1. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Parasitic Infections Slide Set
Prepared by the AETC National Resource Center based on recommendations from the CDC, National Institutes of Health, and HIV Medicine Association/Infectious Diseases Society of America

2. About This Presentation
These slides were developed using recommendations published in May The intended audience is clinicians involved in the care of patients with HIV.
Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.
-AETC National Resource Center
May 2013

3. Parasites Toxoplasma gondii encephalitis Cryptosporidiosis
Microsporidiosis
Malaria
May 2013

4. Parasites
Toxoplasma gondii encephalitis

5. Toxoplasma gondii Encephalitis: Epidemiology
Caused by the T gondii protozoan
Disease almost always caused by reactivation of latent tissue cysts
Primary infection may be associated with acute cerebral or disseminated disease
Seroprevalence varies widely: 11% in the United States, 50-80% in some European, Latin American, and African countries
May 2013

6. Toxoplasma gondii Encephalitis: Epidemiology (2)
In advanced AIDS, 12-month incidence of TE was 33% among Toxoplasma-seropositive patients who were not on prophylaxis or ART
Among seronegative persons, toxoplasmosis is rare
Occurs primarily in patients with CD4 counts of <200 cells/µL, especially <50 cells/µL
Incidence and mortality lower in United States and Europe owing to widespread use of prophylaxis and potent ART
May 2013

7. Toxoplasma gondii Encephalitis: Epidemiology (3)
Primary infection acquired from tissue cysts in undercooked meat or raw shellfish, or ingestion of sporulated oocysts (from cat feces) in soil, water, or food
No transmission by person-to-person contact
May 2013

8. Toxoplasma gondii Encephalitis: Clinical Manifestations
Focal encephalitis with headache, confusion, or motor weakness and fever
May have nonfocal symptoms, including nonspecific headache and psychiatric symptoms
May have focal neurological abnormalities; may progress to seizures, altered mental status, coma
Retinochoroiditis, pneumonia, other organ involvement are rare
May 2013

9. Toxoplasma gondii Encephalitis: Clinical Manifestations
CT or MRI:
Typical findings are multiple contrast-enhancing lesions in gray matter of cortex or basal ganglia, often associated edema
May show single brain lesion, or diffuse encephalitis without focal lesions
May 2013

10. Toxoplasma gondii Encephalitis: Diagnosis
Serum anti-Toxoplasma IgG
Positive in almost all patients with TE; negative IgG makes diagnosis unlikely but not impossible
IgM usually negative
Definitive diagnosis: compatible clinical syndrome + mass lesion(s) on imaging + detection of organism in a clinical sample (brain biopsy)
CT, MRI of brain: typically multiple contrast-enhancing lesions, often with edema
MRI better than CT for radiological diagnosis
PET or SPECT may help distinguish TE from lymphoma
May 2013

11. Toxoplasma gondii Encephalitis: Diagnosis (2)
Check CSF (if safe and feasible) for T gondii PCR, cytology, culture, cryptococcal antigen, PCR for M tuberculosis, EBV, JC virus
CSF PCR specificity for T gondii is %, sensitivity 50%
May 2013

12. Toxoplasma gondii Encephalitis: Diagnosis (3)
Differential diagnosis of focal neurological disease
CNS lymphoma, PML, mycobacterial infection (TB), fungal infection, Chagas disease, abscess
May 2013

13. Toxoplasma gondii Encephalitis: Diagnosis (4)
CT scan of the brain showing contrast-enhancing lesion of toxoplasmosis
Credit: P. Volberding, MD; UCSF Center for HIV Information Image Library
May 2013

14. Toxoplasma gondii Encephalitis: Diagnosis (5)
May initially make empiric diagnosis, established on basis of clinical and radiographic improvement to TE therapy, in absence of a likely alternative diagnosis
Brain biopsy if failure to respond to therapy, or if initial studies suggest etiology other than TE
May 2013

15. Toxoplasma gondii Encephalitis: Preventing Exposure
All HIV+ should be tested for IgG to Toxoplasma at baseline, to detect latent infection
Toxoplasma seronegative: counsel about sources of infection
Patients: avoid eating raw or undercooked meat or shellfish; wash hands after handling raw meat and after contact with soil; wash fruits/vegetables; clean cat-litter boxes daily and wash hands afterward; cats should not be fed raw/undercooked meats
May 2013

