TROPICAL AND OTHER INFECTIONS

Scrub Typhus

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred Treatment	Alternative Treatment	Comments
Scrub Typhus Orientia tsutsugamushi
Uncomplicated	Doxycycline Child <45kg 2-4mg/kg/day PO q12h for 7 days Child> 45 kg use adult dose.	*Azithromycin 20mg/kg PO stat
Complicated (ARDS, septic shock, myocarditis, meningoencephalitis, hepatitis, renal failure)	*Azithromycin 10-15mg/kg/day q24h for 5 days	If not responding to Azithromycin: Rifampicin 10-15mg/kg q24h for 5 days	*Recommend for early IV to Oral switch once symptoms improve or stable.

Brucellosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred Treatment	Alternative Treatment	Comments
Brucellosis *Brucella melitensis, Brucella abortus, Brucella suis, Brucella canis*
Non focal disease	Doxycycline 2-4mg/kg/day PO q12h for 6 weeks PLUS Gentamicin 5mg/kg/24h IV for 7 days	Doxycycline 2-4mg/kg/day PO q12h for 6 weeks PLUS Rifampicin 600-900mg max (15mg/kg) PO q24h for 6 weeks
Spondylitis/Sacroiliitis	Doxycycline 2-4mg/kg/day PO q12h for ≥ 12 weeks PLUS Gentamicin 5mg/kg/24h IV for 7 days PLUS Rifampicin 15mg/kg PO q24h for ≥ 12 weeks
Neurobrucellosis	Doxycycline 2-4mg/kg/day PO q12h* PLUS Rifampicin 15mg/kg PO q24h* PLUS Ceftriaxone 100mg/kg/day IV q12h**		At least 6 weeks * Until CSF returns to normal.
Endocarditis	Rifampicin 15mg/kg q24h for 5 days PLUS Doxycycline 2-4mg/kg/day q12h (for child >8yr old) PLUS Trimethoprim-sulfamethoxazole 8mg/kg/day of TMP PO q12h PLUS Gentamicin 5mg/kg/24h IV for 2-4 weeks		Duration: 45 days to 6 months. Surgery Needed.
Pregnancy*	Rifampicin 600-900mg (15 mg/kg) PO q24h for 6 weeks	Rifampicin 600-900mg (15 mg/kg) PO q24h for 4 weeks PLUS Trimethoprim-sulfamethoxazole 8-10mg/kg (of trimethoprim) in 2-4 divided doses for 4 weeks	*Not much data.

Leptospirosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred Treatment	Alternative Treatment	Comments
LEPTOSPIROSIS Leptospira spp.
Mild to Moderate disease	Doxycycline 100mg PO q12h for 5-7 days	Azithromycin 10mg/kg/day stat on D1 followed by 5mg/kg/day for total of 5 days
Severe disease (Leptospiral pulmonary syndrome, multiorgan involvement, sepsis)	Ceftriaxone 75-100 mg/kg/day q24h for 7 days (to deescalate to Benzylpenicillin once symptoms improve/stable) OR Benzylpenicillin 25-50 mg/kg/dose q6h for 7 days		May consider Methylprednisolone 500-1000 mg IV for 3 days if pulmonary hemorrhage present. However, there is insufficient evidence to support the routine use corticosteroid.

Tetanus

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Causative organism Clostridium tetani

Metronidazole 10mg/kg/dose q6-8h for 7-10 days

PLUS

Human Tetanus Immunoglobulin 3000-6000IU IM stat

PLUS

Anti-tetanus toxoid vaccine IM (initiate age-appropriate active immunization at a different site)

Benzylpenicillin 25-50 mg/kg/dose q6h for 7 days

PLUS

Human Tetanus Immunoglobulin 3000-6000IU IM stat

PLUS

Anti-toxoid vaccine IM (initiate age-appropriate active immunization at a different site)

Human Tetanus Immunoglobulin 500IU might be as effective as higher doses of 3,000 to 6,000IU and causes less discomfort.

All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue.

Melioidosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred Treatment	Alternative Treatment	Comments
Melioidosis *Bukholderia pseudomallei*
Intensive Therapy (Uncomplicated)	Ceftazidime 100-120mg/kg/24h IV q6-8h (in children) Adults: 2gm IV q6h for 10-14 days PLUS *Trimethoprim-sulfamethoxazole (Dose as per eradication therapy below)		*Add on Trimethoprim-sulfamethoxazole in eye, neurologic, testicular, prostatic, pericardium, bone and joint melioidosis. Drainage of abscesses should be attempted wherever appropriate such as pericardial and prostatic abscess, and empyema. Duration of intensive therapy: Skin, bacteraemia with no foci, mild pneumonia: 2 weeks Complicated pneumonia, prostatic, deep-seated foci, septic arthritis: 4 weeks Osteomyelitis: 6 weeks Neurologic/CNS: 8 weeks To use clinical judgement to guide prolongation of intensive phase if improvement is slow/ persistent bacteraemia
Intensive Therapy (Complicated) (Severe melioidosis or neuromelioidosis)	Meropenem 75mg/kg/24h IV q8h if neurologic, 120mg/kg/day q8h OR Imipenem 50mg/kg/24h IV q6h PLUS *Trimethoprim-sulfamethoxazole (Dose as per eradication therapy below)
Eradication/Maintenance Therapy	Trimethoprim-sulfamethoxazole 8-10mg/kg (of trimethoprim) in 2-4 divided doses for 4 weeks	Amoxicillin-clavulanate 35-50mg/kg/day in 2-3 divided doses	Duration of eradication therapy: Osteomyelitis, Neurologic/CNS: 24 weeks Others: minimum 12 weeks

Malaria

Refer to National Guidelines

Opportunistic Infections In HIV Patients

Infection/Condition and Likely Organism	Treatment		Comments
	Preferred therapy	Alternative therapy
OPPORTUNISTIC INFECTIONS IN HIV PATIENTS
Various co-infections, comorbidities and other health conditions are common among PLHIV. Opportunistic infections (OI) are defined as infections that are more frequent or more severe because of immunosuppression in HIV-infected patients. These are the most important cause of morbidity and mortality in this population. Cotrimoxazole Prevention Therapy (CPT): CPT is a cost-effective intervention effective against following infections in HIV positive patients: n Common bacterial infections, including bacterial pneumonia, septicaemia. Diarrhoea, including that caused by Cystoisospora belli. Malaria. Toxoplasmosis. Pneumocystis pneumonia (PCP, primary or recurrent). CPT for children should be started for: age 6wk -1 year with any CD4 count 1-2 year <750 CD4 count 2-5yr <500 CD4 count >5yr <200 CD4 count All with severe and advanced HIV disease (WHO stage 3 or 4) All aged 6 weeks and born to HIV infected mothers till HIV is ruled out. The regimen is: 150 mg TMP/m²/day PO divided q12hr for 3 days a week or alternate days or daily. Continuation of CPT should be as follow: Lifelong (irrespective of CD4 count) if client is not in ART CPT must be discontinued in the following situation Severe cutaneous reaction, such as Steven-Johnson syndrome, renal and /or hepatic failure and severe hematological toxicity. Timing of CPT: Cotrimoxazole and ART should not be started at the same time. Cotrimoxazole should be started and after 2 weeks ART should be initiated if the individual is stable on Cotrimoxazole and has no rash. Alternative to Cotrimoxazole: In patients intolerant to Cotrimoxazole, Dapsone 100 mg once daily is the first alternative medicine.

