have recurrent serious bacterial infections (BI), although such treatment may not provide additional benefit to children who are being administered daily TMP-SMZ. However, IVIG may be considered for children who have recurrent serious bacterial infections despite receiving TMP-SMZ (CIII) or other antimicrobials.

Note Regarding Pregnancy
(11) Pneumococcal vaccination is recommended during pregnancy for patients who have not been vaccinated during the previous 5 years (BIII). 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 (CIII).

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