1

aiv infeqcia/SidsiT avadmyofTa

mkurnaloba da movla

klinikuri marTvis nacionaluri rekomendacia

(gaidlaini)

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) `aiv

infeqcia/SidsiT avadmyofTa mkurnaloba da movla~ miRebulia klinikuri

praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa

marTvis saxelmwifo standartebis (protokolebi) SemuSavebis, Sefasebis

da danergvis erovnuli sabWos 2007 wlis 21 martis #1 sxdomaze da

damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri

dacvis ministris 2008 wlis 26 ivlisis #176/o brZanebiT.

3

aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla

klinikuri rekomendaciebis zogadi mizani

klinikuri saxelmZRvanelo-rekomendaciebis mizans warmoadgens uaxles

samecniero mtkicebulebebze dafuZnebuli informaciis miwodeba aiv-

infeqcia/SidsiT avadmyofTa gamokvlevis, mkurnalobis, oportunistuli

infeqciebis, vaqcinaciis, monitoringis Sesaxeb eqim -

infeqcionistebisTvis, ojaxis eqimebisTvis, jandacvis pirveladi rgolis

muSakebisTvis, zemoT aRniSnul dargSi momuSave saSualo samedicino

personalisTvis da yvela dainteresebuli pirisTvis.

ganxiluli klinikuri sakiTxebi

mocemuli klinikuri rekomendaciebi ganixilaven aiv-infeqcia/Sidsis

antiretrovirusul mkurnalobasTan dakavSirebul sakiTxebs,

oportunistuli infeqciebis profilaqtikas, gamovlinebebs,

diagnostikasa da mkurnalobas, vaqcinaciis ZiriTad principebs,

avdmyofebis laboratorul-instrumentul gamokvlevebs mkurnalobamde

da mkurnalobis dawyebis Semdeg, romlebic unda Catardes profilur

dawesebulebaSi Sesabamisi kvalifikaciis mqone specialistis mier.

gaidlaini gankuTvnilia

eqim-infeqcionistebisTvis, nebismieri profilis eqimebisTvis

socialuri muSakebisTvis da eqTnebisaTvis.

mtkicebulebaTa doneebisa da rekomendaciebis xarisxi

winamdebare saxelmZRvaneloSi yvela rekomendacias gaaCnia gradacia,

romelic aRiniSneba laTinuri asoebiT А-dan D-mde. amave dros yovel

gradacias Seesabameba monacemTa mtkicebulebis garkveuli done. rac

ufro maRalia rekomendaciis gradacia, miT ufro maRalia kvlevebis

sizuste, romlebzec is aris dafuZnebuli

4

done mtkicebulebis siZlieris done

(Muir Gray) xarisxi rekomendaciis

xarisxi

(Cook et al) I

Zlieri mtkicebuleba, eyrdnoba

minimum erT sistemur

mimoxilvas, romelic efuZneba

swori dizainis mqone

randomizebul kontrolirebad

kvlevas

A

eyrdnoba I donis

mtkicebulebas da

Sesabamisad mtkiced

rekomendebulia

II

Zlieri mtkicebuleba, eyrdnoba

minimum erTi swori dizainis

mqone randomizebul

kontrolirebad kvlevas

B

eyrdnoba I donis

mtkicebulebas da

Sesabamisad

rekomendebulia

III

klinikuri kvleva

randomizaciis gareSe,

kohortuli da SemTxveva-

kontrolis kvlevebi

C

eyrdnoba III donis

mtkicebulebas

SeiZleba CaiTvalos

Sesabamisad

IV

araeqsperimentuli

multicentruli kvlevebi

D

eyrdnoba IV da

Vdonis

mtkicebulebas

saWiroebs konsesuss

Va

avtoritetul profesionalTa

mosazreba

Vb

klinikuri gamocdileba,

aRwerilobiTi kvlevebi an

eqspertTa angariSi

5

aabbrreevviiaattuurraa

aaiivv adamianis imunodeficitis virusi

aalltt alaninaminotransferaza

anrti

ara-nukleoziduri revers transkriftazas

inhibitori

aarrvv antiretrovirusuli

aarrTT antiretrovirusuli Terapia

aasstt aspartataminotransferaza

vvdd virusuli datvirTva

iirrss imunuri rekonstituciis sindromi

iiffaa imunofermentuli analizi

mmaaaarrTT maRalaqtiuri antiretrovirusuli Terapia

mmggbb mJavagamZle baqteria

mmrrttbb multirezistentuli tuberkulozi

nrti

nukleoziduri revers transkriftazas

inhibitori

ooii oportunistuli infeqciebi

ppii proteazas inhibitorebi

ppjjrr polimerizaciis jaWvuri reaqcia

ttbb tuberkulozi

SSiiddssii SeZenili imunodeficitis sindromi

jjaannmmoo jandacvis msoflio organizacia

AABBCC abakaviri

ddddII didanozini

EEFFVV efavirenzi

FFTTCC emtricitabini

LLPPVV//rr lopinavir/ritovaniri

NNFFVV nelfinaviri

ZZDDVV zidovudini

RRTTVV ritonaviri

SSQQVV seqvinaviri

TTDDFF tenofoviri

33TTCC lamivudini

UUNNAAIIDDSS gaeros aiv/Sidsis gaerTianebuli programa

6

1. daavadebis definicia, klasifikacia da terminologia

Sidsi abreviaturaa da iSifreba, rogorc SeZenili imunodeficitis

sindromi. daavadeba Sidsis gamomwvevia adamianis imunodeficitis virusi

(aiv-i). aiv infeqcia ewodeba daavadebas virusiT inficirebis momentidan

sicocxlis bolomde. terminiT Sidsi aRiniSneba aiv infeqciis bolo

stadia. aiv -i adamianis organizmSi SeWris Semdeg azianebs imunur

sistemas, ris Sedegad inficirebul pirs SesaZloa ganuviTardes

nebismieri infeqcia an/da simsivne, xSirad, sasikvdilo SedegiT.

aiv infeqciis klasifikaciis sistema (CDC)

kkaatteeggoorriiaa CCDD44 uujjrreeddeebbiiss

rraaooddeennoobbiiss

mmiixxeeddvviiTT

kklliinniikkuurrii

kkaatteeggoorriiaa

kklliinniikkuurrii

kkaatteeggoorriiaa AAkklliinniikkuurrii

kkaatteeggoorriiaa BB

kklliinniikkuurrii

kkaatteeggoorriiaa CC

A B C

• asimptomuri aiv infeqcia;

• persistuli

generali-

zebuli

limfade-

nopaTia

(pgl)*;

simptomuri,

garda A da C kategoriebSi

miTiTebuli

mdgomareo-

bebisa

ezofaguri da/an traqeo-

bronquli kandidozi;

• eqstrapulmonuri

koqcidiodomikozi;

• eqstrapulmonuri

kriptokokozi;

• saSvilosnos yelis

invaziuri kibo;

1) >500/mm3

(≥29%) A1 B1 C1

2) 200-500 mm3

(14-28%) A2 B2 C2

3) <200

(<14%) A3 B3 C3

7

* ruxi feriT moniSnul ujrebSi

miTiTebuli kategoriebi

Seesabameba Sidss.

• mwvave (pirve-ladi) aiv

daavadeba

* limfuri

kvanZebi or an

met midamoSi

(sazardulis

garda)

diametriT

> 1 sm-ze,

3 an meti Tvis

ganmavlobaSi.

• baqteriuli

angiomatozi;

• persistuli

vulvova-

ginaluri

kandidozi, 1

Tveze meti

xangrZli-

vobis,

romelic

cudad

eqvemdebareba

mkurnalobas;

• saSvilosnos

yelis mZime

displazia an

karcinoma

insitu; • konstitu-ciuri

simptomebi,

mag., cxeleba

(≥38,50C) an diarea 1

Tveze meti

xnis

ganmavlobaSi

• da sxva.

-----------------------------

aRniSnuli

mdgomareobebi

ganpirobebuli

unda iyos aiv

infeqciiT.

• qronikuli intestinuri

kriptosporidiozi;

• citomegalovirusuli

infeqcia: retiniti, an

sxva lokalizaciis,

garda RviZlis,

elenTis, limfuri

kvanZebisa;

• aiv encefalopaTia;

martivi herpesi: kanis da

lorwovanis wylulebiT

1 Tveze meti xnis

ganmavlobaSi,

bronqiti, pnevmonia;

• diseminirebuli,

eqstrapulmonuri

histoplazmozi;

• qronikuli

izosporiazi;

• kapoSis sarkoma; • limfoma: berkitis,

imunoblasturi, Tavis

tvinis pirveladi;

• atipiuri mikobaqteriiT

(M.avium an M.kansasii) infeqcia;

• pulmonuri an

eqstrapulmonuri

tuberkulozi;

• Pneumocystic carinii-iT

gamowveuli pnevmonia;

• rekurentuli pnevmonia,

(2 an meti epizodi

weliwadSi);

• progresirebadi mravalkerovani leiko-

encefalopaTia (pml);

• rekurentuli

salmoneluri

baqteriemia;

• cerebruli

toqsoplazmozi;

• aiv-iT gamowveuli

ganlevis sindromi.

terminologia:

virusuli datvirTva – ewodeba adamianis imunodeficitis virusis (aiv-is)

rnm-is raodenobas (koncentracias) plazmis 1 ml-Si;

“fanjara” periodi – ewodeba periods adamianis imunodeficitis virusis

organizmSi SeWridan aiv-antisxeulebis gamomuSavebamde;

mwvave retrovirusuli sindromi – ewodeba aiv-is organizmSi SeWridan 2-

3 kviris Semdeg ganviTarebul “infeqciuri mononukleozis msgavs

sindroms”, romelic grZeldeba 2-3 kvira, mas mosdevs klinikuri

gaumjobesebisa da serokonversiis periodi;

klinikuri gaumjobeseba da serokonversia moicavs 2-4 kviras; am

periodSi organizmSi gamomuSavdeba aiv-antisxeulebi;

asimptomuri/qronikuli aiv infeqcia grZeldeba saSualod 8 weli; am

periodis ganmavlobaSi TandaTan mcirdeba CD4+ limfocitebis

absoluturi raodenoba SratSi da izrdeba virusuli datvirTva

plzmaSi;

oportunistuli infeqcia ewodeba iseT infeqciebs, romlis gamomwvevi

(baqteria, virusi, paraziti Tu soko) Cveulebriv SeiZleba janmrTeli

8

adamianis organizmSic binadrobdes da ar iwvevdes paTologias da

mxolod imunokomprometirebul pirebSi gamoiwvios davaadeba. maRalaqtiuri antiretrovirusuli Terapia (maarT)- (HAART - High Activity antiretroviral Therapy) –3 an meti antiretrovirusuli preparatis kombinaciis xangrZlivad gamoyenebaa aiv infeqcia/SidsiT avadmyofebSi, romlis

Sedegad: aRdgeba dazianebuli imunuri sistema, xangrZlivad iTrguneba

Sidsis virusis replikacia, xangrZlivdeba avadmyofis sicocxle da

umjobesdeba pacientis sicocxlis xarisxi.

imunuri rekonstituciis sindromi (irs) – ewodeba paradoqsul reaqcias,

romelic viTardeba antiretrovirusuli mkurnalobis dawyebis Semdeg

da gamoxateba mdgomareobis gauaresebiT, rac dakavSirebulia latentur

mdgomareobaSi myofi ama Tu im oportunistuli paTogenis

gaaqtiurebasTan. imunuri rekonstituciis sindromi aixsneba

antiretrovirusuli Terapiis Sedegad aRdgenili imunuri sistemis

uCveulod mZlavri zemoqmedebiT mag: tuberkulozis mikobaqteriaze.