16. Toxoplasma gondii Encephalitis: Primary Prophylaxis
For all Toxoplasma IgG positive with CD4 count <100 cells/µL
Recommended:
TMP-SMX 1 DS QD
Alternative:
TMP-SMX 1 DS PO TIW
TMP-SMX 1 SS QD
Dapsone* 50 mg PO QD + pyrimethamine 50 mg PO Q week + leucovorin 25 mg PO Q week
Dapsone* 200 mg PO Q week + pyrimethamine 75 mg PO Q week + leucovorin 25 mg PO Q week
Atovaquone 1,500 mg PO QD +/- pyrimethamine 25 mg PO QD + leucovorin 10 mg PO QD
* Avoid dapsone if patient has G6PD deficiency; screen before treatment with dapsone, if possible.
May 2013

17. Toxoplasma gondii Encephalitis: Primary Prophylaxis (2)
Toxoplasma seronegative patients: retest for Toxoplasma IgG if CD4 count declines to <100 cells/µL, unless taking PCP prophylaxis that also is active against TE
May 2013

18. Toxoplasma gondii Encephalitis: Discontinuing Primary Prophylaxis
Discontinue if on effective ART with CD4 count of >200 cells/µL for >3 months
Restart prophylaxis if CD4 count decreases to < cells/µL
May 2013

19. Toxoplasma gondii Encephalitis: Treatment
Preferred:
Pyrimethamine 200 mg PO 1 dose, then:
For weight ≤60 kg: pyrimethamine 50 mg PO QD + sulfadiazine 1,000 mg PO Q6H + leucovorin mg PO QD
For weight >60 kg: pyrimethamine 75 mg PO QD + sulfadiazine 1,500 mg PO Q6H + leucovorin mg PO QD
Duration: ≥6 weeks, longer if extensive disease or incomplete response at 6 weeks
The initial therapy of choice consists of the combination of pyrimethamine plus sulfadiazine plus leucovorin ( ) (AI).
Pyrimethamine penetrates the brain parenchyma efficiently even in the absence of inflammation (126).
Use of leucovorin prevents the hematologic toxicities associated with pyrimethamine therapy (127,128). The
preferred alternative regimen for patients unable to tolerate or who fail to respond to first-line therapy is
pyrimethamine plus clindamycin plus leucovorin (122,123) (AI).
Acute therapy should be continued for at least 6 weeks, if there is clinical and radiologic improvement ( )
(BII). Longer courses might be appropriate if clinical or radiologic disease is extensive or if response is incomplete at
6 weeks.
May 2013

20. Toxoplasma gondii Encephalitis: Treatment (2)
Alternative:
Pyrimethamine as above + clindamycin 600 mg IV or PO Q6H + leucovorin as above
TMP-SMX (5 mg/kg TMP and 25 mg/kg SMX) IV or PO BID
Atovaquone 1,500 mg PO BID + pyrimethamine, as above + leucovorin as above
Atovaquone 1,500 mg PO BID + sulfadiazine (weight-based as above)
Atovaquone 1,500 mg PO BID (variable absorption)
Pyrimethamine as above + azithromycin 900-1,200 mg PO QD + leucovorin as above
TMP-SMX was reported in a small (77 patient) randomized trial to be effective and better tolerated than
pyrimethamine-sulfadiazine (129). On the basis of less in vitro activity and less experience with this regimen,
pyrimethamine plus sulfadiazine with leucovorin is the preferred therapy (BI). For patients who cannot take an oral
regimen, no well-studied options exist. No parenteral formulation of pyrimethamine exists; the only widely available
parenteral sulfonamide is the sulfamethoxazole component of TMP-SMX. Therefore, certain specialists will treat
severely ill patients requiring parenteral therapy initially with oral pyrimethamine plus parenteral TMP-SMX or
parenteral clindamycin (CIII).
Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents – Page 11
At least 3 regimens have activity in the treatment of TE in at least 2 nonrandomized, uncontrolled trials,
although their relative efficacy compared with the previous regimens is unknown: 1) atovaquone (with meals or oral
nutritional supplements) plus pyrimethamine plus leucovorin (130) (BII); 2) atovaquone combined with sulfadiazine
or, for patients intolerant of both pyrimethamine and sulfadiazine, as a single agent (130) (BII) (If atovaquone is
used alone, measuring plasma levels might be helpful, given the high variability of absorption of the drug among
different patients; plasma levels of >18.5 µg/mL are associated with an improved response rate) (131–133); and 3)
azithromycin plus pyrimethamine plus leucovorin daily (134,135) (BII).
The following regimens have been reported to have activity in the treatment of TE in small cohorts of patients or in
case reports of one or a few patients: clarithromycin plus pyrimethamine (136) (CIII); 5-fluoro-uracil plus
clindamycin (137) (CIII), dapsone plus pyrimethamine plus leucovorin (138) (CIII); and minocycline or
doxycycline combined with either pyrimethamine plus leucovorin, sulfadiazine, or clarithromycin (139,140) (CIII).
Although the clarithromycin dosage used in the only published study was 1 g twice a day, dosages >500 mg have been
associated with increased mortality in HIV-1–infected patients treated for disseminated MAC. Dosages >500 mg twice
a day should not be used (DIII).
May 2013

