Patient handout

Opportunistic infection overlay — HIV / transplant / biologic immunocompromise

PRODUCTION

1. Your condition

This handout is for opportunistic infection overlay — hiv / transplant / biologic immunocompromise. Your care team identified this based on: cd4 < 200 cells/mm³ in hiv+ host — initiate pcp / toxo prophylaxis (dhhs 2024 oi; idsa 2024).

Other reasons your team may use this plan: solid-organ transplant recipient on calcineurin / mtor / steroid immunosuppression (ast idcop 2019/2024); hsct recipient — pre-engraftment neutropenia + post-engraftment gvhd on steroids (asbmt/idsa 2009; ecil series); b-cell-depleting agent (rituximab / ocrelizumab / natalizumab / tnf-α inhibitor) or chronic ≥ 20 mg pred ≥ 4 wk (idsa 2024; ast idcop 2024).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
trimethoprim-sulfamethoxazole	1 SS PO daily OR 1 DS PO 3×/wk (PCP); 1 DS PO daily (PCP + toxo if Toxo-IgG+ and CD4 < 100)	PO	daily or 3×/wk	DHHS 2024 OI — TMP-SMX is PCP prophylaxis of choice; also covers Toxoplasma at CD4 < 100; covers nocardia + Listeria in transplant (AST IDCOP 2024)
azithromycin	1200 mg PO weekly	PO	weekly	DHHS 2024 OI — MAC prophylaxis at CD4 < 50; discontinue when CD4 > 100 × 3 mo + VL suppressed
valganciclovir	900 mg PO daily × 100-200 days post-transplant (CMV D+/R- or R+ high-risk)	PO	daily	AST IDCOP 2024 — universal CMV prophylaxis in D+/R- and R+ high-risk SOT × 100-200 days; pre-emptive monitoring is alternative strategy (AST IDCOP 2024 Razonable)
letermovir	480 mg PO/IV daily × 100 days post-HSCT (or 240 mg if cyclosporine concomitant)	PO/IV	daily	Marty NEJM 2017 PMID 29211658 — letermovir reduced clinically-significant CMV infection 38% vs placebo through week 24 post-HSCT; FDA-approved 2017 for CMV prophylaxis in CMV-seropositive HSCT recipients
isoniazid	300 mg PO daily × 9 mo (or alternates: 4 mo rifampin; 3 mo INH-rifapentine weekly DOT)	PO	daily	DHHS 2024 OI — LTBI treatment regardless of CD4; WHO 2024; AST IDCOP 2024 pre-transplant LTBI mandatory
posaconazole	300 mg PO daily (DR tablet; after 300 mg BID × 1 day load)	PO	daily	ECIL-6 2017 — posaconazole reduced invasive fungal infections in high-risk HSCT GVHD and AML induction; preferred over fluconazole for mold coverage (Cornely NEJM 2007; Ullmann NEJM 2007)

Plan: OI prophylaxis by host substrate + CD4 / immunosuppression (DHHS 2024 OI; AST IDCOP 2024)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — On prophylaxis + asymptomatic

If you have:

Taking all prophylaxis medications daily as prescribed
No new fever, cough, headache, vision change, focal weakness, or rash
Vaccinations up to date per ACIP
Surveillance labs scheduled

Do this:

Take prophylaxis every day at the same time
Avoid live vaccines if on transplant IS or CD4 < 200
Avoid raw / undercooked meat (toxoplasmosis), unwashed produce, unpasteurised dairy (Listeria)
Use HEPA filter at home if severely immunocompromised
Have HIV-negative household member clean cat litter; avoid reptiles
Keep all surveillance appointments

YELLOW — New mild symptoms or surveillance abnormality

If you have:

Mild fever < 38.5 °C for < 24 hours
New dry cough without dyspnea
Mild headache without neck stiffness or focal deficit
Mild diarrhea without dehydration
Surveillance CMV / EBV / BK PCR rising at routine check

Do this:

Continue prophylaxis
Call your provider within 24 hours
Hydrate; monitor temperature 3×/day
Avoid OTC NSAIDs (renal risk in transplant)
Do NOT start new antibiotics or antivirals without your transplant / ID team