2. epidemiologia aiv infeqcia/Sidsis gavrceleba msoflioSi

aiv/Sidsis epidemia kvlav rCeba dinamikur da mzardi xasiaTis epidemiad,

romelmac saocari siswrafiT moicva msoflios praqtikulad yvela

kontinenti, yvela qveyana da daamtkica, rom igi Tanabrad emuqreba yvelas

rasis, sqesis, asakis, erovnebis, ganaTlebisa da sarwmunoebis miuxedavad.

jandacvis msoflio organizaciis (janmo) monacemebiT Sidss msoflioSi

sikvdilianobis mizezTa Soris meoTxe adgili ukavia. marTalia,

antiretrovirusuli Terapiis (arT) xelmisawvdomobam da efeqturma

profilaqtikurma programebma ganapirobes ganviTarebul qveynebSi

mdgomareobis stabiluroba, magram mTlianad msoflioSi aiv

inficirebulTa ricxvi mudmivad izrdeba.

Sidsi registrirebulia msoflios 216 qveyanaSi. maTgan 41 qveyanaSi aqvs

generalizebuli xasiaTi, xolo 85 – koncentrirebulia mxolod maRali

riskis jgufebSi.

gaeros Sidsis programis (UNAIDS) 2004 wlis monacemebiT msoflioSi

epidemiis dawyebidan dRemde inficirebulia 39.4 milioni adamiani, maT

Soris:

mozrdilebi 37.2 mln

qalebi 17,6 mln

bavSvebi <15w 2.2 mln

epidemiis dawyebidan dRemde gardaicvala 20 milionze meti adamiani.

mxolod 2004 wels dainficirda 4,9 milioni adamiani, maT Soris:

mozrdilebi 4,3 mln

bavSvebi <15w 640 000

2004 wels gardaicvala 3,1 milioni adamiani, maT Soris:

mozrdilebi 2,6 mln

bavSvebi <15w 510 000

9

aRsaniSnavia, rom msoflioSi inficirebis axali SemTxvevebis naxevari 15-

dan 24 wlis asakze modis. amasTan, Tu epidemiis dasawyisSi aiv

inficirebuli mamakacebis raodenoba mniSvnelovnad aRemateboda

inficirebuli qalebis raodenobas, ukanasknel wlebSi proporcia

dairRva da 2002 wlidan msoflioSi Sidsis virusiT inficirebulTa

TiTqmis naxevari qalebma da gogonebma Seadgines. es tendencia

gansakuTrebiT SesamCvevia msoflios im regionebSi, sadac dominirebs aiv-

is gadacemis heteroseqsualuri gza.

sayuradReboa aiv inficirebul orsul qalTa da axalSobilTa

raodenobis mzardi dinamika. gamokvlevebiT dadginda, rom bavSvTa 90%

aiv-iT inficirdeba vertikaluri (dedidan Svilze gadacemis) gziT.

gansakuTrebuli msjelobis sagania Sidsis gamo daoblebuli bavSvebi.

mxolod, sub-saharul afrikaSi Sidsis Sedegad daaxloebiT 12 milion

bavSvs daeRupa erTi an orive mSobeli.

aiv infeqcia/Sidsis yvelaze meti SemTxveva oficialurad aRricxulia

aSS-Si. Tumca realurad inficirebulTa raodenoba yvelaze metia

afrikis kontinentze.

marTalia, sub-saharul afrikaSi dedamiwis populaciis mxolod 10%

cxovrobs, magram msoflioSi yvela aiv inficirebulTa 2/3 swored am

regionze modis. subsaharuli afrikis qveynebSi aiv infeqciis gadacemis

ZiriTadi gza heteroseqsualuri kontaqtebia.

amerikis kontinentze aRricxulia daaxloebiT 2,7 mln aiv inficirebuli

(CrdiloeTi amerika – 1 mln SemTxveva, samxreTi amerika – 1,7 mln).

kanadasa da aSS-Si aiv inficirebis SemTxvevaTa 25% gamowveulia

narkotikebis ineqciuri moxmarebiT.

amerikis kontinentze aiv infeqcia aSS-s Semdeg yvelaze farTod

braziliasa da meqsikaSi aris gavrcelebuli. am qveynebSi dominirebs aiv

infeqciis gavrceleba narkotikebis ineqciuri moxmarebiT an

homoseqsualuri kontaqtebis Sedegad.

dasavleT evropaSi aiv/Sidsis yvelaze meti SemTxveva aRricxulia

inglisSi (≈ 62.000), Semdeg SveicariaSi, portugaliasa da germaniaSi.

aiv/Sidsis gavrcelebis maRali maCveneblebi dafiqsirda holandiaSi,

SvedeTSi, saberZneTSi, safrangeTsa da italiaSi. inficirebulTa 37%

qalia, 29% _ axalgazrdebi 30 wlamde. am qveynebSi aiv inficirebis

ZiriTadi mizezebia

• 50% _ heteroseqsualuri kontaqtebi

• 30% _ homo/biseqsualuri kontaqtebi

• 11% _ narkotikebis ineqciuri moxmareba

centralur evropaSi kvlav SenarCunebulia aiv/Sidsis SemTxvevaTa

dabali prevalentoba, Tumca am regionSi maRalia pediatriuli Sidsis

maCveneblebi.

aziis kontinentze registrirebulia aiv infeqciis 7.4 mln. SemTxveva. es

regioni didi xnis manZilze aiv infeqciisagan Tavisufal zonad

iTvleboda, amJamad ki axali SemTxvevebis gamovlinebis mxriv azia erT-

erT pirvel adgilze aRmoCnda. gansakuTrebiT SemaSfoTebeli

10

statistikaa samxreT (pirvel rigSi CineTsa da indoeTSi) da samxreT

aRmosavleT aziaSi.

epidemia Zalas ikrebs aRmosavleT evropis qveynebSi. ukanasknel wlebSi

msoflioSi aiv infeqciis yvelaze swrafi aRmavloba swored am regionSi

dafiqsirda. axali SemTxvevebis 76% modis ruseTis federaciaze, sadac

yovelwliurad ormagdeba inficirebulTa raodenoba. aiv/Sidsis

epidafeTqeba aRiniSneba ukrainasa da belorusiaSi. ukrainaSi

mosaxleobis 1%-ia inficirebuli.

aRmosavleT evropis qveynebSi aiv inficirebis mizezebia:

• 61% _ narkotikebis ineqciuri moxmareba

• 24% _ heteroseqsualuri kontaqtebi

• 0,3% _ homo/biseqsualuri kontaqtebi

aiv infeqcia/Sidsis gavrcelebis ZiriTadi gza am regionSi ineqciuri

narkomaniaa, Tumca sul ufro izrdeba aiv-is heteroseqsualuri

transmisiis SemTxvevebi. aRniSnulis gaTvaliswinebiT saxezea Sidsis

virusis riskis jgufis pirebidan mosaxleobis farTo fenebSi

gavrcelebis tendencia.

aiv infeqcia/Sidsis gavrceleba saqarTveloSi 2006 wlis 31 dekembris monacemebiT saqarTveloSi oficialurad

registrirebulia aiv infeqcia/Sidsis 1800 SemTxveva, maTgan 2006 wels

gamovlinda 243 aiv inficirebuli adamiani.

registrirebul SemTxveevaTa 79% saqarTvelos sazRvrebs garedan

Semotanili infeqciaa. 18,5% Semotanili infeqciis lokaluri

gavrcelebis Sedegia aiv inficirebulis meuRleebsa da sqesobriv

partniorebze infeqciis gadacemis Sedegad.

gamovlenil inficirebulTagan 195 qalia, 643 mamakaci. 339 ganuviTarda

Sidsi, 174 - gardaicvala.

saqarTveloSi gamovlenili aiv inficirebulebis 64.3% daavadda

narkotikebis ineqciuri gziT moxmarebis Sedegad, 28.4% dainficirda

heteroseqsualuri kontaqtiT, 3,4% _ homo/biseqsualuri kontaqtiT, 1,1 %-

daavadda virusis vertikalurad (dedidan bavSvze) gadacemis gziT, 1,6,%-

Si inficirebis gza daudgenelia, 1,2 % dainficirda sisxlis gadasxmiT.

aiv inficirebis yvelaze meti SemTxveva registrirebulia TbilisSi 306,

Semdeg samegreloSi - 129, aWaraSi - 121 da imereTSi - 78. gamovlinda

ucxoeTis 25 moqalaqe, maTgan 10 dabrunda TavianT qveyanaSi.

saqarTveloSi SeiniSneba aiv infeqciis gavrcelebis aRmavali tempi. 2000

wels moxda aiv infeqciis registrirebuli SemTxvevebis gaormageba (1999

wlis 34 SemTxvevasTan SedarebiT 2000 wels gamovlinda 79 axali

SemTxveva), Semdeg 2004 wels moxda 2003 welTan SedarebiT SemTxvevaTa

1,5-jer zrda. 2005 wlis 20 oqtombris monacemebiT gamovlinda 170 axali

SemTxveva, rac aRemateba mTeli 2004 wlis manZilze gamovlenil

SemTxvevaTa ricxvs. saqarTveloSi aiv infeqciis gavrcelebis

Taviseburebani iseTivea, rogorc aRmosavleT evropis qveynebSi. Sidsis

gavrcelebis upirveles risk-jgufs aqac ineqciuri narkomanebi

11

warmoadgenen. magram, rogorc sxva qveynebis gamocdileba gviCvenebs,

Sidsis epidemia ar Semoifargleba mxolod narkomanTa wriT, Sidsis

Semdegi msxverplni narkomanTa sqesobrivi partniorebi iqnebian.

aiv infeqciis gadacemis gzebi

aiv infeqciis wyaros warmoadgens aiv inficirebuli an SidsiT

daavadebuli adamiani, rogorc daavadebis usimptomo periodSi, aseve -

klinikuri suraTis gaSlis Semdeg.

aiv aRmoCenilia adamianis mTel rig biologiur siTxeebSi. mas

gansakuTrebiT maRali koncentraciiT Seicavs sisxli, sperma, vaginaluri

sekreti, Tavzurgtvinis siTxe da dedis rZe.

Sidsis virusi gadaecema

• sqesobrivi kontaqtiT _ rogorc hetero, ise homoseqsualuri

kontaqtebiT (vaginaluri, analuri, oraluri);

• aiv inficirebuli sisxlis an misi calkeuli komponentebis gadasxmiT;

aiv inficirebuli sisxliT dabinZurebuli Spricis, nemsis da sxva

samedicino instrumentebis gamoyenebis SemTxvevaSi;

• inficirebuli dedisgan nayofze an axalSobilze mucladyofnis

periodSi, mSobiarobis an ZuZuTi kvebis dros.