Tuberculosis

Infection/Condition and Likely Organism	Treatment		Comments
	Preferred therapy	Alternative therapy
Tuberculosis
Among PLHIV, TB is the most frequent life-threatening OIs and a leading cause of death accounting for about a third of all mortality. ART should be provided to all PLHIV with active TB disease. HIV care setting should implement WHO Three I’s strategy: Intensified TB case-finding. Isoniazid Preventive Therapy (IPT). Infection control at all clinical encounters. Isoniazid Preventive Therapy (IPT) Preventive therapy against TB is the use of anti-TB drugs in individuals with latent Mycobacterium tuberculosis infection regardless of CD4 cell count or ART status in order to prevent progression to active tuberculosis. IPT should only be used in patients whom active tuberculosis has been excluded, active patient follow-up is possible and highlevel adherence can be attained and should be provided for 6 months. Cotrimoxazole and ART should not be started at the same time as IPT. Regimen: Isoniazid 300 mg daily for 6 months. Vitamin B6 25 mg/day (pyridoxine) should be given together with IPT for 6 months. TB management among PLHIV: All HIV-infected patients with diagnosis of active TB should be put on TB treatment immediately. ATT regimen is same for PLHIV as for non-HIV patients. ART should be started in all TB patients, including those with drug resistant TB, irrespective of CD4 count. Anti-tubercular treatment should be initiated first, followed by ART as soon as possible within the first 8 weeks of treatment (2 weeks, if CD4 <50 cells). In all HIV-infected pregnant women with active TB, ART should be started as early as feasible, both for maternal health and for elimination of vertical transmission of HIV. (For ART dug choice in TB co-infection refer to National HIV Testing and Treatment guideline 2020)

Cryptococcal Infection

Infection/Condition and Likely Organism	Treatment		Comments
Infection/Condition and Likely Organism	Preferred therapy	Alternative therapy	Comments
Causative organism Cryptococcus neoformans
The incidence of cryptococcal meningitis increases as the CD4 count falls below 100 cells/ml and most cases occur when CD4 count falls below 50 cells/ml. Mostly they present as sub-acute meningitis or meningoencephalitis with the following symptoms: Fever. Malaise. Headache. Neck stiffness and photophobia (i.e. meningeal symptoms in 25-30%). Altered mental status/confusion, personality changes, memory loss. Impaired consciousness and coma. Focal signs, including cranial nerve palsy.
Induction phase	Cryptococcal meningitis, non CNS extrapulmonary cryptococcosis and diffuse pulmonary disease Amphotericin B IV (0.7-1mg/kg/day) PLUS Flucytosine PO 25 mg/kg q6h Non CNS cryptococcosis with mild to moderate symptoms or focal pulmonary cryptococcosis: Fluconazole: 6-12 mg/kg q24h IV or PO	In decreasing order of efficacy Preferred alternative: Amphotericin B IV 0.7-1 mg/kg/day PLUS Fluconazole 6-12 mg/kg q24h IV or PO Option 2 (less efficient) 5FC (Flucytosine)25 mg/kg q6h PLUS Fluconazole 6-12 mg/kg q24h IV or PO Option 3 (Least efficient) Fluconazole 1200 mg/day	Amphotericin B therapy should be administered in qualified health facilities capable of close clinical and laboratory monitoring. Dosage of Amphotericin B and Flucytosine should be adjusted to creatinine clearance rate. Opening CSF pressure should always be measured at initiation of treatment and when lumbar puncture is performed. Repeat LPs are essential to effectively manage raised intracranial pressure. Corticosteroids and mannitol are ineffective to decrease intracranial pressure in Cryptococcus meningitis.
Consolidation phase 8 week Followed by maintenance phase	Fluconazole 6-12 mg/kg q24h IV or PO	If induction phase with Fluconazole 1200 mg/day: Consolidation with Fluconazole 800 mg/day
Maintenance Phase At least 12 months: Fluconazole can be stopped in patients who have been on ART and have CD4 consistently above100 cells/ mm³for at least 6 months. If there is fall in CD4 count, Fluconazole should be restarted again	Fluconazole 6-12mg/kg/ day

