Routine screening of respiratory or gastrointestinal specimens for Mycobacterium avium complex (MAC) microorganisms is not recommended (BIII), but a blood culture for MAC should be obtained to rule out disseminated disease before initiating prophylaxis (AIII). -
Prophylaxis with either clarithromycin or azithromycin should be offered to HIV-infected children who have advanced immunosuppression (AII).
Children aged <1 year: <750 cells/mm3. Children aged 1 to <2 years: <500 cells/mm3. Children aged 2 to <6 years: <75 cells/mm3. Children aged ≥6 years: <50 cells/mm3
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Discontinuing Primary Prophylaxis: Primary prophylaxis can be discontinued in HIV-infected children aged ≥2 years receiving stable combination antiretroviral therapy (cART) for ≥6 months and experiencing sustained (>3 months) CD4 T lymphocyte (CD4) cell count recovery well above the age-specific target for initiation of prophylaxis (i.e., as in adults, >100 cells/mm3 for children aged ≥6 years (AI); and >200 cells/mm3 for children aged 2 to <6 years) (BII*).
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Treating Disease:
Testing of MAC isolates for susceptibility to clarithromycin or azithromycin is recommended (BIII). Combination therapy with a minimum of two drugs (e.g., clarithromycin or azithromycin plus ethambutol) is recommended to prevent or delay the emergence of resistance (AI*). Some experts use clarithromycin as the preferred first agent (AI*), reserving azithromycin for patients with substantial intolerance to clarithromycin or when drug interactions with clarithromycin are a concern (AII*). Use of rifabutin as a third drug added to the macrolide/ethambutol regimen is controversial. Some experts would add rifabutin as a third drug to the clarithromycin/ethambutol regimen, particularly in the absence of cART and in the presence of high mycobacterial counts (CIII); however, drug interactions should be checked carefully, and more intensive toxicity monitoring may be warranted with such combination therapy (AIII). Other experts recommend against using this third agent in children because of rifabutin’s increased cytochrome P450 activity, which leads to increased clearance of other drugs such as protease inhibitors and non-nucleoside reverse transcriptase inhibitors, and the potential for increased toxicity associated with concomitant administration of drugs (CIII). Treatment failure is defined as the absence of clinical response and the persistence of mycobacteremia after 8 to 12 weeks of treatment. Repeat susceptibility testing of MAC isolates is recommended in this situation, and a new multidrug regimen of two or more drugs not previously used and to which the isolate is susceptible should be administered (AIII). Drugs that should be considered for this scenario include rifabutin, amikacin, and a quinolone.
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Secondary Prophylaxis:
Children with a history of disseminated MAC and continued immunosuppression should receive lifelong prophylaxis to prevent recurrence (AII*). Secondary prophylaxis typically consists of continued multidrug therapy used in treatment of disease. -
Some experts recommend discontinuation of therapy in HIV-infected children who meet all of the following criteria:
Aged ≥2 years and have completed ≥12 months of treatment for MAC; Remain asymptomatic for MAC; Receiving stable cART (i.e., cART not requiring change for virologic or immunologic failure); Have sustained (≥6 months) CD4 count recovery well above the age-specific target for initiation of primary prophylaxis (i.e., as in adults, >100 cells/mm3 for children aged ≥ 6 years (AII*) and >200 cells/mm3 for children aged 2 to <6 years) (CIII).
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