Call your provider if:

Fever ≥ 38.5 °C
Symptoms worsen or persist > 48 hours
New medication started by another provider

RED — Severe symptoms — go to ED immediately

If you have:

Severe dyspnea / hypoxia (cannot finish a sentence)
Severe headache + fever + neck stiffness or photophobia (cryptococcal)
Sudden vision change / floaters (CMV retinitis)
New focal neuro deficit (toxoplasmosis, PML, cryptococcoma)
Confusion / seizure
Sustained fever ≥ 38.5 °C > 24 hours
New severe rash with fever (DRESS, abacavir HSR)

Do this:

Go to ED immediately
Bring all medications + transplant card + ID specialist contact
Tell ED you are immunocompromised, your CD4 (if HIV+), your transplant type + date, your current IS regimen, and your prophylaxis history

Call your provider if:

Always seek emergency care for these symptoms

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Pneumocystis jirovecii pneumonia with PaO2 < 70 mmHg or A-a gradient > 35 mmHg (Bozzette NEJM 1990 criteria) — severe PCP(life-threatening)
Cryptococcal meningitis with opening pressure ≥ 250 mmH2O OR AMS / focal deficit / hydrocephalus on imaging (IDSA 2010 Perfect)(life-threatening)
CMV tissue-invasive disease — retinitis (visual symptoms + dilated fundus) OR pneumonitis (respiratory failure + biopsy / BAL) OR encephalitis OR colitis (DHHS 2024 OI; AST IDCOP 2024)
Disseminated Mycobacterium avium complex (blood / bone-marrow / lymph-node culture positive) in CD4 < 50 (DHHS 2024 OI)
Paradoxical immune-reconstitution inflammatory syndrome — clinical worsening 2-12 wk after ART start or immune-recovery, with new or worsening inflammation around treated OI (DHHS 2024 OI)
EBV-driven post-transplant lymphoproliferative disorder — rising EBV viral load + lymphadenopathy or mass + biopsy CD20+ polyclonal or monoclonal proliferation (AST IDCOP 2024)
BK virus nephropathy in kidney transplant — viruria + viremia (typically > 10K cp/mL plasma) + biopsy SV40+ tubulointerstitial nephritis with rising creatinine (AST IDCOP 2024 Hirsch)
Progressive multifocal leukoencephalopathy — JC virus reactivation in natalizumab / rituximab / mycophenolate / ocrelizumab / immunomodulator user with new focal neuro deficit + MRI showing T2-hyperintense non-enhancing white-matter lesions + CSF JC-PCR or biopsy (FDA boxed warnings)(life-threatening)
Solid-organ transplant or HSCT recipient with persistent fever or syndrome despite empiric therapy + negative routine cultures — broaden differential to endemic fungi (histoplasma, coccidioides, blastomyces), donor-derived infection, atypical mycobacteria, parasitic (strongyloides, Chagas, leishmaniasis), viral (HHV-6, HHV-8 KS, HBV reactivation, HEV) (AST IDCOP 2024)

5. Follow-up

Secondary prophylaxis until immune recovery: TMP-SMX until CD4 > 200 × 3 mo + VL suppressed (PCP); fluconazole 200 mg/d until CD4 > 200 × 6 mo + VL suppressed (cryptococcal); valganciclovir maintenance until CD4 > 100 × 3-6 mo (CMV); MAC continuation ≥ 12 mo + CD4 > 100 × 6 mo; lifelong surveillance for transplant recipients; vaccinations per ACIP (DHHS 2024 OI; AST IDCOP 2024; ACIP 2024)

6. Sources

Guideline: NIH/CDC/IDSA Adult & Adolescent OI Guidelines (clinicalinfo.hiv.gov; continuously updated, 2025 web edition) + AST IDCOP 2019/2024 series + ASBMT/IDSA HSCT OI 2009 (Tomblyn) + ECIL-6 2017 + IDSA 2010 Cryptococcal (Perfect) + IDSA 2016 Candidiasis (Pappas) + IDSA 2016 Aspergillosis (Patterson)