Sidsis virusi ar gadaecema:

• haer-wveTovani gziT. Sesabamisad ar aris saSiSi aiv inficirebulTan

saubari, virusi ar gadaecema daxvelebiT, daceminebiT an kocniT.

• sayofacxovrebo da socialuri kontaqtebiT. ar aris saSiSi xelis

CamorTmeva, moxveva, daavadebulis mier gamoyenebuli WurWliT,

TeTreuliT, saerTo tualetiT da abazaniT sargebloba. ar aris

saSiSi aiv inficirebulTan erTad yofna sazogadoebrivi TavSeyris

adgilebSi da mgzavroba transportiT.

• virusi ar gadaecema mwerebis an/da cxovelebis saSualebiT.

3. aiv infeqciis etiopaTogenezi

aiv miekuTvneba retrovirusebis ojaxs,

lentivirusebis qveojaxs. lenti-

virusebi, Cveulebriv, nel infeqciebs

iwveven. maTTvis damaxasiaTebelia

daavadebis xangrZlivi latenturi

periodi, paTologiur procesSi

nervuli sistemis CarTva da susti

imunuri pasuxi, rasac Tan sdevs

persistuli viremia. ganasxvaveben aiv-1-

sa da aiv-2-s. aiv-2 mogvianebiT

aRmoaCines. igi aiv-1-sgan genetikuri

Taviseburebebis mixedviT gansxvavdeba

da ZiriTadad dasavleT afrikis

zogierT qveyanaSia gavrcelebuli,

Tumca sxva qveynebSic gvxvdeba. aiv-2

aiv-1-Tan SedarebiT ufro Znelad gadaecema. iSvaTia misi vertikaluri

12

gadacemis SemTxvevebic. aiv-2 infeqcia klinikurad aiv-1 infeqciis

msgavsia, Tumca virusuli datvirTva, Cveulebriv, dabalia da

daavadebis klinikuri progresireba ufro nelia.

aiv advilad inaqtivirdeba garemoSi. mSral pirobebSi virusi ramdenime

saaTSi iRupeba, Tumca SesaZloa 1-3 dRe gaZlos. Qqsovilovan kulturaSi

virusi oTaxis temperaturaze 15 dRe Zlebs, xolo 370C-ze – 11 dRe. 56-600C-ze virusi 30 wT-Si iRupeba. virusi advilad eqvemdebareba qimiuri

saSualebebiT sterilizacias. adamianis imunodeficitis virusi mdgradia

dabali temperaturisadmi -700C-ze ar inaqtivirdeba.

aiv-is ZiriTadi samizne ujredebia CD4+ limfocitebi (T helper anu Th limfocitebi), garda amisa igi ainficirebs monocit/makrofagebs, cns-is

mikroglias, folikulur-dendritul ujredebs da sxva.

aiv-iT ujredis inficirebisas virusis garsis cila – gp120 uerTdeba

samizne ujredis CD4 molekulas, rasac mohyveba virusis Sesvla ujredSi

da misi genetikuri masalis integracia maspinZlis genomSi. Semdeg ki

axali virionebis awyoba.

adamianis imunodeficitis virusis sasicocxlo cikli

rogorc cnobilia, CD4+ limfocitebi aiv-is ZiriTadi samizne ujredebia.

isini ZiriTad rols asruleben rogorc humoruli, ise – ujreduli

imunuri pasuxis ganxorcielebaSi, ris gamoc maT imunuri orkestris

diriJors uwodeben. aiv infeqciis imunopaTogenezSi wamyvani mniSvneloba

eniWeba CD4+ limfocitebis raodenobis Semcirebas da maTi funqciis

daTrgunvas, rasac Sedegad moyveba imunuri sistemis funqciis daTrgunva

– imunosupresia. CD4+ limfocitebis ricxvi progresulad mcirdeba aiv

infeqciis progresirebasTan erTad. igi virusul datvirTvasTan erTad

mniSvnelovani markeria aiv daavadebis monitorirebisaTvis.

aRsaniSnavia, rom virusis replikaciis TiToeul ciklSi warmoqmnili

Stamebi erTmaneTisgan mniSvnelovnad gansxvavdeba ujreduli tropizmiT,

antigenurobiT, wamlebis mimarT mgrZnobelobiT da sxva. aiv-is maRali

mutagenoba mas saSualebas aZlevs efeqtianad aicilos Tavidan

antivirusuli imunuri pasuxi, rac virusis persistencias uwyobs xels.

garda amisa, aiv-is mutaciis amgvari unari dabrkolebebs qmnis vaqcinis

SemuSavebisas da ganapirobebs wamlebis mimarT rezistentuli Stamebis

warmoqmnas.

13

aiv inficirebis gza, moxvedrili virusis raodenoba, aiv-is mocemuli

Stamis paTogenuroba da maspinZlis genetikuri faqtorebi gavlenas

axdens aiv specifikur imunur pasuxze.

maneitralizebeli antisxeulebi gamomuSavdebian pirveladi infeqciidan

2-4 kviris Semdeg da maqsimums asimptomuri fazis dros aRweven. maTi

gansazRvra sisxlSi rutinuli serologiuri testebiT SesaZlebelia

inficirebidan 4-8 kviris Semdeg. Aantisxeulebis gaCenas sisxlSi

serokonversia ewodeba. xolo periods inficirebidan serokonversiamde –

e.w. window periodi.

aiv antisxeulebis koncentracia mkveTrad ecema Sidsis ganviTarebasTan

erTad. maneitralizebeli antisxeulebi aiv sawinaaRmdego citotoqsikur

T limfocitebTan erTad imunuri pasuxis erT-erTi ZiriTadi komponentia,

romelic dasawyisSi nawilobriv ablokirebs aiv-is replikacias. Tumca

pirveladi infeeqciis dros ar xdeba aiv-is sruli eliminacia, rac

infeqciis qronikul mimdinareobas ganapirobebs. provirus dnm-is

integracia maspinZeli ujredis genetikur masalaSi da

imunokompetenturi ujredebis, upiratesad, CD4+ limfocitebis

destruqcia, imunuri sistemis funqciis moSlas da Rrma imunodeficitis

ganviTarebas iwvevs.

4. klinikuri simptomatika

aiv infeqciis klinikuri speqtri

aiv infeqciis bunebriv mimdinareobaSi (mkurnalobis gareSe) gamoyofen

Semdeg stadiebs:

virusis organizmSi SeWridan – 2-3 kviraSi viTardeba e.w.

mwvave retrovirusuli sindromi – 2-3 kvira;

klinikuri gaumjobeseba da serokonversia – 2-4 kvira;

asimptomuri qronikuli aiv infeqcia – saSualod 8 weli;

simptomuri aiv infeqcia/Sidsi – saSualod 1-3 weli;

sikvdili.

aiv infeqciis pirveladi gamovlinebaa mwvave retrovirusuli sindromi,

romelsac Tan axlavs CD4+ limfocitebis ricxvis mkveTri daqveiTeba,

plazmaSi maRali viremia.

cxrili #1

pirveladi aiv infeqcia: Civilebi da simptomebi (2002; US DHHS)

cxeleba – 96% mialgia – 54% hepatosplenomegalia –

14%

adenopaTia - 74% diarea – 32% wonaSi kleba – 13%

faringiti – 70% Tavis tkivili – 43% rZiana –12%

gamonayari – 70%

(eriTematozuli makulo-

papuluri gamonayari

sisuste da

moTenTiloba – 27%

nevrologiuri

gamovlinebebi – 12%

(aseptiuri meningiti,

14

saxesa da tanze,

iSviaTad – xelisa da

fexis gulebze, zogi

aRniSnavs wylulovan

gamonayars piris RruSi,

saylapavisa da

genitaluri organoebis

lorwovanze)

meningoencefaliti,

periferiuli

neiropaTia, gien-bares

sindromi, mxris

nevriti, kognitiuri

darRvevebi an

fsiqozuri

mdgomareoba)

klinikuri gaumjobesebis fazaSi aRiniSneba plazmaSi viremiis Semcireba,

citotoqsiuri T limfocitebiT ganpirobebuli imunuri pasuxi.

CD4+ limfocitebis ricxvis daqveiTeba kavSirSia virusuli datvirTvis

matebasTan, rac Sidsis ganviTarebisa da avadmyofis sikvdilis mizezia.

2002 wels Catarebuli erT-erTi gamokvlevis SedegebiT CD4+ limfocitebis ricxvi aiv rnm-is koncentraciis yoveli log10-iT

matebisas 1 ml-Si saSualod 4%-iT iklebs weliwadSi.

aiv rnm-is koncentracia plazmaSi mkveTrad imatebs mwvave infeqciis

periodSi da Semdeg iklebs, rac serokonversiisa da imunuri pasuxis

Sedegia.

daavadebis gviani stadia xasiaTdeba CD4+ limfocitebis ricxvis

daqveiTebiT <200 ujredi/mm3 da oportunistuli infeqciebis, zogierTi

simsivnis, ganlevis sindromis da nevrologiuri garTulebebis

ganviTarebiT.

aranamkurnaleb pacientebSi sicocxlis xangZlivoba mas Semdeg, rac CD4+ limfocitebis ricxvi 200 ujredi/mm3–mde daqveiTdeba, 3-7 welia; xolo

Tu SidsTan asocirebuli pirveli klinikuri niSnebis gamovlenis

momentisTvis CD4+ limfocitebis ricxvi udris an naklebia 60-70 ujr/mm3-

Si, maSin avadmyofis sicocxlis xangrZlivoba saSualod 1-3 welia.

daavadebis progresirebis tempi sxvadasxva pacientebSi variabeluria da

mniSvnelovnad aris damokidebuli, erTis mxriv, maspinZlis e.w. dacviT

faqtorebze da meores mxriv, virusis biologiur Taviseburebebze, aseve

mniSvnelovnad icvleba igi mkurnalobisa da profilaqtikis fonze.

