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id.opportunistic-infection.hiv-transplant.v1PRODUCTION
id.opportunistic-infection.hiv-transplant.v1

Opportunistic infection overlay — HIV / transplant / biologic immunocompromise

infectious_diseaseacutechronicadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Overlay engine for OI prophylaxis + diagnosis + treatment in immunocompromised adults (HIV CD4 < 200, SOT, HSCT, biologic-DMARD, chronic steroid). HIV-naive non-immunocompromised hosts and pediatric OIs routed to sibling engines (DHHS 2024 OI; AST IDCOP 2024)

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host substrate + scope confirmed

Patient inputs (17)

PCP < 200; toxo < 100; MAC < 50; cryptococcal screen < 100 (DHHS 2024 OI guidelines)

Calcineurin (tacro/cyclosporine), mTOR (sirolimus/everolimus), anti-metabolite (mycophenolate/azathioprine), steroid dose, biologic (rituximab, natalizumab, infliximab, anti-thymocyte globulin, alemtuzumab) — drives net state of immunosuppression (AST IDCOP 2024)

Defines OI risk profile: HIV-CD4 vs SOT vs HSCT vs biologic / chronic-steroid; drives prophylaxis + empiric coverage (DHHS 2024 OI; AST IDCOP 2024; ASBMT/IDSA 2009)

Persistent fever ≥ 3 days in immunocompromised host triggers OI workup (IDSA 2024)

PaO2 < 70 or A-a gradient > 35 → adjunct prednisone for PCP (Bozzette NEJM 1990 PMID 2233917)

BK virus nephropathy in kidney transplant; foscarnet / amphotericin / TMP-SMX nephrotoxicity dosing (AST IDCOP 2024; DHHS 2024 OI)

EBV viral load rising post-transplant → PTLD risk; biopsy if lymphadenopathy / mass (AST IDCOP 2024)

BK viruria → viremia → nephropathy continuum in kidney transplant; biopsy confirms nephropathy (AST IDCOP 2019/2024 Hirsch)

Ring-enhancing mass + IgG+ → toxoplasmosis; basal-ganglia + subcortical white-matter without enhancement → PML; sub-acute meningitis → cryptococcal (DHHS 2024 OI)

IRIS risk + ART timing + prophylaxis discontinuation thresholds (DHHS 2024 OI)

AST IDCOP 2024 — risk profile differs kidney vs liver vs lung vs heart vs HSCT allo vs auto; time-from-transplant defines OI window (0-1 mo nosocomial; 1-6 mo CMV/PCP/BK; > 6 mo community + late CMV)

Toxoplasma IgG+ in CD4 < 100 → TMP-SMX prophylaxis indicated; in transplant, donor IgG+/recipient IgG- highest risk (DHHS 2024 OI; AST IDCOP 2019)

Pre-emptive monitoring post-transplant weekly × 12 wk; > 10K copies/mL LR+ ~ 10 for tissue-invasive disease (AST IDCOP 2024; Marty NEJM 2017)

CrAg LFA serum LR+ > 100 in CD4 < 100; reflex LP if positive (DHHS 2024 OI; IDSA 2010 cryptococcal Perfect)

Adjunct for invasive fungal — PCP / candidiasis / aspergillosis support (DHHS 2024 OI; IDSA 2016 candidiasis)

Bilateral ground-glass / interstitial → PCP; nodular / halo → aspergillosis / fungal; tree-in-bud → MAC / TB (DHHS 2024 OI; IDSA 2016 aspergillosis)

Azole / TMP-SMX / pyrimethamine hepatotoxicity monitoring (DHHS 2024 OI; IDSA 2010 cryptococcal)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningpcp_with_hypoxia_pao2_below_70
    Pneumocystis jirovecii pneumonia with PaO2 < 70 mmHg or A-a gradient > 35 mmHg (Bozzette NEJM 1990 criteria) — severe PCP
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcryptococcal_meningitis_with_raised_icp
    Cryptococcal meningitis with opening pressure ≥ 250 mmH2O OR AMS / focal deficit / hydrocephalus on imaging (IDSA 2010 Perfect)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningjc_pml_in_biologic_user
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecmv_retinitis_or_pneumonitis
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremac_disseminated_in_cd4_below_50
    Disseminated Mycobacterium avium complex (blood / bone-marrow / lymph-node culture positive) in CD4 < 50 (DHHS 2024 OI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereiris_post_art_severe
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereebv_ptld_post_transplant
    EBV-driven post-transplant lymphoproliferative disorder — rising EBV viral load + lymphadenopathy or mass + biopsy CD20+ polyclonal or monoclonal proliferation (AST IDCOP 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebk_virus_nephropathy_kidney_transplant
    BK virus nephropathy in kidney transplant — viruria + viremia (typically > 10K cp/mL plasma) + biopsy SV40+ tubulointerstitial nephritis with rising creatinine (AST IDCOP 2024 Hirsch)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransplant_recipient_unusual_pathogen_atypical_presentation
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecd4_below_200_no_pcp_prophylaxis
    CD4 < 200 cells/mm³ in HIV+ host without active PCP prophylaxis (DHHS 2024 OI)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives screening
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Recommended regimen