21. Toxoplasma gondii Encephalitis: Treatment (3)
Adjunctive corticosteroids only if indicated for treatment of mass effect; monitor closely and discontinue as soon as possible
Anticonvulsants if history of seizures; continue at least through period of acute therapy
Should not be given prophylactically to all patients
Adjunctive corticosteroids (eg, dexamethasone) should be administered when clinically indicated only for
treatment of a mass effect associated with focal lesions or associated edema (BIII). Because of the potential
immunosuppressive effects of corticosteroids, they should be discontinued as soon as clinically feasible. Patients
receiving corticosteroids should be closely monitored for the development of other OIs, including cytomegalovirus
retinitis and TB disease.
Anticonvulsants should be administered to patients with a history of seizures (AIII), but should not be administered
prophylactically to all patients (DIII). Anticonvulsants, if administered, should be continued at least through the
period of acute therapy.
May 2013

22. Toxoplasma gondii Encephalitis: ART Initiation
No data to guide recommendation on when to start ART
Many recommend starting ART within 2-3 weeks after diagnosis of TE
In one study, lower rate of AIDS progression or death with early ART
Adjunctive corticosteroids (eg, dexamethasone) should be administered when clinically indicated only for
treatment of a mass effect associated with focal lesions or associated edema (BIII). Because of the potential
immunosuppressive effects of corticosteroids, they should be discontinued as soon as clinically feasible. Patients
receiving corticosteroids should be closely monitored for the development of other OIs, including cytomegalovirus
retinitis and TB disease.
Anticonvulsants should be administered to patients with a history of seizures (AIII), but should not be administered
prophylactically to all patients (DIII). Anticonvulsants, if administered, should be continued at least through the
period of acute therapy.
May 2013

23. Toxoplasma gondii Encephalitis: Monitoring and Adverse Events
Follow clinical and radiologic improvement
Ab titers not useful
Monitor for adverse events
Pyrimethamine: rash, nausea, bone marrow suppression
May be reversed with increase in leucovorin dosage
Sulfadiazine: rash, fever, leukopenia, hepatitis, nausea, vomiting, diarrhea, renal insufficiency, crystalluria
Clindamycin: rash, fever, nausea, diarrhea (including Clostridium difficile colitis), hepatotoxicity
TMP-SMX: rash, fever, leukopenia, thrombocytopenia, hepatotoxicity
Atovaquone: nausea, vomiting, diarrhea, rash, headache, hyperglycemia, fever
May 2013

24. Toxoplasma gondii Encephalitis: Monitoring and Adverse Events (2)
IRIS appears to occur rarely
May 2013

25. Toxoplasma gondii Encephalitis: Treatment Failure
Clinical or radiologic deterioration during first week of therapy, or lack of clinical improvement within days
Brain biopsy, if not done previously
If confirmed TE, consider switch to alternative treatment regimen
In patients who adhere to treatment, recurrence is unusual during maintenance therapy following initial clinical and radiographic response
May 2013