Sidsis klinikuri gamovlinebani metad mravalferovania. SidsiT

daavadebuls Rrma imunodeficitis fonze SeiZleba ganuviTardes

praqtikulad nebismieri infeqcia da simsivne, magram maTi ganviTarebis

sixSire erTnairi ar aris. yvelaze xSirad uviTardebaT e.w.

oportunistuli infeqciebi da is simsivneebi, romlebic, savaraudod,

asocirebulia virusebTan.

oportunistuli ewodeba infeqcias, romlis gamomwvevi (baqteria, virusi,

paraziti Tu soko) Cveulebriv SeiZleba janmrTeli adamianis

organizmSic binadrobdes da ar iwvevdes paTologias da mxolod

imunokomprometirebul pirebSi gamoiwvios daavadeba. SidsiT

avadmyofebSi oportunustuli infeqciebi, rogorc wesi, Zalian mZimed

mimdinareobs, cudad eqvemdebareba mkurnalobas da xSirad sikvdiliT

mTavrdeba.

daavadebis progresirebis Sesafaseblad saukeTeso surogati markerebia

virusuli datvirTva (anu virusis koncentracia 1 ml plazmaSi) da CD4+

15

limfocitebis absoluturi ricxvi 1 mm3 sisxlSi, romelTa saSualebiT

SeasZlebelia daavadebis stadiisa da simZimis Sefaseba da mosalodneli

progresirebis prognozireba Sidsis klinikuri niSnebis gamovlenamde 1,5-

2 wliT adre. virusuli datvirTvis matebas, rogorc wesi, Tan sdevs CD4+ limfocitebis absoluturi ricxvis Semcireba. CD4+ pirdapirproporciul kavSirSia oportunistuli daavadebebis

ganviTarebis riskTan. Uufro metic, CD4+ ujredebis garkveul

maCvenebelze, ama Tu im konkretuli oportunistuli infeqciis da/an

simsivneebis ganviTarebaa mosalodneli (ix. cxr. #2).

cxrili #2

CD4+ limfocitebis ricxvis korelacia aiv infeqciis garTulebebTan

CD4+

limfocitebis

ricxvi

infeqciuri garTulebebi arainfeqciuri

garTulebebi

>500/mm3 - mwvave retrovirusuli

sindromi

- vaginaluri kandidozi

- persistuli generalizebuli

limfadenopaTia;

- gien-bares sindromi;

- miopaTia;

- aseptiuri meningiti.

200-500/mm3 - pnevmokokuri da sxva

baqteriuli pnevmoniebi;

- filtvis tuberkulozi;

- herpes zosteri;

- orofaringeuli kandi-

dozi;

- kriptosporidiozi,

TviTgankurnebadi;

- kapoSis sarkoma;

- Tmovani leikoplakia.

- cervikaluri

intraepiTeluri neoplazia;

- cervikaluri simsivne

(asocirebulia adamianis

papilomavirusTan);

- ujreduli simsivne;

- anemia;

- idiopaTiuri

Trombocitopeniuli purpura;

- hojkinis limfoma;

- limfocituri

intersticiuli pnevmonia.

<200/mm3 - pnevmocisturi pnevmonia

- diseminirebuli histo-

plazmozi da koqci-

diomikozi;

- miliaruli an fil-

tvgareSe tuberkulozi;

- progresirebadi multi-

fokaluri leikoencefa-

lopaTia.

- ganlevis sindromi;

- periferiuli neiropaTia;

- aiv asocirebuli demencia;

- kardiomiopaTia;

- vakuoluri mielopaTia;

- progresirebadi

poliradikulopaTia;

- arahojkinis limfoma.

<100/mm3 - diseminirebuli martivi

herpesi;

- toqsoplazmozi;

- kriptokokozi;

- kriptosporidiozi,

qronikuli;

- mikrosporidiozi;

- ezofaguri kandidozi.

16

<50/mm3 - diseminirebuli

citomegalovirusuli

infeqcia

- atipiuri mikobaqteriis

kompleqsiT gamowveuli

diseminirebuli infeqcia

- centraluri nervuli

sistemis limfoma

(asocirebulia

epStein-baris

virusTan)

Sidsi erTi konkretuli virusiT gamowveuli daavadebaa, magram amave

dros igi warmoadgens am virusiT gamowveuli imunodeficitis fonze

ganviTarebul daavadebaTa speqtrs, Aris gamoc Sidsis klinikuri

gamovlinebani imdenad mralavferovani SeiZleba iyos, rom Sidsis

diagnozis dadgena mxolod klinikuri niSnebis safuZvelze praqtikulad

SeuZlebelia. gadamwyveti misi diagnostikisTvis laboratoriuli

gamokvlevaa. Sesabamisad, Sidsze saeWvo SemTxvevaSi diferenciuli

diagnozi gatarebul unda iqnas yvela im daavadebasTan, romelic Sidsis

dros SeiZleba Segvxvdes.

marTalia, aiv infeqcias paTognomuri klinikuri niSnebi ar gaaCnia,

magram mainc SeiZleba gamoiyos simptomebisa da daavadebebis jgufi,

romelTa dros pirvel rigSi eWvi unda iqnas mitanili aiv

infeqcia/Sidsze. Eesenia:

aramotivirebuli (ucnobi etiologiis) cxeleba;

persistuli generalizebuli limfadenopaTia;

ganlevis sindromi (aiv kaxeqsia);

ucnobi etiologiis qronikuli diarea;

sxvadasxva saxis gamonayari kansa da lorwovanze;

gaxangrZlivebuli filtvebis anTeba, romelic cudad eqvemdebareba

Cveulebriv antibaqteriul Terapias;

nervuli sistemis sxvadasxva saxis dazianeba:

demencia, romlis erT-erTi mizezia Tavis tvinis atrofia;

kriptokokuli etiologiis meningiti;

toqsoplazmozuri encefaliti damaxasiaTebeli abscesebiT

Tavis tvinSi;

progresuli multifokaluri leikoencefalopaTia.

SidsisTvis paTognomuria sami simsivnuri daavadeba:

• limfuri sistemis simsivne (hojkinis da ara-hojkinis simsivneebi)

Tavis tvinis pirveladi limfoma, romelic gvxvdeba mxolod Sidsis an

sxva imunokomrpomisis fonze;

17

• saSvilosnos yelis invaziuri kibo da analuri invaziuri kibo

homoseqsual mamkacebSi;

• kapoSis sarkoma.

sayuradReboa, rom samive zemoT CamoTvlili simsivne asocirebula

virusebTan. limfuri sistemis kibo asocirebulia epStein-baris

virusTsan; saSvilosnos yelisa da analuri invaziuri kibo

asocirebulia papilomavirusTan, kapoSis sarkoma asocirebulia

adamianis me-8 tipis herpesis virusTan.

am simsivneebis arsebobis dros aucilebelia aiv intisxeulebze

testireba.

amasTan, aucileblad unda iqnes gaTvaliswinebuli epidemiologiuri

monacemebi (maRali riskis jgufi, aiv inficirebulTan kontaqti da sxva),

garda amisa, aiv infeqciaze gamokvleul unda iyvnen:

• sggd avadmyofebi:

sifilisiT;

gonoreiT;

qlamidioziT;

veneriuli limfogranulomiT;

triqomoniaziT da a.S daavadebulebi.

• B hepatitis virusiT inficirebulni;

• C hepatitis virusiT inficirebulni;

• tuberkulozis nebismieri formiT daavadebulni (filtvis

tuberkulozi, limfuri sistemis tuberkulozi, tuberkulozuri

poliseroziti, tuberkulozuri meningiti).

aramotivirebuli cxeleba (ucnobi etiologiis cxeleba)

ganmarteba: ucnobi etiologiis cxeleba ewodeba sami ZiriTadi

maxasiaTebelis Tanaarsebobas: 1) cxeleba 38.30C-ze an meti, 2)romelic

18

grZeldeba 3 kviraze meti periodis ganmavlobaSi 3) da diagnozis

garkveva ver moxerxda erTkviriani hospitalizaciis ganmavlobaSi.

samkviriani periodi aucilebelia TviTgankurnebadi virusuli

infeqciebis gamosaricxad.

persistuli generalizebuli limfadenopaTia

ganmarteba: persistuli generalizebuli limfadenopaTia ewodeba

mdgomareobas, rodesac 3 kviraze meti periodis ganmavlobaSi

hiperplazirebulia qvemoT CamoTvlili kanqveSa limfuri kvanZebidan 2-3

an meti: yuris wina, qvedaybisqveSa, kisris wina da ukana, kefisukana,

laviwzeda, laviwqveSa, iRliis, idayvis, sazardulis horizontalur

limfur kvanZTa jgufi, sazardulis vertikalur limfur kvanZTa jgufi.

samkviriani periodi aucilebelia limfadenopaTiiT mimdinare

TviTgankurnebadi virusuli infeqciebis gamosaricxad (ix. qvemoT).

persistuli generalizebuli limfadenopaTiis mizezi garda aiv

infeqciisa SeiZleba iyos:

- simsivneebidan: limfomebi, leikemiebi, kapoSis sarkoma,

metastazebi;

- infeqciebidan: brucelozi, katis nakawris daavadeba, veneriuli

limfogranuloma, infeqciuri mononukleozi, wiTura,

tuberkulozi, tularemia, tifoiduri cxeleba, sifilisi.

- autoimunuri daavadebebidan: sistemuri wiTeli mglura,

revmatoiduli arTriti, dermatomioziti, Segrenis sindromi.

- iSviaTad: kavasakis daavadeba, sarkoidozi, medikamentebiT

provocirebuli.

ganlevis sindromi

ganmarteba: wonaSi umizezod kleba sawyis wonasTan SedarebiT 10%-ze

meti erTi Tvis manZilze.

konstituciuri simptomebi (CDC-is klasifikaciiT) (aiv kaxeqsia – janmos

klasifikaciiT)

ganmarteba:

- wonaSi umizezod kleba: sawyisi wonis 10%-ze meti,

- an ucnobi etiologiis qronikuli diarea - 1 Tveze meti

xangrZlivobis,

- an qronikuli sisuste SeuRlebuli xangrZliv (1 Tveze meti)

ucnobi etiologiis cxelebasTan

ucnobi etiologiis qronikuli diarea

ganmarteba: qronikuli ewodeba diareas, romelic meordeba TiTqmis

yoveldRe 1 Tvis an meti drois manZilze. qronikuli diarea SeiZleba

mimdinareobdes ganlevis sindromiT an mis gareSe, temperaturiT an mis

gareSe.

afebriluri qronikuli diareis gamomwvevi SeiZleba iyos

kroptosporidia, izospora, mikrosporidia.

temperaturuli reaqcia Tan axlavs qronikuli diareis Semdeg mizezebs:

Jiardiozi, amebiazi, citomegalovirusiT gamowveuli diarea.

19

garda zemoT CamoTvlili gamomwvevebisa qronikuli diareis mizezi Rrma

imunodeficitis dros SeiZleba iyos: Mycobacteria Avium, Cyclospora cayetyaensis, Enteric virusis. zemoT CamoTvlili gamomwvevebis umravlesobis identifikacia Zalian

rTulia da aucilebelia an kvlevis kulturaluri meTodebis an

nawlavis biofsiis gamoyeneba.

gamonayari kansa da lorwovanze

imunokomprometirebul pirebSi gvxvdeba kanisa da lorwovanis igive

daavadebebi, rac imunokompetentur pirebSi, Tumca imunokom-

prometirebulebSi kanisa da lorwovanis banaluri daavadebebi

mimdinareobs rTulad, aqvs persistuli xasiaTi da rTulia samkurnalod.

qvemoT, mokled aris daxasiTebuli kanisa da lorwovanis is daavadebebi,

romlebic ufro xSirad viTardeba aiv infeqcia/Sidsis fonze.

Sesabamisad, klinicistma qvemoT aRwerili kanis da lorwovanis

romelime daavadebis identifikaciisas avadmyofi unda gamoikvlios aiv

antisxeulebze.