OI prophylaxis by host substrate + CD4 / immunosuppression (DHHS 2024 OI; AST IDCOP 2024)
axis: oi_prophylaxis_by_host
Selected axis "OI prophylaxis by host substrate + CD4 / immunosuppression (DHHS 2024 OI; AST IDCOP 2024)" by default fallback (first axis)
  • trimethoprim-sulfamethoxazole
    first line
    sulfonamide
    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
    triggers: HIV_CD4_<200, chronic_steroids_>=20mg_pred_>=4wk, SOT_protocol_per_AST_IDCOP, HSCT_per_ASBMT_protocol, Toxo_IgG_positive_with_CD4_<100
    DHHS 2024 OI — TMP-SMX is PCP prophylaxis of choice; also covers Toxoplasma at CD4 < 100; covers nocardia + Listeria in transplant (AST IDCOP 2024)
    rxcui 10831
  • azithromycin
    first line
    macrolide
    1200 mg PO weekly • PO • weekly
    triggers: HIV_CD4_<50, not_on_ART_or_VL_detectable
    DHHS 2024 OI — MAC prophylaxis at CD4 < 50; discontinue when CD4 > 100 × 3 mo + VL suppressed
    rxcui 18631
  • valganciclovir
    first line
    antiviral_nucleoside
    900 mg PO daily × 100-200 days post-transplant (CMV D+/R- or R+ high-risk) • PO • daily
    triggers: SOT_CMV_donor_positive_recipient_negative, SOT_CMV_recipient_positive_high_risk, HSCT_pre_engraftment_CMV_R_positive
    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)
    rxcui 275891
  • letermovir
    first line
    cmv_terminase_inhibitor
    480 mg PO/IV daily × 100 days post-HSCT (or 240 mg if cyclosporine concomitant) • PO/IV • daily
    triggers: HSCT_allogeneic_CMV_R_positive
    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
    rxcui 1988648
  • isoniazid
    first line
    antimycobacterial
    300 mg PO daily × 9 mo (or alternates: 4 mo rifampin; 3 mo INH-rifapentine weekly DOT) • PO • daily
    triggers: LTBI_IGRA_or_TST_positive_pre_transplant_or_pre_biologic, HIV_with_LTBI_any_CD4
    DHHS 2024 OI — LTBI treatment regardless of CD4; WHO 2024; AST IDCOP 2024 pre-transplant LTBI mandatory
    rxcui 6038
  • posaconazole
    first line
    azole
    300 mg PO daily (DR tablet; after 300 mg BID × 1 day load) • PO • daily
    triggers: HSCT_acute_GVHD_on_high_dose_steroids, AML_induction_chemotherapy_with_prolonged_neutropenia, secondary_prophylaxis_post_invasive_mold
    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)
    rxcui 282446

outpatient playbook — drug actions (6)

