Initial anti-microbial treatment is usually empirical and should be chosen according to: (a) pneumonia severity; (b) the likelihood of particular pathogens as indicated by risk factors; (c) the potential for antibiotic resistance; and (d) potential toxicities. A number of guidelines developed to guide the management of CAP in HIV-seronegative individuals exist and the possible regimens suggested in these guidelines are adapted from them (see Table 3.5) [94–97]. HIV-seropositive individuals with community-acquired pneumonia should be treated as per HIV-seronegative populations (category IV recommendation). Antibiotic prophylaxis is not indicated for bacterial pneumonia.

The capsular polysaccharide vaccine protects against 23 pneumococcal serotypes. The Department of Health includes ERK inhibition HIV-seropositive individuals amongst the ‘high-risk’ groups for whom vaccination is recommended [98]. Pneumococcal and Haemophilus vaccination strategies are discussed in the British HIV Association Immunization

guidelines [99]. The effects of HAART have been demonstrated in vivo through a reduced risk of bacterial pneumonia in individuals using antiretrovirals [84,100]. However, its decline has been less marked than for opportunistic infections [1]. 3.6.1 Background and epidemiology (see section 2.4 Cryptococcus neoformans) The presenting symptoms may be indistinguishable from PCP, with fever, cough (which may be productive), exertional dyspnoea and pleuritic GSK1120212 clinical trial chest pain often present [101,102]. Chest radiographs show solitary nodules, consolidation, interstitial infiltrates, cavities, intrathoracic lymphadenopathy or pleural effusions [102,103]. Diffuse interstitial infiltrates, which may contain small nodules or have a miliary appearance [104], are most common in those with advanced immunosuppression or those with co-infections [102,103]. As with PCP, pneumothoraces may develop [105]. C59 Disseminated disease is however the most common presentation (see section 2.4 Cryptococcus

neoformans). C. neoformans is identified in induced sputum, BAL or pleural fluid by Giemsa stain, Indian ink staining (which reveals an encapsulated yeast) or by calcofluor white with fluorescence microscopy. Cryptococcal antigen can be detected in BAL; sensitivity 100% and specificity 98% [106]. The yeast can be cultured from BAL or biopsy specimens using blood agar or fungal media such as Sabouraud media [102]. Diagnosis usually requires culture of the yeast with or without a positive antigen test or staining of yeast on BAL or pleural fluid. Biopsy specimens can be stained with special fungal stains such as Grocott–Gomori methenamine silver. Blood culture or serum cryptococcal antigen assay is frequently positive and suggest disseminated disease but may be negative.