5. daavadebis diagnozi

laboratoriuli diagnostika

vinaidan aiv infeqcias paTognomuri klinikuri niSnebi ar gaaCnia,

gadamwyveti mis diagnostikaSi laboratoriuli gamokvlevaa.

aiv infeqciis laboratoriuli diagnostika sxvadasxva meTodiT

xorcieldeba, virusis kultivireba Semdgomi identifikaciiT, sisxlsa da

sxva biologiur siTxeebSi virusis antigenis da antisxeulebis

gansazRvra, virusis genomis gamovlena da sxva.

dReisaTvis aiv infeqciis laboratoriuli diagnostikis ZiriTadi

saSualebebia sisxlSi aiv sawinaaRmdego antisxeulebis da virusis

genetikuri masalis gansazRvra.

aiv antisxeulebis gansazRvris meTodebi or jgufad iyofa – pirveladi

anu skrininguli da damadasturebeli anu komfirmaciuli. skriningul

meTodebs miekuTvneba: aiv antisxeulebis gamovlena imunofermentuli

analizis (ifa), imunofluorescenciis, hemaglutinaciis,

imunoqromatografiis, mikroprecipitaciis da sxva meTodebiT.

gamokvlevis xangrZlivobis mixedviT es meTodebi iyofa Cveulebriv

(xangrZlivoba 2-5 saaTi) da swraf/martiv (xangrZlivoba 5-30 wuTi)

meTodebad. konfirmaciuli meTodebidan ZiriTadad gamoiyeneba

imunoblotingi (Western blot).

skriningul meTodebs Soris yvelaze farTod gamoiyeneba aiv

antisxeulebis gamovlena ifa da swrafi/martivi meTodebiT, romlebic

maRali mgrZnobelobiTa da specifikurobiT xasiaTdeba da amasTan,

advilad xelmisawvdomia. maTi saSualebiT aiv antisxeulebi sisxlSi

vlindeba inficirebidan 4-8 kviris Semdeg. dadebiTi Sedegis SemTxvevaSi

20

kvleva grZeldeba damadasturebeli anu, konfirmaciuli meTodiT –

imunoblotingiT (Western blot). imunoblotingis meTodi saSualebas iZleva

ganisazRvros specifikuri antigenebis, anu virusis calkeuli cilebis

sawinaaRmdego antisxeulebi.

sadReisod yvelaze zusti da maRalmgrZnobiare meTodia virusis genomis

(rnm, dnm) gamovlena polimerizaciis jaWvuri reaqciis (PCR) meTodiT.

arsebobs virusis genomis gamovlenis alternatiuli meTodebic – bDNA (branched chain DNA) da NASBA (Nucleic Acid Sequence-Based Amplification). Tumca

Tavisi mgrZnobelobiTa da specifikurobiT sadReisod isini PCR meTods

CamorCeba. bDNA meTodiT xdeba virusis rnm-is moniSnuli monakveTidan

signalis amplifikacia komplementuri dnm-iT hibridizaciis gziT. xolo

PCR da NASBA meTodebis SemTxvevaSi xdeba virusis moniSnuli rnm-is

amplifikacia fermentuli meTodebiT ise, rom gamravlebuli rnm

ganisazRvros Cveulebrivi meTodebiT.

PCR, romelic 80-ian wlebSi dainerga, didi win gadadgmuli nabijia

zogadad infeqciuri daavadebis, maT Soris aiv infeqciis diagnostikaSic.

misi saSualebiT xdeba infeqciuri agentis genetikuri masalis

amplifikacia da gamovlena im SemTxvevaSic ki, roca misi koncentracia

gamosakvlev masalaSi ukiduresad mcirea (1 virusi 100 000 ujredze).

PCR meTodi ori saxisaa: Tvisobrivi da raodenobrivi. Tvisobrivi

gamoiyeneba aiv infeqciis diagnostikisaTvis adreul stadiaze – sisxlSi

antisxeulebis gaCenamde, agreTve ifa da imunoblotingiT saWvo pasuxis

miRebis SemTxvevaSi. gansakuTrebiT didia misi diagnostikuri

Rirebuleba inficirebuli dedis axalSobilis aiv infeqciis

diagnostirebisas. rogorc cnobilia, aiv inficirebuli dedis

axalSobils SesaZloa arainficirebis SemTxvevaSic ki aReniSnos aiv

antisxeulebis arseboba maTi transplacenturi barieris gavlis gamo.

amitom gadamwyveti mniSvneloba axalSobilis aiv infeqciis

diagnostikaSi swored PCR meTods eniWeba.

raodenobrivi meTodi saSualebas iZleva ganisazRvros e.w. virusuli

datvirTva, anu virusis raodenoba 1 ml plazmaSi. virusuli datvirTva

saukeTeso markeria daavadebis prognozirebisa da mkurnalobis

efeqtianobis Sesafaseblad.

21

I. aiv inficirebul pacientTa marTva

1. pacientTa gamokvleva pirveli vizitisas

aiv inficirebuli pacientis gamokvleva pirveli vizitisas moicavs:

• detalur personalur, ojaxis da samedicino istorias;

• fizikalur gamokvlevas;

• laboratoriul da sxva gamokvlevebs;

• Sesabamisi specialistis gamokvlevas.

personaluri, ojaxis da samedicino istoria cxrili 3.

informacia, romelic aucileblad unda Sediodes samedicino istoriaSi

pirveli vizitisas

ZiriTadi informacia:

• pacientis saxeli;

• dabadebis weli, Tve, ricxvi;

• sqesi;

• vizitis TariRi.

informacia testirebis Sesaxeb:

• pirveli pozitiuri aiv testirebis TariRi;

• mizezi, Tu ratom Caitara testireba;

• bolo aiv negatiuri testirebis TariRi, Tu cnobilia.

aiv eqspoziciis riski da gadacemis kategoria (Tu cnobilia):

• saineqcio narkotikebis gamoyeneba;

• sqesobrivi (sqesobrivi kontaqtis saxis miTiTebiT);

• sisxlis an misi produqtebis gadasxma, organos an qsovilis

gadanergva;

• dedidan bavSvze gadacema;

• samsaxureobrivi eqspozicia (aRwerilobiT);

• ucnobi;

• sqesobrivi partnior(eb)is aiv statusi (Tu cnobilia);

• sqesobrivi partnior(eb)is risk-faqtorebi (Tu cnobilia).

aiv infeqciis gadadebis dro da adgili (qveyana), romelic yvelaze metad

aris savaraudo an cnobili (a)

aiv infeqciis mkurnalobis da movlis istoria: (ix. damateba 1)

• vizitamde aiv infeqciis mkurnalobis dro da adgili,

mkurnalobis Sewyvetis miTiTebiT;

• mkurnalobis reJimi;

• gverdiTi efeqtebi;

• reJimis dacva;

• laboratoriuli monacemebi (CD4, virusuli datvirva,

eleqtrolitebi, RviZlis funqciebi, Tirkmlis funqciebi,

sisxlis saerTo analizi, didi xnis win inficirebuli

pacientisTvis dalagebuli unda iyos qronologiurad) (7);

• vizitamde rezistentobis testis dokumentirebuli Sedegi (Tu

iyo gakeTebuli).

22

aiv asocirebuli daavadebebi da mdgomareobebi:

• tuberkulozi;

• respiratoruli infeqciebi;

• virusuli, baqteriuli da sokovani infeqciebi;

• hepatiti B da C; • neoplaziebi;

• sxva.

sxva daavadebebi da mdgomareobebi:

• hospitalizacia;

• qirurgiuli Careva;

• sulieri mdgomareoba (depresia da a.S.);

• Tirkmlis an RviZlis daavadebebi;

• endokrinologiuri daavadebebi;

• sqesobrivi gziT gadamdebi daavadebebi (sggd);

• vaqcinaciebi;

• alergiebi;

• sxeulis cvlilebebi;

• mimdinare medikamentebi.

ojaxis samedicino istoria (diabeti, arteriuli hipertenzia, kanis

daavadebebi, simsivneebi da a.S.)

gul-sisxlZarRvTa daavadebebi da daavadebis risk-faqtorebi (simsuqne,

Tambaqos Warbad moxmareba, arteriuli hipertenzia da a.S.)

eqspozicia tuberkulozTan (personaluri an ojaxuri kontaqtebi) b

mimdinare medikamentebi (opioid CanacvlebiTi Terapiis CaTvliT)

nivTierebaTa moxmareba:

• akrZaluli saineqcio narkotikebis moxmareba (warsulSi an

awmyoSi);

• alkoholuri damokidebuleba.

reproduqciuli da sqesobrivi janmrTeloba

• kontracefciis meTodebi qalebSi;

• orsuloba (wina, mimdinare, dagegmili);

• sqesobrivi praqtika.

socialuri istoria

• sacxovrebeli pirobebi (partnior(eb)i / meuRle / ojaxis wevrebi,

bavSvebi da a.S.);

• profesia da Tanamdeboba;

• daxmarebis qseli (socialuri da samedicino dazRveva,

sazogadoebrivi jgufi, vin icis pacientis aiv statusis Sesaxeb

da a.S.).

a. saWiroa epidemiologiisTvis, virusis subtipi da savaraudo

rezistentuli Stamebis profili. b tuberkulozze Semdgomi gamokvlevis instuqciisTvis ix. aiv

infeqciis da tuberkulozis koinfeqciis marTvis gaidlaini

23

fizikaluri gamokvleva

fizikaluri gamokvlevisas unda dafiqsirdes arsebuli simptomebi da

niSnebi, raTa ganisazRvros cvlilebebi statusSi. sasurvelia

vixelmZRvaneloT standartuli istoriiT da gamokvlevis kiTxvariT; ix

cxrili 2.

cxrili 4.

sawyisi fizikaluri gamokvleva

garegnuli monacemebi:

• simaRle da wona;

• lipodistrofia;

• karnovskis indeqsi an zogadi mdgomareobis sxva standartuli

Sefaseba;

sasicocxlo niSnebi:

• arteriuli wneva;

• temperatura;

• pulsi.

Tavi

• garegnuli monacemebi;

• kbilebis mdgomareoba;

• oraluri kandidozi;

• Tmovani leikoplakia;

• pirveladi sifilisi;

• saxis kani.

gul-mkerdi

• suTqva, xveleba, dispnoe;

• gul-mkerdis forma;

• emfizemis riskis kontroli.

sarZeve jirkvlis daTvaliereba (qalebsa da mamakacebSi) karcinomis

riskis gasakontroleblad

gulis mdgomareoba kardiovaskuluri riskis SefasebisTvis

antiretrovirusul mkurnalobaze (8,9) (CIII) an endokarditis riski

saineqcio narkomanebSi

muclis Rrus da gastrointestinuri sistemis gamokvleva (sawyisi

informacia antiretrovirusuli mkurnalobis gverdiTi efeqtebisTvis,

gansakuTrebiT qronikuli hepatitis, alkoholuri intoqsikaciis da

cirozis SemTxvevebSi)

• RviZlisa da elenTis konsistencia, zomebi da forma;

• nawlavebis muSaoba;

• muclis sirbile;

• rigidoba;

• sisuste, moTenTiloba, disfagia.

genitaluri da analuri regionis gamokvleva:

• martivi herpesi.