26. Toxoplasma gondii Encephalitis: Preventing Recurrence
Secondary prophylaxis:
Preferred:
Pyrimethamine mg PO QD + sulfadiazine 2,000-4,000 mg PO daily in 2-4 divided doses + leucovorin mg PO QD
Alternative:
Clindamycin 600 mg PO Q8H + pyrimethamine mg PO QD + leucovorin mg PO QD (not effective as PCP prophylaxis)
TMP-SMX DS 1 tablet BID
Atovaquone 750-1,500 mg PO BID + pyrimethamine 25 mg PO QD (+ leucovorin 10 mg PO QD)
Atovaquone 750-1,500 mg PO BID + sulfadiazine 2,000-4,000 mg PO daily in 2-4 divided doses
Atovaquone 750-1,500 mg PO BID
May 2013

27. Toxoplasma gondii Encephalitis: Preventing Recurrence (2)
Discontinuing maintenance therapy: consider in asymptomatic patients after successful initial therapy for TE, resolution of signs and symptoms of TE, and sustained increase in CD4 count to >200 cells/µL for >6 months, on ART
Consider brain MRI before treatment discontinuation; continue therapy if mass lesions present or enhancement persists
Restart secondary prophylaxis if CD4 count decreases to <200 cells/µL
May 2013

28. Toxoplasma gondii Encephalitis: Considerations in Pregnancy
Check T gondii IgG during pregnancy
If suspected or confirmed T gondii infection, evaluate and manage with a maternal-fetal specialist
Diagnostic considerations same as for nonpregnant women
May 2013

29. Toxoplasma gondii Encephalitis: Considerations in Pregnancy (2)
Perinatal transmission usually occurs only with acute maternal infection; case reports of transmission with reactivation of chronic infection in women with severe immunosuppression
If toxoplasmosis during pregnancy (primary infection or reactivation of chronic toxoplasmosis):
Detailed ultrasound of fetus
Consider PCR of amniotic fluid in select circumstances
Neonate should be evaluated for evidence of congenital infection
May 2013

30. Toxoplasma gondii Encephalitis: Considerations in Pregnancy (3)
Primary prophylaxis: recommended
TMP-SMX preferred
Balance possible risks with expected benefits
Treatment: as in nonpregnant adults
Secondary prophylaxis: as in nonpregnant women
May 2013

31. Toxoplasma gondii Encephalitis: Considerations in Pregnancy (4)
Pyrimethamine appears safe in human pregnancy
Sulfadiazine appears safe though, if given around time of delivery, may increase risk of neonatal kernicterus
Clindamycin considered same in pregnancy
Dapsone: risk of mild maternal hemolysis with long-term therapy; low risk of hemolytic anemia in exposed fetuses with G6PD deficiency
May 2013

32. Toxoplasma gondii Encephalitis: Considerations in Pregnancy (5)
Consider immediate initiation of ART, to decrease risk of perinatal HIV transmission, especially for women diagnosed with TE in 3rd trimester
Preconception care for women receiving TE prophylaxis: discuss option of deferring pregnancy until TE prophylaxis can be discontinued safely
May 2013

33. Parasites
Cryptosporidiosis

34. Cryptosporidiosis: Epidemiology
Caused by Cryptosporidium species
Protozoan parasites
Infect small intestine mucosa; in immunosuppressed patients, also infect large intestine and other sites
Advanced immunosuppression (eg, CD4 <100 cells/µL) associated with prolonged, severe, or extraintestinal disease
May 2013

35. Cryptosporidiosis: Epidemiology (2)
Infection results from ingestion of oocysts excreted in feces of infected humans or animals
Water supplies and recreational water sources (oocysts may withstand standard chlorination)
Person-to-person transmission common, via oral-anal contact, from infected children to adults (eg, during diapering), or care of patients with diarrhea
May 2013

36. Cryptosporidiosis: Epidemiology (3)
Common cause of chronic diarrhea in AIDS patients in developing countries
In developed countries with low rates of envrionmental contamination and widespread use of effective ART, <1 case per 1,000 person-years in AIDS patients
May 2013

37. Cryptosporidiosis: Clinical Manifestations
Acute or subacute onset of profuse watery, nonbloody diarrhea, often with nausea, vomiting, and abdominal cramping
Fever in 1/3 of patients
Can be very severe, especially with immune suppression
Malabsorption is common; dehydration, electrolyte abnormalities, malnutrition may result
Biliary tract and pancreatic duct may be infected, causing scleroding cholangitis and pancreatitis
Pulmonary infection is possible
May 2013

