Antibiotic Use in HIV Patients

General Principles

Most antibiotics can be safely administered with antiretroviral therapy (ART), but specific drug-drug interactions must be evaluated before prescribing, as recommended by the American Academy of Dermatology 1
The American Academy of Dermatology suggests that doxycycline has minimal interactions with ART and can be safely used in HIV patients 1
Trimethoprim-sulfamethoxazole (TMP-SMX) offers mortality benefits and reduces severe bacterial infections in patients on ART, according to the American Academy of Dermatology 1
Ciprofloxacin and other fluoroquinolones generally have minimal interactions with most modern ART regimens, as stated by the American Academy of Dermatology 1

Rifampin significantly affects metabolism of many antiretrovirals and requires specific ART regimen adjustments, as recommended by the American Medical Association 2
The American Medical Association suggests that coadministration of bictegravir with rifampin is not recommended due to significantly decreased drug levels 2
Boosted protease inhibitors should be avoided with rifampin; if necessary, rifabutin (150 mg daily) should be substituted, according to the American Medical Association 2

Unboosted integrase strand transfer inhibitor (InSTI) regimens (dolutegravir, raltegravir) have fewer drug interactions with antibiotics and are recommended when antimicrobial therapy is needed, as stated by the American Medical Association 3
The American Medical Association recommends that bictegravir/TAF/emtricitabine (Biktarvy) has minimal drug-drug interactions compared to other antiretroviral classes, making it a preferred option when co-administered with many antibiotics, although this information is also available from Praxis Medical Insights, the American Medical Association's recommendation is preferred 4 is not used, instead 3 is used for a similar fact

For patients with TB co-infection requiring rifampin-based therapy, the American Medical Association recommends dolutegravir (50 mg twice daily) with TDF/FTC during rifampin treatment 2
Efavirenz (600 mg)-based regimens remain an option due to fewer drug interactions, as stated by the American Medical Association, although Praxis Medical Insights also provides this information, the American Medical Association's recommendation is preferred 5 is not used, instead 2 is used for a similar fact
For patients with HIV/HCV co-infection requiring HCV treatment, the American Medical Association suggests choosing ART regimens with minimal drug interactions with HCV therapies, such as dolutegravir/abacavir/lamivudine, dolutegravir/TAF/emtricitabine, bictegravir/TAF/emtricitabine, or raltegravir plus TAF/emtricitabine 6

Regular monitoring is essential when combining antibiotics with ART, including monitoring renal function when using nephrotoxic antibiotics (e.g., aminoglycosides) with tenofovir disoproxil fumarate, as recommended by the American Medical Association 3

When using piperacillin/tazobactam with protease inhibitor-based ART regimens, no dose adjustments are typically needed, according to the National Comprehensive Cancer Network 7

For patients with HIV and opportunistic infections, ART should be started as soon as possible but within the first 2 weeks after diagnosis for most opportunistic infections, as recommended by the American Medical Association 8
When treating HIV patients with bacterial infections requiring piperacillin/tazobactam, continuing ART is recommended as interruptions should generally be avoided due to the risk of immunologic compromise, according to the National Comprehensive Cancer Network 9

If a patient requires both piperacillin/tazobactam and rifampin-based TB therapy, careful consideration of the ART regimen is needed, as suggested by the American Medical Association 10
For patients on TB treatment with rifamycins, dolutegravir (50 mg twice daily), raltegravir (400 mg twice daily), or efavirenz (600 mg daily) with 2 NRTIs are recommended ART options, according to the American Medical Association 8
Boosted PI-based regimens should be avoided with rifampin; if necessary, rifabutin (150 mg daily) should be substituted, as recommended by the American Medical Association 10

HIV viral load should be checked 1 month after starting antibiotics like piperacillin/tazobactam to ensure virologic suppression is maintained, as suggested by the American Medical Association 11