  1. 1. TMP-SMX prophylaxis
    1 SS PO daily OR 1 DS PO 3×/wk • PO • daily or 3×/wk
    trigger: CD4 < 200 (HIV) OR chronic ≥ 20 mg pred ≥ 4 wk OR SOT protocol (typically 6-12 mo post-transplant) OR HSCT protocol
    DHHS 2024 OI — PCP prophylaxis; also covers Toxo at CD4 < 100; nocardia + Listeria in transplant. Discontinue HIV at CD4 > 200 × 3 mo + VL suppressed; transplant per local protocol.
  2. 2. azithromycin MAC prophylaxis
    1200 mg PO weekly • PO • weekly
    trigger: CD4 < 50 + not on ART OR VL detectable
    DHHS 2024 OI — MAC prophylaxis at CD4 < 50; discontinue when CD4 > 100 × 3 mo + VL suppressed.
  3. 3. valganciclovir universal CMV prophylaxis
    900 mg PO daily × 100-200 days • PO • daily
    trigger: SOT D+/R- OR R+ high-risk (lung, intestinal); some kidney D+/R-
    AST IDCOP 2024 Razonable — universal prophylaxis × 100-200 d in high-risk SOT; pre-emptive monitoring is alternative (weekly PCR + treat at threshold).
  4. 4. letermovir HSCT CMV prophylaxis
    480 mg PO/IV daily × 100 days (240 mg if cyclosporine) • PO/IV • daily
    trigger: HSCT allogeneic + CMV-seropositive recipient
    Marty NEJM 2017 PMID 29211658 — reduced clinically-significant CMV 38% vs placebo through week 24 post-HSCT.
  5. 5. INH or INH-rifapentine LTBI
    INH 300 mg/d × 9 mo OR INH 900 + rifapentine 900 weekly DOT × 12 wk OR rifampin 600 daily × 4 mo • PO • daily or weekly
    trigger: LTBI confirmed pre-transplant or pre-biologic or HIV diagnosis
    DHHS 2024; WHO 2024; AST IDCOP 2024 — LTBI treatment prevents reactivation; rifampin / rifapentine DDI screen with calcineurin inhibitors + INSTI (avoid in transplant; rifabutin alternative).
  6. 6. posaconazole mold prophylaxis
    300 mg PO daily (DR tablet) • PO • daily
    trigger: HSCT with acute GVHD on high-dose steroids OR AML induction chemotherapy with prolonged neutropenia OR secondary prophylaxis post-mold disease
    ECIL-6 2017 — posaconazole reduced invasive fungal infections in high-risk HSCT GVHD and AML induction.

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: CD4 < 200 cells/mm³ in HIV+ host — initiate PCP / toxo prophylaxis (DHHS 2024 OI; IDSA 2024); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Opportunistic infection overlay — HIV / transplant / biologic immunocompromise** (id.opportunistic-infection.hiv-transplant.v1).
Phenotype framing: Distinguish PCP vs CMV pneumonitis vs viral / bacterial / fungal pneumonia vs drug pneumonitis; toxoplasmosis vs primary CNS lymphoma vs PML; cryptococcal vs bacterial / TB meningitis; CMV vs HHV-6 / HSV / VZV; BK vs CMV vs acute rejection on transplant biopsy (DHHS 2024 OI; AST IDCOP 2024)
Scope: Overlay engine for OI prophylaxis + diagnosis + treatment in immunocompromised adults (HIV CD4 < 200, SOT, HSCT, biologic-DMARD, chronic steroid). HIV-naive non-immunocompromised hosts and pediatric OIs routed to sibling engines (DHHS 2024 OI; AST IDCOP 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **OI prophylaxis by host substrate + CD4 / immunosuppression (DHHS 2024 OI; AST IDCOP 2024)**.
1. 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 (sulfonamide, first line) — DHHS 2024 OI — TMP-SMX is PCP prophylaxis of choice; also covers Toxoplasma at CD4 < 100; covers nocardia + Listeria in transplant (AST IDCOP 2024)
2. azithromycin 1200 mg PO weekly PO weekly (macrolide, first line) — DHHS 2024 OI — MAC prophylaxis at CD4 < 50; discontinue when CD4 > 100 × 3 mo + VL suppressed
3. valganciclovir 900 mg PO daily × 100-200 days post-transplant (CMV D+/R- or R+ high-risk) PO daily (antiviral_nucleoside, first line) — 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)
4. letermovir 480 mg PO/IV daily × 100 days post-HSCT (or 240 mg if cyclosporine concomitant) PO/IV daily (cmv_terminase_inhibitor, first line) — 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
5. isoniazid 300 mg PO daily × 9 mo (or alternates: 4 mo rifampin; 3 mo INH-rifapentine weekly DOT) PO daily (antimycobacterial, first line) — DHHS 2024 OI — LTBI treatment regardless of CD4; WHO 2024; AST IDCOP 2024 pre-transplant LTBI mandatory
6. posaconazole 300 mg PO daily (DR tablet; after 300 mg BID × 1 day load) PO daily (azole, first line) — 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)