Pneumocystis jiroveci

Infection/Condition and Likely Organism	Treatment		Comments
	Preferred therapy	Alternative therapy
*Pneumocystis jiroveci (carinii) interstitial pneumonia (PJP/PCP)**
Treatment	Trimethoprim-sulfamethoxazole 15-20mg/kg/day [TMP component] IV/PO in 3-4 divided doses	For mild to moderate cases: (PO₂ 70-80mmHg) Clindamycin 10-40mg/kg/day in 3 divided doses PLUS Primaquine 0.25mg/kg/day q24h OR Dapsone 1-2 mg/kg/day q24h PLUS Trimethoprim 15 mg/kg/ day PO in 3-4 divided doses For severe cases: (PO₂ < 70mmHg) Pentamidine 4mg/kg/day IV (in 1 pint D5% or NS run over 1-2 hours) OR Clindamycin 10-40mg/kg/day in 3 divided doses PLUS Primaquine 0.25mg/kg/day q24h	Duration 21 days Patients with severe disease should receive corticosteroids as soon as possible (within 72 hours of starting PCP treatment): Prednisolone dose: 40 mg PO q12h for 5 days, then 40mg PO q24h for 5 days, then 20 mg PO q24h for 11 days (Total duration is 21 days) Trimethoprim-sulfamethoxazole and Clindamycin has excellent bioavailability, and may switch to PO after clinical improvement. Patients given dapsone or primaquine should be tested for G6PD deficiency.

Prophylaxis (Primary and secondary) Indications: CD4 count <200 cells/µl CD4 count 200-250 Cells/µl if ART cannot be initiated	Trimethoprim-sulfamethoxazole 20-50mg/kg/day in 2 or 3 divided doses for 7-14 days	Dapsone 1-2 mg/kg/day q24h OR Aerosolized Pentamidine 4mg/kg/dose monthly via ultrasonic nebulizer	Discontinuation: Can consider when CD4 100-200 cells/µL if HIV RNA is suppressed for 3-6 months with ART. Restarting prophylaxis: CD4 count falls to <200 cells/µL or PCP occurs at a CD4 > 200 cells/µL (lifelong prophylaxis should be considered). Patients receiving Sulfadiazine-Pyrimethamine or Sulfadoxine-Pyrimethamine for treatment or suppression of toxoplasmosis do not require additional prophylaxis for PCP.

Toxoplasma gondii Encephalitis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred	Alternative	Comments
Acute Infection (up to 97% patients are Toxo IgG +ve)	Trimethoprim-sulfamethoxazole 10mg/ kg/day (TMP component) IV/PO in 2 divided doses	Pyrimethamine: 2 mg/kg loading dose for 2 days followed by 1mg/kg/ day for 4 weeks PLUS Folinic acid 10-25 mg IV/PO q24h PLUS Clindamycin 10-40mg/kg/day in 3 divided doses OR *Sulfadiazine 100-200mg/ kg/day in 4 divided doses	Duration: At least 6 weeks Adjunctive corticosteroids (E.g. dexamethasone) should be administered when clinically indicated to treat mass effect associated with focal lesions or associated oedema but should be discontinued as soon as clinically feasible. *Pyrimethamine and (Sulfadoxine- Pyrimethamine) can be used interchangeably depending on availability;
Suppressive/Maintenance	Trimethoprim-sulfamethoxazole 8-10 mg/kg (of trimethoprim) in 2-4 divided doses for 4 weeks	Dapsone 1-2 mg/kg/day q24h OR Clindamycin 10-40mg/kg/day in 4 divided doses PLUS Pyrimethamine 2 mg/kg loading dose for 2 days followed by 1 mg/kg daily for 4 weeks PLUS Folinic acid 10-25 mg PO twice-weekly OR Sulfadiazine 0.5-1 gm PO q6h PLUS Pyrimethamine 25-50 mg PO q24h PLUS Folinic acid 10-25 mg PO q24h	Discontinuation: Consider when CD4>200 cells/µL if HIV RNA is suppressed for 6 months with ART.
Primary Prophylaxis Indications: Toxoplasma IgG +ve with CD4<100	Trimethoprim-sulfamethoxazole 8-10 mg/kg (of trimethoprim) in 2-4 divided doses for 4 weeks	Dapsone 1-2mg/kg/day PLUS Pyrimethamine 50 mg PO once weekly PLUS Folinic acid 25 mg PO once weekly OR Dapsone 200 mg PO once weekly PLUS Pyrimethamine 75 mg PO once weekly PLUS Folinic Acid 25 mg PO once weekly	Discontinuation: CD4>200 cells/µL for > 3 months. CD4>100 cells/µL, if HIV viral load suppressed for 3 to 6 months.

