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2. Тактика ведения пациентов

с оппортунистическими инфекциями и общими симптомами ВИЧ/СПИДа

Клинический протокол для европейского региона ВОЗ

Содержание

I. Общие принципы.

II. Ведение пациентов с оппортунистическими инфекциями.

1. Общие сведения.

2. Первичное обследование.

3. Консультирование по проблеме ОИ и другим заболеваниям.

4. Профилактика ОИ у ВИЧ-инфицированных пациентов.

5. Диагностика и лечение ОИ.

5.1. Инфекции респираторного тракта.

5.1.1. Бактериальные пневмонии.

5.1.2. Инфекции, вызванные атипичными микобактериями.

5.1.3. Пневмоцистная пневмония.

5.1.4. Пневмонии другой этиологии у лиц с иммунодефицитом.

5.2. Инфекции желудочно-кишечного тракта.

5.3. Кандидоз.

5.4. Криптококковый менингит.

5.5. Гистоплазмоз.

5.6. Саркома Калоши (СК).

5.7. Рак шейки матки.

5.8. Другие злокачественные новообразования.

5.8.1. Неходжкинская лимфома.

5.8.2. Лимфома Беркитта.

5.9. Инфекции нервной системы.

5.9.1. Токсоплазмоз.

5.9.2. Инфекция, вызванная ВПГ.

5.9.3. Опоясывающий лишай.

5.9.4. Цитомегаловирусная инфекция.

5.9.5. Инфекция, вызванная вирусом Эпштейна-Барр.

III. Общие симптомы.

1. Персистирующая генерализованная лимфаденопатия у ВИЧ-инфицированных взрослых.

2. Лихорадка.

3. Потеря веса у ВИЧ-инфицированных взрослых.

4. Хроническая диарея у ВИЧ-инфицированных взрослых.

5. Поражения полости рта.

6. Заболевания кожи и ногтей.

6.1. Дерматомикозы.

6.2. Онихомикозы.

6.3. Себорейный дерматит.

6.4. Чесотка.

6.5. Стафилококковый фолликулит.

6.6. Контагиозный моллюск.

Библиография.

I. Общие принципы

Выявление и лечение оппортунистических инфекций (ОИ) - обязательный элемент комплексной медицинской помощи пациентам с ВИЧ.

Лечение должны получать все больные с ОИ, независимо от пола и социального положения, в том числе потребители инъекционных наркотиков (ПИН), работники коммерческого секса, заключенные, иммигранты и другие уязвимые группы населения. Решение о необходимости лечения принимается исключительно по медицинским показаниям.

Во время медикаментозной профилактики или лечения ОИ лечение других сопутствующих заболеваний необходимо продолжать.

II. Ведение пациентов с оппортунистическими инфекциями

1. Общие сведения.

Обусловленные ВИЧ-инфекцией ОИ перечислены в табл. 1.

Таблица 1. Инфекции и заболевания, обусловленные ВИЧ-инфекцией

В Европейском регионе ВОЗ самыми распространенными являются следующие ОИ:

туберкулез (ТБ);

бактериальные инфекции;

пневмоцистная пневмония (ПЦП);

герпетические инфекции [включая, опоясывающий лишай (вирус варицелла-зостер), инфекции, вызванные вирусом простого герпеса типа 1 и 2 (ВПГ 1-2) и цитомегаловирусом (ЦМВ)];

кандидозный эзофагит;

криптококковый менингит;

токсоплазмоз.

Реже встречаются следующие заболевания:

инфекция, вызванная комплексом Mycobacterium avium-intracellulare (МАК);

саркома Капоши (СК);

неходжкинская лимфома (НХЛ);

ЦМВ инфекция (ретинит, колит, энцефалит).

В зависимости от различных факторов (как связанных, так и не связанных с эпидемией ВИЧ-инфекции) порядок заболеваний в этом перечне может меняться.

2. Первичное обследование.

Пациентам с неизвестным ВИЧ-статусом, у которых обнаружено заболевание из числа часто встречающихся при ВИЧ-инфекции, необходимо предложить тестирование на ВИЧ и консультирование. Врач должен объяснить пациенту причины, по которым ему предлагается пройти тестирование на ВИЧ, и важность полученного результата для правильного лечения. Однако пациент имеет право отказаться от тестирования.