38. Cryptosporidiosis: Diagnosis
Microscopic identification of oocysts in stool or tissue
DFA very sensitive, specific, is current gold standard for stool specimens
Acid-fast staining often used
PCR extremely sensitive
ELISA or immunochromatographic tests
Small intestine biopsy with identification of Cryptosporidium organisms
May 2013

39. Cryptosporidiosis: Diagnosis (2)
Single specimen usually sufficient in profuse diarrhea
Repeat stool sampling is recommended in mild disease
May 2013

40. Cryptosporidiosis: Prevention
Preventing exposure
Avoid exposure to infected contacts
Contact with diarrhea
Potential oral exposure to feces during sex
Direct contact with farm animals, stool from pets
Scrupulous handwashing after potential contact with feces (eg, after diapering), after handling pets or other animals, gardening, before preparing food or eating, before and after sex
May 2013

41. Cryptosporidiosis: Prevention (2)
Avoid exposure to contaminated water, food
Do not drink or swallow water from recreational sources (lakes, streams, pools)
Ice, fountain beverages, water fountains may be contaminated
Avoid raw oysters
May 2013

42. Cryptosporidiosis: Prevention (3)
Boil tap water for ≥1 minute during outbreaks or when community advisory is issued
Submicron water filters or bottled water may reduce risk
For non-outbreak settings, data are inadequate to recommend that all persons with low CD4 counts avoid drinking tap water
Consider drinking only filtered water
May 2013

43. Cryptosporidiosis: Prevention (4)
Preventing disease
Primary prophylaxis:
Appropriate initiation of ART before severe immunosuppression should prevent disease
Rifabutin and possibly clarithromycin are protective, but data insufficient to recommend as chemoprophylaxis
May 2013

44. Cryptosporidiosis: Treatment
Preferred strategies
ART with immune restoration (to CD4 count >100 cells/µL)
Usually results in complete resolution; should be offered as part of initial management of cryptosporidiosis
Symptomatic treatment: antidiarrheals
Tincture of opium may be more effective than loperamide
Octreotide usually not recommended (no more effective than other antidiarrheals)
Supportive care: aggressive hydration, electrolyte repletion, nutritional support (IV therapies may be needed)
May 2013

45. Cryptosporidiosis: Treatment (2)
Alternative strategies
No consistently effective antimicrobial therapy in absence of ART
Consider nitazoxanide or other antiparasitic drugs in conjunction with ART, not instead of ART
Nitazoxanide 500-1,000 mg PO BID for 14 days + ART and other measures above
Some studies show clinical improvement with nitazoxanide
Paromomycin 500 mg PO QID for days + ART and other measures above
Limited data; may improve clinical response in conjunction with ART
May 2013

46. Cryptosporidiosis: Starting ART
ART should be offered as part of initial management of this infection
PIs inhibit Cryptosporidium in animal models – some experts prefer PI-based ART
May 2013

47. Cryptosporidiosis: Monitoring and Adverse Events
Monitor closely for volume depletion, electrolyte loss, weight loss, and malnutrition
TPN may be indicated
IRIS not reported
May 2013

48. Cryptosporidiosis: Treatment Failure
Supportive treatment
Optimization of ART
May 2013

49. Cryptosporidiosis: Prevention of Recurrence
No effective prevention, other than immune restoration with ART
May 2013

50. Cryptosporidiosis: Considerations in Pregnancy
Rehydration and ART initiation as with nonpregnant adults
Nitazoxanide not teratogenic in animals, but no data in pregnant humans
Use after 1st trimester in severely symptomatic women
Paromomycin: limited information on teratogenicity; minimal systemic absorption with PO administration
May 2013

51. Cryptosporidiosis: Considerations in Pregnancy (2)
Loperamide: possible risk of hypospadias with 1st-trimester exposure
Avoid during 1st trimester, unless benefits expected to outweigh risks
Preferred antimotility agent during late pregnancy
Tincture of opium not recommended during late pregnancy
Opiate exposure during late pregnancy associated with neonatal respiratory depression; chronic exposure may result in neonatal withdrawal
May 2013

52. Parasites
Microsporidiosis

53. Microsporidiosis: Epidemiology
Protists, related to fungi
Many species, including Enterocytozoon bieneusi, Encephalitozoon cuniculi, Encephalitozoon intestinalis
Ubiquitous, may be zoonotic and/or waterborne
Risk greatest with CD4 count <100 cells/µL
Incidence dramatically lower in areas with widespread use of effective ART
May 2013