Mucocutaneous Candidiasis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred	Alternative	Comments
Oropharyngeal (oral thrush)	Nystatin suspension 500,000units PO 4-5 times daily OR *Itraconazole Oral Clotrimazole mouth paint locally twice daily for 5-7 days	Fluconazole 6 mg/kg loading dose followed by 3 mg/kg q24h for 7-10 days	Duration: 7-14 days. Chronic suppressive therapy is usually not recommended. *Itraconazole: Absorption depends on gut acidity. Take a capsule with food and acidic beverages (e.g.: Cola drinks). Avoid PPIs and H2 blockers. Significant drug-drug interaction with p450 enzyme inducers (e.g.: Rifampicin). Consider fluconazole if in doubt.
Oesophageal	Itraconazole 3-5 mg/kg q24h	Fluconazole 6 mg/kg loading dose followed by 3 mg/kg q24h for 7-10 days OR Amphotericin B deoxycholate 0.6mg/kg IV q24h	Duration: 14-21 days. Candidiasis is the most common cause of oesophagitis with HIV infection, but CMV, HSV and aphthous ulcerations can present with similar complaints. Endoscopy required with unusual presentations or lack of response to azole within several days.

Histoplasmosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred	Alternative	Comments
Moderate to severe disseminated disease or CNS involvement	Induction therapy *Amphotericin B deoxycholate 0.7-1.0mg/kg IV q24h for at least 2 weeks Followed by Maintenance therapy Itraconazole 200 mg PO q8h for 3 days, then 200 mg q12h for at least 12 months		*The lipid formulations of amphotericin B may be used instead if available. All the triazole antifungals have the potential to interact with certain ARV agents and other antiinfective agents.
Mild disseminated disease (Blood culture positive but patient is asymptomatic)	Induction and maintenance therapy *Itraconazole 3-5 mg/kg q24h	For patients intolerant to Itraconazole: Fluconazole 6 mg/kg loading dose followed by 3 mg/kg q24h for 7-10 days OR Voriconazole 400 mg PO q12h on day 1, then 200 mg PO q12h	Duration: At least 12 months *Itraconazole: Absorption depends on gut acidity. Take a capsule with food and acidic beverages (e.g.: Cola drinks). Avoid PPIs and H2 blockers.
Chronic Suppressive therapy (Secondary prophylaxis) Indication: Severe disseminated or CNS infection after completion of at least 12 months of treatment Relapsed despite appropriate initial therapy	*Itraconazole 3-5 mg/kg q24h	Fluconazole 6 mg/kg loading dose followed by 3 mg/kg q24h for 7-10 days	Discontinuation: Received azole for > 1 year, AND Negative fungal blood cultures, AND CD4 count > 150 cells/µL for ≥6 months on ART Restarting secondary prophylaxis: CD4 count < 150 cells/µL *Itraconazole: Absorption depends on gut acidity. Take a capsule with food and acidic beverages (e.g. Cola drinks). Avoid PPIs and H2 blockers.

Penicilliosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred	Alternative	Comments
Acute infection (Severely-ill patients)	Induction therapy *Amphotericin B deoxycholate 0.6-0.7mg/kg IV for 2 weeks Must be followed by consolidation therapy	Voriconazole 6 mg/kg IV q12h on day 1, then 200 mg PO q12h for at least 3 days Must be followed by consolidation therapy.	The lipid formulations of amphotericin B may be used instead If available. All the triazole antifungals have the potential to interact with certain ARV agents and other anti-infective agents. *Itraconazole: Absorption depends on gut acidity: Capsule: Take with food and acidic beverage (e.g.: cola drinks). Liquid preparation: Take on empty stomach. Avoid PPIs and H2 blockers.
Acute infection (Severely-ill patients)	Consolidation therapy **Itraconazole 3-5mg/kg/ day PO q12h for 10 weeks Must be followed by maintenance therapy	Fluconazole 6 mg/kg loading dose followed by 3 mg/kg q24h for 10 weeks Must be followed by maintenance therapy
Acute infection (Mild disease)	**Itraconazole 3-5mg/kg/ day for at least 8-12 weeks Must be followed by maintenance therapy	Fluconazole 6 mg/kg loading dose followed by 3 mg/kg q24h for at least 8-12 weeks Must be followed by maintenance therapy	**Itraconazole: Absorption depends on gut acidity: Capsule: Take with food and acidic beverage (e.g.: cola drinks). Liquid preparation: Take on empty stomach. Avoid PPIs and H2 blockers.
Maintenance therapy/ Secondary prophylaxis	**Itraconazole 3-5mg/kg/ day	Fluconazole 6 mg/kg loading dose followed by 3 mg/kg q24h	Discontinuation: CD4 count>100 cells/µL for ≥6 months on ART.

Mycobacterium Avium Complex (MAC) Disease

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred	Alternative	Comments
Treatment	Clarithromycin 15mg/kg/day in 2 divided doses PLUS Ethambutol 15 mg/kg PO q24h **PLUS 3^rd/4^th drug: Amikacin 10-15mg/kg IV q24h OR Streptomycin 15 mg/kg IM q24h OR Levofloxacin 500 mg PO q24h OR Ciprofloxacin 500-750 mg PO q12h	Azithromycin 20mg/kg q24hr PLUS Ethambutol 15 mg/kg PO q24h *PLUS 3^rd/4^th drug: Amikacin 10-15mg/kg IV q24h OR Streptomycin 15 mg/kg IM q24h OR Levofloxacin 500 mg PO q24h OR Ciprofloxacin 500-750 mg PO q12h	Duration: At least 12 months. * Azithromycin: use if drug interaction or intolerance precludes the use of Clarithromycin. **Addition of 3^rd/4^th drug should be considered for patients with disseminated disease, CD4 count <50 cells/µL or in the absence of effective ART. Discontinuation: Consider if the patient is on ART and viral load is suppressed, CD4 > 100 cells/µL >6 months, asymptomatic or MAC, and has completed > 12 months of therapy.
Maintenance/ Secondary Prophylaxis	Same as the treatment regimen		Restarting secondary prophylaxis: CD4 < 100 cells/µL again.
Primary Prophylaxis Indications: CD4 < 750 cells/µL in<1yr CD4<500 cells/µL1-2yr CD4<75 cells/µL2-6 yr CD4<50 cells/µL>6yr or previous infection. Ruled out active MAC and TB	Azithromycin 20 mg/kg PO once weekly	Clarithromycin 15mg/kg/ day PO q12h	Discontinuation: Consider if patient is on ART AND Viral load is suppressed, CD4 > 100 cells/µL ≥ 3 months

Cytomegalovirus (CMV) Disease

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred	Alternative	Comments
Cytomegalovirus (CMV) Disease
Treatment (CMV Retinitis) (Immediate Sight Threatening Lesions Adjacent to the Optic Nerve or Fovea)	Intravitreal injections of Ganciclovir (2mg/injection) biweekly until scarring PLUS Ganciclovir 5 mg/kg IV q12h OR Valganciclovir 14-16 mg/kg/dose q12h Followed by maintenance	Intravitreal injections of Foscarnet (2mg/injection) biweekly until scarring PLUS Ganciclovir 5 mg/kg IV q12h OR Valganciclovir 14-16 mg/ kg/dose PO q12h Followed by maintenance	Duration: 14-21 days Immune recovery is essential for successful treatment. Start ART within 2 weeks if possible
Treatment (CMV Retinitis) (For Small Peripheral Lesions)	Ganciclovir 5mg/kg IV q12h Followed by maintenance	Valganciclovir 14-16 mg/ kg/dose PO q12h Followed by maintenance
Treatment (Extraocular CMV disease) (Oesophagitis, colitis, interstitial pneumonitis, neurological disease)	Ganciclovir 5mg/kg IV q12h Followed by maintenance	May consider switch to Valganciclovir 14-16mg/kg/ dose PO q12h once patient tolerate orally (in CMV oesophagitis and colitis only) Followed by maintenance	Duration: 21-42 days or until signs and symptoms have been resolved. Immune recovery is essential for successful treatment. Start ART within 2 weeks if possible.
Maintenance/ Secondary prophylaxis (CD3 <100 cells/µL)	Ganciclovir 5mg/kg IV q24h 5-7 times weekly	Valganciclovir 14-16 mg/ kg/dose PO q12h	Discontinuation: Consider if the patient is on ART and viral load well suppressed, CD4 > 100 cells/µL ≥ 3 months after 3-6 months of CMV treatment. Maintenance therapy is generally not necessary; ART offers best hope for prevention of relapses.