Первичная оценка ВИЧ-статуса должна включать:

дотестовое консультирование;

серологическое исследование (как правило, иммуноферментный анализ (ИФА) или экспресс-методы) на антитела к ВИЧ с подтверждением полученного результата иммуноблоттингом;

послетестовое консультирование 'независимо от результата исследования включает информацию о снижении рискованного поведения'.

При положительном результате тестирования проводят первичное клиническое обследование для определения стадии ВИЧ-инфекции и выявления сопутствующих заболеваний и состояний. Подробнее см. в Протоколе 1 «Обследование и антиретровирусная терапия у взрослых и подростков».

3. Консультирование по проблеме ОИ и другим состояниям.

Врачи и медсестры должны объяснять пациентам и их родственникам, что ВИЧ-инфекция - это хроническое заболевание, которое может сопровождаться ОИ.

Необходимо проинформировать пациентов о том, что некоторые ОИ можно предупредить (см. табл. 2).

Пациенты должны понимать важность ранней диагностики ОИ и необходимость обращения к врачу при подозрении на прогрессирование ВИЧ-инфекции.

Необходимо рассказать о симптомах, которые могут указывать на ОИ и о которых следует сообщить лечащему врачу.

К ним относятся:

одышка: ПЦП, ТБ, пневмония другого происхождения;

кашель: ПЦП, ТБ, пневмония другого происхождения;

кровохарканье: ТБ, пневмония другого происхождения;

неврологические нарушения: церебральный токсоплазмоз, церебральная лимфома или

менингит/энцефалит;

потеря веса, лихорадка, ночная потливость: ТБ, атипичный микобактериоз, лимфома;

снижение остроты зрения: ретинит, вызванный ЦМВ;

боль при глотании: кандидозный эзофагит;

диарея: колит, вызванный ЦМВ, криптоспоридиоз, микроспоридиоз, сальмонеллез и

др.;

сужение полей зрения (чтение газеты - хороший тест);

слабость в конечностях: церебральный токсоплазмоз;

любые изменения психического состояния или поведения, которые замечают друзья и/или родственники пациента и которые могут быть признаком психических нарушений:

герпетический менингит, токсоплазмоз, прогрессирующая мультифокальная лейкоэнцефалопатия и пр.);

поражения кожи или (чаще) слизистой ротовой полости:

кандидоз («молочница») - может быть признаком неэффективности антиретровирусной терапии (APT).

Пациенты должны понимать важность наблюдения за проявлениями хронических заболеваний, которые у них имеются.

Пациенты с хроническим гепатитом должны дважды в год проходить ультразвуковое исследование (УЗИ) брюшной полости в связи с риском развития гепатоклеточной карциномы.

Пациенты с ТБ в анамнезе должны раз в год проходить рентгенологическое исследование грудной клетки.

ВИЧ-инфицированные пациенты старшего возраста, страдающие ожирением и гипертонической болезнью и получающие APT с ингибиторами протеазы (ИП), должны проходить регулярные исследования для выявления возможных сердечно-сосудистых заболеваний, сахарного диабета и других заболеваний.

Пациентов необходимо обеспечить графиком регулярных лабораторных и клинических и исследований. График может меняться при изменении состояния или появлении сопутствующих заболеваний.

Дополнительную информацию по консультированию см. в Протоколе 1 «Обследование и антиретровирусная терапия у взрослых и подростков».

4. Профилактика ОИ у ВИЧ-инфицированных пациентов.

Некоторые ОИ у людей, живущих с ВИЧ (ЛЖВ), можно предупредить.

Профилактика ОИ у ЛЖВ должна быть частью комплексной помощи, которая им предоставляется.

Отмена первичной профилактики ОИ допустима в случаях, когда на фоне APT в течение 3-6 месяцев число лимфоцитов CD4 увеличивается до определенного уровня (например, для ПЦП >200/мкл, для токсоплазмоза >100/мкл, для инфекции, вызванной МАК >50/мкл). Отмена вторичной профилактики допустима при тех же условиях, однако требуется тщательное наблюдение за пациентом. Если число CD4 вновь падает ниже указанных уровней, профилактику возобновляют.

В табл. 2 обобщены самые современные рекомендации по профилактике ОИ.

Таблица 2. Профилактика ОИ у ВИЧ-инфицированных пациентов