Setting playbook (outpatient) — CD4-driven + transplant-protocol prophylaxis, vaccination per ACIP, surveillance PCRs, secondary prophylaxis continuation, IS coordination with primary transplant team (DHHS 2024 OI; AST IDCOP 2024)
7. TMP-SMX prophylaxis 1 SS PO daily OR 1 DS PO 3×/wk PO daily or 3×/wk — CD4 < 200 (HIV) OR chronic ≥ 20 mg pred ≥ 4 wk OR SOT protocol (typically 6-12 mo post-transplant) OR HSCT protocol (DHHS 2024 OI — PCP prophylaxis; also covers Toxo at CD4 < 100; nocardia + Listeria in transplant. Discontinue HIV at CD4 > 200 × 3 mo + VL suppressed; transplant per local protocol.)
8. azithromycin MAC prophylaxis 1200 mg PO weekly PO weekly — CD4 < 50 + not on ART OR VL detectable (DHHS 2024 OI — MAC prophylaxis at CD4 < 50; discontinue when CD4 > 100 × 3 mo + VL suppressed.)
9. valganciclovir universal CMV prophylaxis 900 mg PO daily × 100-200 days PO daily — SOT D+/R- OR R+ high-risk (lung, intestinal); some kidney D+/R- (AST IDCOP 2024 Razonable — universal prophylaxis × 100-200 d in high-risk SOT; pre-emptive monitoring is alternative (weekly PCR + treat at threshold).)
10. letermovir HSCT CMV prophylaxis 480 mg PO/IV daily × 100 days (240 mg if cyclosporine) PO/IV daily — HSCT allogeneic + CMV-seropositive recipient (Marty NEJM 2017 PMID 29211658 — reduced clinically-significant CMV 38% vs placebo through week 24 post-HSCT.)
11. INH or INH-rifapentine LTBI INH 300 mg/d × 9 mo OR INH 900 + rifapentine 900 weekly DOT × 12 wk OR rifampin 600 daily × 4 mo PO daily or weekly — LTBI confirmed pre-transplant or pre-biologic or HIV diagnosis (DHHS 2024; WHO 2024; AST IDCOP 2024 — LTBI treatment prevents reactivation; rifampin / rifapentine DDI screen with calcineurin inhibitors + INSTI (avoid in transplant; rifabutin alternative).)
12. posaconazole mold prophylaxis 300 mg PO daily (DR tablet) PO daily — HSCT with acute GVHD on high-dose steroids OR AML induction chemotherapy with prolonged neutropenia OR secondary prophylaxis post-mold disease (ECIL-6 2017 — posaconazole reduced invasive fungal infections in high-risk HSCT GVHD and AML induction.)

Non-pharmacologic actions:
- Avoid live vaccines (MMR, varicella, yellow fever, live influenza, oral typhoid, BCG) in transplant / biologic users + CD4 < 200
- HEPA-filter environment counselling for severely immunocompromised (avoid construction, gardening with soil, compost, bird/cat litter for toxo, raw dairy for Listeria, undercooked meat for toxo)
- Pet counselling: cats screened for Toxoplasma if CD4 < 100; avoid cleaning litter or have HIV− household member do it; avoid reptiles (Salmonella) + young animals (Cryptosporidium)
- Travel counselling: pre-travel ID consult; malaria prophylaxis; live-vaccine-free regimen; food/water safety
- IS coordination with primary transplant team (nephrology / hepatology / pulmonology / cardiology / heme-onc / rheumatology) for reduction during active OI
- Patient education: signs of new OI (fever, weight loss, dyspnea, headache, focal neuro deficit, vision change, persistent diarrhea, rash) → return promptly

AVOID / contraindication checks:
- Tmpsmx folate supplement during pregnancy (DHHS 2024 OI)
- Tmpsmx hyperkalemia risk with RAAS or spironolactone (FDA / DailyMed)
- Azithromycin discontinue after VL suppressed and CD4_>100_x_3mo (DHHS 2024 OI)
- Valganciclovir myelosuppression CBC weekly (AST IDCOP 2024; DailyMed)
- Letermovir CYP3A4 DDI cyclosporine tacrolimus sirolimus monitor (DailyMed letermovir label)
- INH pyridoxine supplementation and LFT monitoring (DHHS 2024; WHO 2024)
- Posaconazole CYP3A4 DDI calcineurin inhibitor dose reduction (ECIL 6 2017; DailyMed)
- Posaconazole TDM target trough_>=1 (ECIL 6 2017)

Monitoring

Regimen monitoring:
- CBC weekly during valganciclovir or ganciclovir (AST IDCOP 2024)
- tacrolimus cyclosporine trough q3-7d during azole or letermovir overlap (AST IDCOP 2024; ECIL-6 2017)
- LFT monthly during INH (DHHS 2024; WHO 2024)
- CD4 q3-6mo to decide prophylaxis discontinuation (DHHS 2024 OI)
- discontinue PCP prophylaxis when CD4 >200 x 3mo with VL suppressed (DHHS 2024 OI)
- discontinue MAC prophylaxis when CD4 >100 x 3mo with VL suppressed (DHHS 2024 OI)
- CMV PCR weekly during universal prophylaxis or pre emptive monitoring (AST IDCOP 2024)