Herpes Simplex Virus (HSV) Infections

Refer to other sections - Oral infection, CNS infection and National STI guidelines

Varicella-Zoster Virus (VZV Diseases)

Refer to Skin and Soft Tissue Infection

Bacterial Enteric Infections

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Salmonellosis

Salmonella non-typhi

Ampicillin 100-200mg/kg/ day IV q4-6h

OR

Trimethoprim-sulfamethoxazole 20-50mg/kg/day in 2 or 3 divided doses for 7-14 days

Ciprofloxacin 20 mg/kg/day for 7 days OR

Ceftriaxone 75 mg/kg/day q24h for 7 days

Susceptibility profile may help guide final choice.

Duration:

IF CD4≥200: 7-14 days. If CD4<200 and with bacteraemia: 6 weeks.

Longer course with debridement and drainage needed for persistent bacteraemia or metastatic disease.

PML (Progressive Multifocal Leukoencephalopathy)

Infection/Condition and Likely Organism	Suggested Treatment		Comments
	Preferred	Alternative
Polyomavirus JC virus (JCV)	No effective therapy exists		With ART, some patients improve and others stabilize. Few may deteriorate due to immune reconstitution.

Isospora belli Infection

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Initial Therapy

Trimethoprim-sulfamethoxazole 15-20 mg/kg/day of TMP in 2 or 3 divided doses for 7-14 days

Pyrimethamine 50-75 mg PO q24h

PLUS

Folinic acid 10-25 mg PO q24h

OR

Ciprofloxacin 20mg/kg/day for 7 days

Duration: 10 Days.

Cryptosporidiosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
	Preferred	Alternative
Cryptosporidium spp.	Symptomatic treatment of diarrhea		Effective ART (to increase CD4 > 100 cells/µL) can result in complete, sustained clinical, microbiological and histologic resolution.

Microsporidiosis

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Microsporidium spp.

Albendazole 10-15mg/kg/ day PO q12h for 2-4 weeks

PLUS

Symptomatic treatment of diarrhea (The best treatment option is ART and fluid support)

Effective ART (to increase CD4 > 100 cells/µL) can result in complete, sustained clinical, microbiological and histologic resolution.

Syphilis (Treponema pallidum Infection)

Refer to National STI guidelines

Bartonellosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
	Preferred	Alternative
For Bacillary Angiomatosis, Peliosis hepatis, Bacteraemia, and Osteomyelitis	Doxycycline 4 mg/kg stat OR Erythromycin 30-50mg/kg/ day PO/IV q6h 30-50mg/kg/day in 3-4 divided doses	Azithromycin 10mg/kg/ day stat on D1 followed by 5mg/kg/day for total of 5 days OR Clarithromycin 15mg/kg/ day in 2 divided doses	Duration: At least 3 months. If relapse occurs after initial (>3 month) Course of therapy, long-term suppression with Doxycycline or a macrolide is recommended as long as CD4 < 200 cells/µL.
Other Severe Infection (or CNS involvement)	Doxycycline 4mg/kg stat PLUS* Rifampicin 10-15mg/kg q24h for 5 days OR Erythromycin 60-100mg/ kg/day PO/IV q6h PLUS Rifampicin 10-15mg/kg q24h for 5 days