• citomegalovirusi;

24

• sifilisi;

• adamianis papilomavirusi (maxvilwvetiani kondilomebi, analuri

karcinoma) (10) (BII), sxva sqesobrivi gziT gadamdebi daavadebebi

(sggd).

qvemo kidurebi (moZraoba, mobiluroba, lipodistrofia)

antiretrovirusuli mkurnalobis gverdiTi efeqtebis

gasaTvaliswineblad

kani (sxeulis):

• gadatanili herpes zosteri;

• RviZlis daavadebebi;

• kapoSis sarkoma;

• seboreuli deramatiti;

• narkotikis ineqciis adgilebi.

kanis dazianebebi mag: moyavisfro an muqi laqebi umjobesia avsaxoT

fotoebSi, kanis sxva SesaZlo dazianebis gamiricxvis mizniT (moqaveba da

gafxaWna) momavali gamokvlevisas

limfuri kvanZebi

nevrologiuri statusi (neiropaTiis niSnebi)

gonebrivi statusi

mxedveleobiTi da smeniTi funqcia

laboratoriuli da sxva gamokvlevebi

cxrili 5.

laboratoriuli testebi

aiv infeqciasTan dakavSirebuli testireba:

• aiv serologiuri gamokvleva (tipurad ELISA an swrafi testi),

romelsac mohyveba damadasturebeli testi (tipiurad vestern

blotingi) (11) (AI); • CD4 ujredebis ricxvi imunodeficitis xarisxis gansazRvrisTvis;

orsul qalebSi CD4% (12,13) (AI) da • virusuli datvirTvis testi polimerazuli jaWvuri reaqciis (pjr)

meTodiT, virusis replikaciis donis gansazRvrisTvis (AI) a ; testireba sxva infeqciebze (CIII)

• testi sifilisze (VDRL); • vaginaluri, asos an analuri Camonafxeki gonoreisa da Chlamydia

trachomatis identifikaciisTvis;

• testireba toqsoplazmis IgG serologiur testze da informacia

infeqciis riskis Sesaxeb Tu serologiis Sedegi uaryofiTia;

• kriptokokis antigenis titri rodesac CD4 limfocitebis ricxvi <

200 mm3 da saxezea kriptokokozis klinikuri niSnebi;

• CMV antigenemia (pp65 adreuli antigeni), rodesac CD4 ujredebis

ricxvi < 100 mm3 b;

• serologiuri testi B,C hepatitis virusebze (anti HCV, HBsAg) g

25

ZiriTadi laboratoriuli testebi:

• eleqtrolitebi (natriumi, kaliumi); N

• RviZlis funqciuri sinjebi (ALT, AST, tute fosfataza,

saerTo da arapirdapiri bilirubini);

• Tirkmlis funqciebi (Sardovana, kreatinini);

• laqtaddehidrogenaza (limfomebis dros ujredTa ZiriTadi

brunva, filtvis infeqciebis niSnebi, miokardiumis infarqti,

kunTebis dazianebani da a.S.);

• INR an proTrombinis dro;

• sisxlis saerTo analizi (formuliTa da Trombocitebis

ricxviT);

• orsulobis testi arv Terapiis dawyebamde.

Tu SesaZlebelia:

• glukoza;

• qolesterini (HDL, VLDL); • trigliceridebi;

• lipaza;

• C-reaqtiuli cila (CRP); • Tiroid-mastimulirebeli hormoni (TSH ).

a. testebi umjobesia gakeTdes erTidaigive laboratoriaSi, raTa Tavidan

aviciloT teqnikuri winaaRmdegobani; b. CMV infeqciis adreuli deteqcia SesaZlebelia da pp65 adreuli

antigeni kargi markeria CMV infeqciis mkurnalobis efeqturobis

SefasebisTvis; g. virusul hepatitebze testirebis Semdgomi informaciisTvis ix. C hepatitis da HIV koinfeqciis da B hepatitis da HIV koinfeqciis

menejmentis protokolebi.

cxrili 6.

sxva gamokvlevebi

• tuberkulinis kanis testi; a

• naxvelis nacxis mikroskopia da gul-mkerdis rentgenologiuri

gamokvleva Tu saxezea tuberkulozis niSnebi;

• ekg (gamokvleva mkurnalobamde arT-ze myof pacientebSi gul-

sisxlZarRvovani daavadebis didi riskis gaTvaliswinebiT,

SedarebisTvis) (14) (BII).

a. Semdgomi informaciisTvis tuberkulinis kanis testze gTxovT

mimarToT tuberkulozis da HIV koinfeqciis menejmentis protokols

sxva gamokvlevebis Catareba SesaZlebelia gaxdes saWiro Tanmxlebi

daavadebebis gaTvaliswinebiT, magaliTad HCV/HIV an HBV/HIV

koinfeqiebis dros: muclis Rrus organoebis eqoskopia limfuri

kvanZebis, RviZlisa da elenTis zomebisa da formis Sesafaseblad an

26

gastrointestinuri traqtis daavadebebis klinikuri niSnebis arsebobisas

_ zemo an qvemo gastrointestinuri traqtis endoskopia. endoskopiuri

monacemebi sasurvelia dokumentirebuli iyos fotoebiT.

cxrili 7.

specialistTa konsultaciebi

• nevrologiuri gamokvleva, rodesac HIV pirvelad aris

diagnostirebuli (mag. periferiuli neiropaTiis identifikaciisTvis)

• ofTalmologiuri gamokvleva yovel sam TveSi erTxel CMVretinitis identifikaciisTvis, rodesac CD4 ujredebis ricxvi <

100mm3

• ginekologiuri gamokvleva PAP nacxis CaTvliT yovel 6 TveSi

erTxel (adamianis papilomavirusiT gamowveuli karcinoma)

• sxva specialistebis konsultacia aucileblobis SemTxvevebSi

2. aiv infeqciasTan dakavSirebuli debulebebi

aiv infeqcia/SidsiT mcxovrebi pacientebis menejmenti moicavs:

pacientebis janmrTelobis monitorings;

arT-s dawyebas da mis xelSewyobas;

oportonistuli infeqciebis da sxva Tanmxlebi infeqciebisa da

daavadebebis profilaqtikasa da mkurnalobas;

fsiqologiur mxardaWeras;

mkurnalobis reJimis dacvis meTvalyureobas;

konsultirebas;

movlas.

pacientebis konsultireba unda daiwyos maTi socialuri mdgomareobis

ganxilviT, romelic moicavs:

megobrul ganwyobas;

samsaxureobriv statuss, samuSaos tips da mdgomareobas;

adamianebs, romlebic unda iyvnen informirebulni pacientis aiv

statusis Sesaxeb;

adamianebs, romlebTan erTadac jandacvis muSaks SeuZlia

ganixilos pacientis janmrTelobasTan dakavSirebuli sakiTxebi;

ojaxis wevrebs da naTesavebs;

medikamentebis Senaxvis reJimis dacvis SesaZleblobas;

cxovrebis stils, romelic SesaZloa zemoqmedebas axdendes

mkurnalobaze (15-17) (CIII).

jandacvis muSakebma inficirebul pacientebTan erTad unda ganixilon

mTeli rigi informaciisa, romelic unda esmodes pacients:

avadmyofs unda aexsnas riskis Semcireba (daculi sqesobrivi

kontaqti, ineqciis unar-Cvevebis gacnoba da sxva) romelic moicavs

aiv pozitiur partniorTan daucveli sqesobrivi kontaqtis

27

SemTxvevaSi aiv super infeqciis saSiSroebas rezistentuli StamiT.

(18) (BII) toqsoplazmozis negatiuri serologiis SemTxvevaSi avadmyofs

unda ganemartos misi gadacemis gzebi (maT Soris riski, romelic

dakavSirebulia cxovelebTan) da profilaqtikis meTodebi (ix.

protokoli 2 aiv/Sidsis ZiriTadi simtomebis da oportunistuli

infeqciebis menejmenti);

radgan HBV/HIV da HCV/HIV koinfeqcia xSiria da dakavSirebulia

mTel rig sirTuleebTan, didi mniSvneloba eniWeba maT prevencias.

Tanabrad mniSvnelovania RviZlis dazianebis da dedidan bavSvze

infeqciebis gadacemis riskis Semcireba.;

pacientebi saWiroa iyvnen informirebulni SesaZlo

oportunistuli infeqciebis niSnebze (ix. protokoli 2 aiv/Sidsis

ZiriTadi simtomebis da oportunistuli infeqciebis menejmenti)

saineqcio narkotikebis momxmareblebTan unda ganvixiloT misi

Sewyvetis mniSvneloba. Tu pacients ar surs an ar SeuZlia

Sewyvitos saineqcio narkotikebis moxmareba maSin unda

ganvumartoT zianis Semcirebis arsi;

avadmyofs unda esmodes jansaRi cxovrebis wesis kerZod, Zilis,

kvebis, varjiSis mniSvneloba;

pacientebs, romelTac unda daiwyon antiretrovirusuli Terapia,

unda ganemartoT Semdegi sakiTxebi:

• mkurnalobis reJimis dacvis mniSvneloba;

• antiretrovirusuli medikamentebis SesaZlo toqsiuroba;

• medikamentebis urTrierTqmedeba;

• kontracefciis aucilebloba, rodesac pacienti imyofeba

efavirenzis Semcvel reJimze;

pacientebi informirebulni unda iyvnen maTi legaluri

pasugismgeblobebisa da uflebebis Sesaxeb;

pacientebi informirebulni unda iyvnen imunizaciis Sesaxeb da

samsaxureobrivi riskis Sesaxeb.

3. oportunistuli da sxva infeqciebis profilaqtika

aiv infeqcia/SidsiT avadmyofebi imunizirebul unda iyvnen A da B hepatitis virusebisa da gripis virusis sawinaRmdegod.

yvela aiv inficirebuli, romlis CD4 limfocitebis ricxvi naklebia 200

mm3 unda daewyoT profilaqtikuri mkurnaloba mTel rig infeqciebze,

maT Soris pnevmocisturi pnevmoniaze. ko-trimoqsazoliT

profilaqtikuri Terapia unda gagrZeldes manamde, sanam CD4 ujredebis

ricxvi ar gaxdeba 200 mm3 meti arv mkurnalobis dawyebidan 3 Tvis

ganmavlobaSi stabilurad.