Setting (outpatient) monitoring:
- CD4 + VL q3-6 mo while CD4 < 500
- CMV PCR weekly × 12 wk post-transplant then risk-stratified (AST IDCOP 2024)
- BK PCR blood + urine quarterly year 1 post-kidney-transplant; biopsy if biopsy-confirmed nephropathy suspected
- EBV PCR quarterly post-transplant in EBV D+/R- recipients (PTLD risk)
- LFT monthly during INH; CBC during valganciclovir
- CD4 + VL + CrAg titre for cryptococcal maintenance discontinuation decision (CD4 > 200 × 6 mo + VL suppressed)

Follow-up plan: 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)
- Close-out criterion: long-term secondary prophylaxis + surveillance plan documented

Monitoring phase: Pathogen-specific response: PCP-LDH + repeat CXR + ABG; CMV PCR weekly until undetectable then bi-weekly; cryptococcal LP at 2 wk for sterilisation; BK PCR q1-2 wk + creatinine; EBV PCR q1-2 wk post-PTLD treatment; CD4 + VL q3 mo; IRIS surveillance 2-12 wk post-ART (DHHS 2024 OI; AST IDCOP 2024)

Disposition

Current setting: outpatient — CD4-driven + transplant-protocol prophylaxis, vaccination per ACIP, surveillance PCRs, secondary prophylaxis continuation, IS coordination with primary transplant team (DHHS 2024 OI; AST IDCOP 2024)

Disposition criteria:
- Stable on prophylaxis + asymptomatic → continue outpatient surveillance
- New OI symptom or surveillance trigger → admit per escalation triggers above

Escalation triggers (move to higher acuity):
- Persistent fever ≥ 3 d in immunocompromised host → admit + broaden workup + empiric coverage (DHHS 2024 OI)
- New hypoxia / bilateral interstitial infiltrate → admit + empiric PCP coverage + BAL (DHHS 2024 OI)
- New headache + AMS in CD4 < 100 → admit + LP + L-AmB + flucytosine empiric for cryptococcal (IDSA 2010 Perfect)
- New focal neuro deficit in biologic user → admit + MRI brain + JC PCR for PML; discontinue biologic
- CMV PCR rising > 10K cp/mL or tissue-invasive symptoms → admit + IV ganciclovir induction
- New visual change → emergent ophthalmology + dilated fundus for CMV retinitis
- Rising BK PCR + creatinine bump in kidney transplant → admit + biopsy + IS reduction

Patient Action Plan

**OI self-management + secondary prophylaxis plan (DHHS 2024 OI; AST IDCOP 2024)**
Personalised values: cd4_count, transplant_type, current_immunosuppression, active_secondary_prophylaxis.

**On prophylaxis + asymptomatic** (green):
Triggers:
- 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
Actions:
- 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

**New mild symptoms or surveillance abnormality** (yellow):
Triggers:
- 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
Actions:
- 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
Contact provider when:
- Fever ≥ 38.5 °C
- Symptoms worsen or persist > 48 hours
- New medication started by another provider

**Severe symptoms — go to ED immediately** (red):
Triggers:
- 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)
Actions:
- 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
Contact provider when:
- Always seek emergency care for these symptoms

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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)

Citations

- 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) [PMID:2233917](https://pubmed.ncbi.nlm.nih.gov/2233917/)
- Cited evidence (PMID 29211658) [PMID:29211658](https://pubmed.ncbi.nlm.nih.gov/29211658/)
- Cited evidence (PMID 24963568) [PMID:24963568](https://pubmed.ncbi.nlm.nih.gov/24963568/)
- Cited evidence (PMID 26679628) [PMID:26679628](https://pubmed.ncbi.nlm.nih.gov/26679628/)
- Cited evidence (PMID 27365388) [PMID:27365388](https://pubmed.ncbi.nlm.nih.gov/27365388/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 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) — PMID:2233917
  • Cited evidence (PMID 29211658) — PMID:29211658
  • Cited evidence (PMID 24963568) — PMID:24963568
  • Cited evidence (PMID 26679628) — PMID:26679628
  • Cited evidence (PMID 27365388) — PMID:27365388