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Azithromycin and measles, mumps, rubella (MMR) vaccine
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Azithromycin and pneumococcal vaccine
Trimethoprim-sulfamethoxazole and MMR vaccine
Trimethoprim-sulfamethoxazole and pneumococcal vaccine
Trimethoprim-sulfamethoxazole and live-attenuated zoster vaccine
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This patient with HIV and a CD4 cell count of <200 cells/mm^3 requires prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) and the pneumococcal vaccine.All patients with HIV and a CD4 cell count <200 cells/mm^3 require prophylaxis against Pneumocystis pneumonia with TMP-SMX. For those with CD4 cell counts <100 cells/mm^3, prophylaxis against toxoplasmosis using TMP-SMX is also indicated. In addition, all patients with HIV should initially receive the 13-valent pneumococcal vaccine, followed by the 23-valent pneumococcal vaccine (PPSV23) 8 weeks later, at 5 years later, and at the age of 65. It is preferable to give the PPSV23 vaccine when CD4 counts are at least 200 cells/mm^3. Patients with HIV should also receive the coronavirus disease-19 (COVID-19) vaccine, inactivated seasonal influenza vaccine, tetanus toxoid with acellular pertussis (TdaP), human papillomavirus (HPV) vaccination in patients less than 26 years of age, hepatitis A vaccine, hepatitis B vaccine, and meningococcal vaccination. Crane et al. review the optimal timing of routine vaccinations for HIV-infected persons. They note that the measles, mumps, and rubella (MMR) vaccine and the varicella are both live vaccines. Therefore, they recommend that these vaccines should be given only to susceptible adults with CD4 cell counts >200 cells/mm^3. Incorrect Answers:Answer 1: Azithromycin is given as prophylaxis against Mycobacterium avium complex (MAC) for patients with CD4 cell counts <50 cells/mm^3 and thus would not be indicated in this patient. Additionally, the MMR vaccine is a live vaccine and is contraindicated in a patient with a CD4 cell count <200 cells/mm^3. It would be worth investigating if the patient was previously vaccinated or if titers could be obtained to determine if he has evidence of immunity. Answer 2: Azithromycin is given as prophylaxis against MAC in patients with CD4 cell counts <50 cells/mm^3 and is not indicated for this patient.Answer 3: TMP-SMX should be given in this patient for prophylaxis against Pneumocystis pneumonia given the CD4 cell count <200 cells/mm^3, but the MMR vaccine is contraindicated in this immunocompromised patient as it is a live vaccine. It would be worth investigating if the patient was previously vaccinated or if titers could be obtained to determine if he has evidence of immunity. Answer 5: TMP-SMX should be given in this patient for prophylaxis against Pneumocystis pneumonia given the CD4 cell count <200 cells/mm^3. The live-attenuated zoster vaccine is contraindicated in this immunocompromised patient. However, the inactivated zoster vaccine can be given to patients greater than 50 years old regardless of CD4 cell count.Bullet Summary:In patients with HIV and a CD4 cell count <200 cells/mm^3, trimethoprim-sulfamethoxazole prophylaxis against Pneumocystis pneumonia and the pneumococcal vaccine are indicated.
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