4. antiretrovirusuli Terapia

4.1. arT dawyeba

arT dawyebis optimaluri dro ar aris dadasturebuli da igi ganxilvis

sagania (19) (CIII). sxvadasxva kohortuli kvlevis da saxelmRvanelo

28

rekomendaciebis mimoxilva aCvenebs farTod gavrcelebul Sexedulebas,

rom am gadawyvetilebis misaRebad saukeTeso markeria CD4 ricxvi, xolo

virusuli datvirTva meoradi markeria (20-30) (CIII). arT dawyebamde unda

daiwyos avadmyofis mxardaWera reJimis maqsimaluri dacvis

uzrunvelsayofad;

janmo rekomendacias uwevs arT dawyebas klinikuri da imunologiuri

kriteriumebis safuZvelze. rekomendaciebi arT dawyebis Sesaxeb

Sejamebulia cxrilSi 8.

cxrili 8

rekomendaciebi arT dawyebis Sesaxeb

janmo klinikuri stadia a CD4 ricxvi rekomendacia

1 < 200/mm3 umkurnaleT

200 - 350/mm3 ganixileT mkurnalobis

SesaZlebloba b, g

2 < 200/mm3 umkurnaleT

200 - 350/mm3 ganixileT mkurnalobis

SesaZlebloba b, g

3 200 - 350/mm3 umkurnaleT

4 CD4 ricxvisgan

damoukideblad

umkurnaleT

a) ix. damateba 2 klinikuri stadiebis aRwerilobis Sesaxeb

b) rodesac CD4 ricxvi 350/mm3-is midamoSia, daiwyeT msjeloba pacientTan

arT dawyebis saWiroebis moaxloebis da mkurnalobis sawyisi reJimis

Sesaxeb.

c) virusuli datvirTva dakavSirebulia CD4 ricxvis klebasTan. rodesac

virusuli datvirTva maRalia (> 100000 asli/ml), maRalia CD4 ricxvis

swrafad klebis albaToba. Sesabamisad, Tu virusuli datvirTva

maRalia da CD4 ricxvi 350/mm3-ia, rekomendebulia arT dawyeba.

arT dawyeba unda efuZnebodes CD4 ricxvis orjerad gansazRvras 14 – 28

dRis SualediT, raTa gamoiricxos laboratoriuli Secdoma an gadaxris

sxva mizezi (magaliTad, Tanmxlebi daavadeba).

4.1.1. virusuli datvirTva

virusuli datvirTva TavisTavad ar aris arT dawyebis markeri. Tumca, im

SemTxvevaSi Tu virusuli datvirTva 100 000 asli/ml-ze maRalia (man

SeiZleba 1 milion asli/ml-s miaRwios), SesaZloa adgili hqondes CD4

ricxvis swraf klebas. marTalia virusuli datvirTvis gansazRvra

ZviradRirebulia, mniSvnelovania vicodeT misi mniSvneloba mkurnalobis

dawyebamde, raTa SemdgomSi SevafasoT mkurnalobis efeqturoba. Tu

virusuli datvirTva ar aris xelmisawvdomi, maSin CD4 ricxvi da

klinikuri simptomebi sakmarisia mkurnalobis dawyebis gadawyvetilebis

misaRebad. polimerizaciis jaWvuri reqciisa (pjr) da virusuli

29

datvirTvis ar arseboba ar unda gaxdes mkurnalobis gadadebis

kriteriumi.

4.1.2 rezistentobis testi

mosazreba pirveli rigis mkurnalobamde rezistentobis testis Catarebis

Sesaxeb gansxvavebulia. rezistentobaze testireba rekomendebulia im

qveynebSi, sadac maRalia priveladi rezistentoba. evropaSi Catarda

multicentruli kvleva axaldiagnozdasmul aiv inficirebulebSi 1996 da

2002 wlebSi. am jgufSi rezistentobis prevalentobam Seadgina 10% (31)

(BII). aSS 40 qalaqSi Catarebul kvlevaSi rezistentobam 14% Seadgina (32)

(BII). yvelaze maRali sixSire aRiniSna espaneTSi 26% (33) (BII) da san-

franciskoSi 19% (34) (BII). sloveniis monacemebiT rezistentobis sixSire

dabalia – 3,9% (35) (BII). eqspertebi rekomendacias uweven rezistentobis testirebas arT dawyebamde axaldiagnozdasmul pacientebSi (36-38) (BII), sadac igi xelmisawvdomia, xolo SezRuduli resursebis pirobebSi

rezistentobaze sentineluri (saguSago) zedamxedvelobis dawesebas. arT

dawyeba SesaZlebelia rezistentobaze testirebis gareSe. ixileT

damateba 3 rezistentobis testirebaze damatebiTi informaciisTvis.

4.2 pirveli rigis maarT reJimi

rekomendebulia, rom pirveli rigis arT Seicavdes or

nukleozid/nukleotidis analog revers transkriftazas inhibitors

(nrti anu NRTI) da erT ara-nukleozidis analogis revers

transkriptazas inhibitors (anrti anu NNRTI). rekomendebuli

dozebisTvis ixileT damateba 4. cxrili 9

rekomendaciebi pirveli rigis arT Sesaxeb

arT reJimi medikamentebis kombinacia

2 NRTI-s + 1 NNRTI

ZDV + 3TC + (EFVa or NVP) an

TDF + FTC + (EFVa or NVP) an

ABC + 3TC + (EFVa or NVP)

a. EFV ganixileba, rogorc upiratesi anrti (AI) 4.2.1. nrti komponenti

• pirveli rigis arT-s ZiriTadi Semadgeneli nawilia ori nrti-s

kombinacia. erT-erTi unda iyos lamivudini (3TC) an emtricitabini

(FTC) (39) (AI), xolo meore yvelaze xSirad zidovudinia (ZDV).

30

vinaidan zidovudini pirveli rekomendebuli arv medikamenti iyo,

masze uxvi monacemebia dagrovili.

• sxva SesaZlo nrti-ebia tenofoviri (TDF) da abakaviri (ABC) 3TC–Tan

an FTC–Tan kombinaciaSi. uaxlesi kvlevebi aCveneben TDF/FTC–is kombinaciis mcire upiratesobas ZDV/3TC–Tan SedarebiT, rodesac

gamoiyeneba efavirenzTan (EFV) kombinaciaSi (40) (AI). aRniSnuli

SesaZloa ganpirobebuli iyos TDF namkurnaleb pacientebSi gverdiTi

movlenebis simciriT. saWiroa damatebiTi kvlevebi aRniSnulis

dasadastureblad. unda aRiniSnos, rom ABC miRebis dros arsebobs saxifaTo hipersensitiurobis sindromis riski.

• TDF da ABC upiratesobaa maTi rezistentobis kargi profili,

romelic saSualebas iZleva momavalSi meti nrti-s kombinaciis

gamoyenebas. Tumca maT aReniSnebaT seriozuli gverdiTi movlenebi da

efeqturobis monacemebic mcirea zidovudinTan SedarebiT (41) (CIII). arv medikamentebi arseboben Semdegi fiqsirebuli dozis kombinaciebis

saxiT (anu ori medikamenti 1 tabletSi):

- ZDV + 3TC - TDF + FTC - ABC + 3TC

• TDF/FTC kombinaciis ABC/3TC kombinaciasTan SedarebiT damatebiTi

upiratesobaa dReSi erTxel misaRebi reJimis arseboba.

• yvela sxva nrti kombinacias pirveli rigis reJimSi gamoyenebisTvis

esaWiroeba safuZvliani mizezi. zogierTi kombinacia ar aris

rekomendebuli (42), xolo sxvebs sWirdebaT gverdiTi movlenebis

mWidro monitoringi. uaxlesi kvlevebi aCveneben gverdiTi movlenebis

maRal sixSires stavudinis (d4T) gamoyenebis dros (40-47) (AI). amis

gamo d4T gamoyenebul unda iqnes mxolod im SemTxvevaSi, Tu sxva

arCevani ar aris an sxva nrti-ebi ukunaCvenebia.

arsebobs nrti-ebis gamoyenebasTan dakavSirebuli ramdenime wesi:

- ar gamoiyenoT d-medikamentebis kombinacia (ddI (didanozini), ddC (zalcitabini), d4T).

- ar daiwyoT mkurnaloba d-medikamentiT arsebuli neiropaTiis dros.

- ar gamoiyenoT ZDV da d4T kombinacia. - ar gamoiyenoT 3TC da FTC kombinacia.

31

4.2.2. anrti komponenti

• saukeTeso monacemebi arsebobs ZDV + 3TC + EFV Sesaxeb (48–50) (AI). aRniSnuli sami medikamentisgan Semdgari kombinacia dReSi orjer

misaRebia. igi swrafadmoqmedia - EFV gamoyenebis dros virusuli

datvirTva swrafad iklebs pirvel ori kviris ganmavlobaSi, CD4 ricxvis mateba sxva reJimebis dros aRniSnuli matebis msgavsia. Tumca

aucilebelia mkurnalobis dawyebamde Tanmxlebi fsiqiatriuli

daavadebebis gamoricxva.

• nevirapini (NVP) kidev erTi rekomendebuli anrtia, romelic nrti-

ebTan kombinaciaSi gamoiyeneba. RviZlis daavadebebis dros maRalia

misi toqsiuroba (52) (AI). amis gamo misi gamoyeneba rekomendebulia

qalebSi Tu CD4 ricxvi <250 ujrdi/mm3, xolo mamakacebSi - Tu CD4 ricxvi <400 ujrdi/mm3. ufro maRali CD4 ricxvis SemTxvevaSi

nevirapinis gamoyeneba dakavSirebulia met hepatotoqsiurobasaTan.

nevirapinis efeqturoba efavirenzis msgavsia (52) (BII). mkurnalobis

dasawyisSi saWiroa nevirapinis 14-dRiani sawyisi doza - 200mg erTxel

dReSi. 14 dRis Semdeg doza unda gaizardos - 200mg 2-jer dReSi.

erTxel dReSi misaRebi doza gamokvlevis fazaSia.

• delavirdini (DLV), mesame anrti, ar gamoiyeneba evropaSi. igi

naklebefeqturia danarCen antri-ebTan SedarebiT, aqvs meti gverdiTi

movlenebi da yoveldRiurad didi raodenobiT tabletis miRebaa

saWiro. Tumca es ukanaskneli sadReisod gaumjobesda da gamoiyeneba

200mg tableti 3-jer dReSi. igi SesaZloa gamoyenebul iqnas im

SemTxvevaSi, Tu sxva anrti-ebi ver aitaneba an arsebobs rezistentobis

gansakuTrebuli forma.

• ori nrti da erTi anrti-s alternativa SeiZleba iyos erTi klasisgan

Sedgenili reJimi – “sammagi nukleozidi”3 an “oTxmagi nuklezidi”,

romlebic mxolod sami an oTxi nrti-sgan Sedgeba. marTalia, am

reJimze sawyisi pasuxi kargia, 24 kviris Semdeg rezistentobis

ganviTarebis meti albaTobaa (48) (AI). Sesabamisad, sami nrti-s

kombinacia unda gamoiyenebodes gansakuTrebul situaciebSi,

magaliTad TB an HCV koinfeqciis SemTxvevaSi, rodesac erTdrouli

mkurnalobaa saWiro, an alternativis saxiT, Tu antri ar aris

xelmisawvdomi.

• ori anrti-s da erTi nrti-s kombinacia ar aris rekomendebuli (53)

(AI). • bustirebuli proteazas inhibitori (pi) or nrti-sTan erTad SesaZloa

gamoyenebul iqnes pirveli rigis arT saxiT, Tu ukunaCvenebia anrti-

ebi (anu verc efavirenzi da verc nevirapini ver iniSneba):

- fsiqiatriuli daavadebebi da alt-s mateba 3-5-jer;

- cirozi;

- orsuloba, Tu CD4 ricxvia 250 - 350 ujrdi/mm3.

