Panel’s Recommendations
Preventing Exposure Ingestion of undercooked meats that could contain tissue cysts and contact with cat feces that could contain sporulated oocysts should be avoided (AIII).
Initiating Primary Prophylaxis Toxoplasma-seropositive children aged <6 years with CD4 T lymphocyte (CD4) cell percentage <15% and children aged ≥6 years with CD4 <100 cells/mm3 should be administered prophylaxis against Toxoplasma encephalitis (TE) (AIII). The preferred agent for prophylaxis of TE is trimethoprim-sulfamethoxazole, one double-strength tablet daily for adolescents and adults (or weight-equivalent dosing for children) (AII*). Primary preventive therapy can be discontinued once a child responds to combination antiretroviral therapy (cART) with a sustained rise in CD4 percentage above 15% for children <6 years of age, and >200 cells/mm3 for children aged ≥6 years (BIII). Most experts recommend treating pregnant women with acute toxoplasmosis in an attempt to prevent fetal infection (BII). For more extensive information on diagnosis, prevention, and treatment of pregnant women with toxoplasmosis, please see the Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. Empiric therapy should be strongly considered for newborns of HIV-infected mothers who had symptomatic or asymptomatic primary Toxoplasma infection during pregnancy, regardless of whether treatment was administered during pregnancy (BIII). The preferred treatment for congenital toxoplasmosis is pyrimethamine combined with sulfadiazine, with supplementary leucovorin (AII). The recommended duration of treatment of congenital toxoplasmosis in HIV-infected infants is 12 months (AIII). Therapy for acquired toxoplasmosis in HIV-infected children is sulfadiazine plus pyrimethamine and leucovorin (AI*). Corticosteroids are recommended for HIV-infected children with central nervous system toxoplasmosis when cerebrospinal fluid protein is highly elevated (i.e., >1,000 mg/dL) or who have focal lesions with substantial mass effect (BIII). Anticonvulsants should be administered only to children with TE who have a history of or current seizures (AIII). Complete blood count should be monitored weekly in patients taking daily pyrimethamine (AIII). Patients who have completed initial therapy for TE should be given suppressive therapy (i.e., secondary prophylaxis or chronic maintenance therapy) unless cART results in immune reconstitution (AI*). The preferred regimen for suppressive therapy for TE is sulfadiazine plus pyrimethamine and leucovorin (AI*).

Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials in children^† with clinical outcomes and/or validated endpoints; I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children^† from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children^† with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children^† from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = Expert opinion

^†Studies that include children or children/adolescents, but not studies limited to post-pubertal adolescents