54. Microsporidiosis: Clinical Manifestations
Most common: diarrheal illness
Other manifestations: cholangitis, hepatitis, encephalitis, ocular infection, sinusitis, myositis, disseminated infection
Clinical syndromes may vary by species
May 2013

55. Microsporidiosis: Diagnosis
Microscopic identification of stool or tissue samples
Identification requires high magnification (1,000×), selective stains to differentiate spores from cellular debris
Electron microscopy, PCR, Ab-specific stains can determine species
Evaluate 3 stool samples
Small bowel biopsy if stool studies are negative and suspicion is high
Urine examination may be useful if cause is Encephalitozoon or Trachipleistophora spp
May 2013

56. Microsporidiosis: Prevention
Preventing exposure
Handwashing; avoidance of undercooked meat or seafood and exposure to infected animals
Patients with CD4 counts of <200 cells/μL should avoid drinking untreated water
Primary prophylaxis
Appropriate initiation of ART before severe immunosuppression should prevent disease
No chemoprophylaxis known to be effective
May 2013

57. Microsporidiosis: Treatment
ART with immune restoration (to CD4 count >100 cells/µL)
Should be offered to all as part of initial management
If severe dehydration, malnutrition, wasting: hydration, nutritional support (IV therapies may be needed)
Antimotility agents, if needed for diarrhea control
May 2013

58. Microsporidiosis: Treatment (2)
E bieneusi GI infections:
ART and fluid support as above
no specific antimicrobial;
Fumagillin 60 mg PO QD or TNP-470: some evidence of efficacy but not available in United States
Nitazoxanide: limited data; cannot be recommended with confidence
Nonocular infection caused by microsporidial other than E bieneusi and V corneae:
Albendazole 400 mg PO BID
May 2013

59. Microsporidiosis: Treatment (3)
Disseminated disease caused by Trachipleistophora or Anncaliia
Itraconazole 400 mg PO QD + albendazole 400 mg PO BID
Ocular infection: fumagillin (Fumidil B) eye drops 70 mcg/mL + albendazole 400 mg PO BID
May 2013

60. Microsporidiosis: Starting ART
ART should be offered as part of initial management of this infection
May 2013

61. Microsporidiosis: Adverse Events
Albendazole: adverse effects are rare; monitor hepatic enzymes
Fumagillin
Topical: no known substantial side effects
Oral: thrombocytopenia
IRIS: 1 report
May 2013

62. Microsporidiosis: Treatment Failure
Supportive treatment
Optimization of ART
May 2013

63. Microsporidiosis: Prevention of Recurrence
Ocular:
If CD4 >200 cells/µL on ART, consider discontinuing treatment after ocular infection resolves; restart if CD4 drops to <200 cells/µL
Other manifestations:
Safety of treatment discontinuation after immune restoration with ART is not known
Reasonable to discontinue maintenance therapy in asymptomatic patients on ART with increase in CD4 count to >200 cells/µL for ≥6 months (no data to support this approach)
May 2013

64. Microsporidiosis: Considerations in Pregnancy
Initiate ART to restore immune function
Albendazole:
Embryotoxic and teratogenic in animals
Not recommended in 1st trimester, use during later pregnancy only if benefits expected to outweigh risks
Systemic fumagillin: growth retardation in rats: should not be used with pregnant women
Topical fumagillin appears safe
May 2013

65. Microsporidiosis: Considerations in Pregnancy (2)
Itraconazole: avoid in 1st trimester
Loperamide: possible risk of hypospadias with 1st-trimester exposure
Avoid in 1st trimester, unless benefits expected to outweigh risks
Preferred antimotility agent during late pregnancy
Tincture of opium not recommended during late pregnancy
Opiate exposure during late pregnancy associated with neonatal respiratory depression; chronic exposure may result in neonatal withdrawal
May 2013

66. Websites to Access the Guidelines
May 2013

67. About This Slide Set
This presentation was prepared by Susa Coffey, MD, and Oliver Bacon, MD, for the AETC National Resource Center in May 2013
See the AETC NRC website for the most current version of this presentation:
May 2013