• pi Semcveli pirveli rigis arT-s araefeqturobis dros naklebi

arCevania Semdgomi reJimisTvis. zogadad rekomendebulia, rom pi

Semonaxul iqnes meore rigis reJimisTvis.

3“sammagi nukleozidi”: fiqsirebuli dozis tableti, romelic Seicavs ZDV da 3TC da

ABC. igi miiReba dReSi orjer (zidovudini ar aris rekomendebuli dReSi erTxel

miRebisTvis). amJamad igi yvelaze martivi sammagi Terapiuli reJimia.

32

4.3. arT reJimis dacva

mkurnalobis optimaluri Sedegis misaRebad saWiroa mkurnalobis

reJimis dacva. kargad aris cnobili, rom arT reJimis maRal doneze

dacva dakavSirebulia aiv asocirebuli avadobis da sikvdilianobis

mkveTr SemcirebasTan (54) (AI), xolo reJimis arasaTanado dacva aiv-is

wamlebis mimarT rezistentobis swraf ganviTarebas iwvevs (55) (AI). arT-

sTvis ar aris gansazRvruli reJimis dacvis efeqturi done (arsebobs

sxvaoba reJimebs Soris), Tumca reJimis dacva 95%-ze nakleb doneze

dakavSirebulia cud virusologiur da imunologiur pasuxTan, xolo

reJimis 100%-iT dacvas kidev ufro meti sargebeli moaqvs, vidre 95%-iT

dacvas (56, 57) (AI). uaxlesi monacemebi aCveneben korelacias reJimis

dacvasa da arv sxvadasxva klasis mimarT rezistentobas Soris (58) (AI).

dabal an arasakmaris reJimis dacvas mohyveba arasaxarbielo Sedegebi

pacientisTvis, sazogadoebrivi jandacvisTvis da qveynis ekonomikisTvis.

kerZod,

• pacientebi arian mniSvnelovani safrTxis winaSe rezistentobis

ganviTarebis, mkurnalobis araefeqturobis da daavadebis

progresirebis TvalsazrisiT (59, 60) (AI). axali kombinacia erTi

reJimis araefeqturobis SemTxvevaSi umetesad ufro rTulia dacvis

TvalsazrisiT (meti tabletebis ricxvi dReSi, gverdiT movlenebi,

dieturi SezRudevebi, toqsiuroba da dozirebis sirTule).

• rezistentuli virusis gavrceleba gamoiwvevs mis gadacemas axlad

inficirebul pirebSi. aSS (61) (AI) da evropis (62) (AI) monacemebi

aCveneben, rom pirveladi rezistentobis sixSire imatebs, da SeZenil

rezistentobas uaryofiTi gavlena aqvs arT pasuxze.

• rezistentuli Stamis arsebobas mohyveba meore rigis, mesame rigis da

e.w. gadarCenis (salvage) reJimi, romlebic, Cveulebriv, ufro Zviria

pirveli rigis reJimebTan SedarebiT.

• reJimis arasakmarisi dacva, agreTve, moaswavebs daavadebis

progresirebis maRal risks, rac met danaxarjebs moiTxovs

oportunistuli infeqciebis samkurnalod (63) (AI).

4.3.1. barierebi reJimis dacvaSi da maTi sawinaaRmdego zomebi

4.3.1.1. pacientTan dakavSirebuli faqtorebi da strategiebi

pacients ZiriTadi roli akisria reJimis dacvaSi. SeuZlebelia pacientis

mier reJimis dacvis potencialis prognozireba. kvlevebma, romlebic

Seiswavlidnen sqess, rasas, asaks, aiv gadacemis gzas da ganaTlebis

dones, rogorc reJimis dacvis indikatorebs, gansxvavebuli Sedegebi

aCvenes (64) (BII). individualuri reJimis dacvis donec SesaZloa

sxvadasxva dros gansxvavdebodes (65) (BII). umravlesi aiv inficirebuli

raRac dros gamoavlens reJimis dacvis dabal xarisxs.

reJimis dacvis dabali donis SesaZlo mizezebia:

- narkotikebis da alkoholis moxmareba;

- cudi kveba siRaribis gamo;

- religiuri mosazrebebi (66) (DIV);

- aiv statusis gamJRavnebis SiSi medikamentebis rutinuli miRebisas;

- fsiqiatriuli mdgomarebebi (67) (DIV);

33

- gverdiTi movlenebis SiSi da eWvi mkurnalobis saWiroebis Sesaxeb (68)

(DIV).

SesaZlo sawinaaRmdego strategiebi:

- ganaTleba arT saWiroebis Sesaxeb;

- swrafi reagireba pacientis araswor Sexedulebaze;

- arT-s mimarT pacientis ganwyobis regularuli Sefaseba;

- “peer” (Tanasworis) Careva (pacientTa jgufebi);

- fsiqiatriuli problemebis regularuli Sefaseba;

- reJimis dacvisTvis saWiro Cvevebis Sefaseba4

- specializirebuli socialuri samsaxuris an dawesebulebebis CarTva.

4.3.1.2. jandacvis muSakTan dakavSirebuli faqtorebi

jandacvis muSakebi naTlad unda acnobierebdnen reJimis dacvis

mniSvnelobas da mis rols rezistentobis ganviTarebaSi. aiv/Sidsis

dargSi momuSave profesionali unda iRebdes mudmiv ganaTlebas reJimis

dacvis sakiTxebSi. arsebobs ramdenime strategia, romelic unda

gamoiyenos jandacvis muSakma reJimis dacvis xarisxis asamaRleblad.

• TiToeul centrs, sadac tardeba aiv mkurnaloba, unda hqondes

reJimis dacvis werilobiTi strategia, romelic gadaixedeba

regularulad.

• jandacvis muSakebi CarTulni unda iyvnen reJimis dacvis mxardasaWer

programebSi (69) (CIII). • pacientTa survilis gaTvaliswinebam, CaerTos am programebSi

SesaZloa gaaumjobesos reJimis dacva.

• reJimis dacvaSi mxardaWera unda SevTavazoT yvela pacients imis

gaTvaliswinebiT, Tu ra xarisxiT icavs esa Tu is pacienti reJims.

• mxadaWera unda gagrZeldes meore rigis da “gadarCenis" reJimis

drosac. mkurnalobis araefeqturoba unda iyos sakvanZo sakiTxi

reJimis dacvis da mxardaWeris RonisZiebebis gaZlierebisTvis (70).

• reJimis dacvis maRali xarisxi xangrZlivi procesia da ara

erTjeradi movlena (71) (DIV), avadmyofs mxardaWera unda SevTavazoT

arT dawyebisas, Secvlisas da rutinuli meTvalyureobisas.

• jandacvis muSakma unda uzrunvelyos, rom pacients hqondes

adekvaturi codna aiv-is, reJimis dacvas da rezistentobas Soris

kavSiris, gverdiTi movlenebis Sesaxeb. sityvieri informacia unda

gamyardes werilobiTi informaciiT.

• jandacvis muSakma SesaZloa rekomendacia gauwios tabletebis miRebis

dRiurs, cxrilebs, medikamentebis konteinerebs, ojaxis wevrebis da

megobrebis CarTvas “Semxseneblebad” (72) (DIV).

• arT reJimis dacva umjobesdeba, Tu pacienti pozitiurad aRiqvams

kavSirs eqimTan da jandacvis sxva muSakebTan (73) (DIV).

4es SesaZloa gaZlierdes im pirebis CarTviT, vinc kontaqtSia pacientTan (eqTani,

farmacevti, ojaxi), agreTve, grafikis (cxrilebis), saaTiani tabletebis yuTebis

gamoyenebiT, mogzaurobisas gegmis SemuSavebiT, Tu rogor miiRos medikamentebi

garSemomyofebisTvis SeumCnevlad.

34

• reJimis dacvaze adreuli meTvalyureoba unda ganxorcieldes reJimis

dawyebidan an Secvlidan 2 dRis Semdeg imis gasarkvevad, esaWiroeba

Tu ara pacients damatebiTi informacia, an aqvs Tu ara raime

gauTvaliswinebeli problema.

4.3.1.3. reJimTan dakavSirebuli faqtorebi da strategiebi

dozireba dReSi orze metjer dakavSirebulia reJimis dacvis ufro

dabal donesTan (74) (CIII), xolo dReSi erTxel an orjer misaReb

reJimebs Soris sxvaoba savaraudod ar aris (75) (CIII). dReSi erTxel an

orjer misaRebi reJimis dros, dozaTa umravlesoba droulad miiReba.

multivariaciuli analiziT dozis miReba daniSnulze gvian

dakavSirebulia mkurnalobis araefeqturobasTan (76) (AI).

• reJimis dacvis done ar aris dakavSirebuli arv klasTan. Tumca

kvebiTi SezRudva sxvadasxva medikamentisTvis SesaZloa qmnides

problemas (77) (BII). • tabletebis mcire ricxvis dros metia albaToba, rom 48 kviris Semdeg

virusuli datvirTva iqneba < 50 asli/ml (75) (BII). • damazianebelma wamlebis urTierTqmedebam da gverdiTma movlenebma

SesaZloa gavlena moaxdinos reJimis dacvis xarisxze. doza SesaZloa

gamotovebul iqnes gulisrevis da diareis gamo, sisustis gamo

CaZinebam, agreTve, SesaZloa gamoiwvios dozis gamotoveba (78) (DIV).

SesaZlo sawinaaRmdego strategiebi:

• Sefasdes cxovrebis wesi (kvebis, Zilis, samuSao reJimi) da moergos

samkurnalo reJimi;

• Sefasdes pirovnebis ganwyoba sxvadasxva reJimis mimarT (tabletis

zoma, formulireba, raodenoba, dieturi SezRudva da a. S.).

• tabletebis Cveneba pacientisTvis reJimis dawyebamde;

• informaciis micema gverdiTi movlenebis da maTi marTvis Sesaxeb,

mxardaWeris Sesaxeb.

4.4. uSedego mkurnaloba

mkurnalobis araefeqturoba SesaZloa Sefasdes virusuli datvirTvis da

CD4 ricxvis gansazRvriT, agreTve, klinikuri gamoklveviT.

4.4.1. virusologiuri araefeqturoba

• virusuli datvirTva (vd) mkurnalobis warmatebis an araefeqturobis

yvelaze adreuli indikatoria, romelsac mohyveba CD4 ricxvi

daaxloebiT 1 Tvis Semdeg. iSviaTad viTardeba paradoqsuli reaqcia

virusologiuri pasuxiT da imunologiuri araefeqturobiT.

Sesabamisad, aucilebelia vd Sefasdes CD4 ricxvTan erTad

kombinaciaSi.

• virusologiur araefeqturobad miiCneva, Tu vd ar gaxda 400 asli/ml-

ze naklebi mkurnalobis 24-e kviraze an 50 asli/ml-ze naklebi

mkurnalobis 48-e kviraze.

35

• Tu vd gaxda ganusazRvreli, magram Semdgomi ori gamokvlevisas 4-8

kviris intervaliT igi kvlav metia 400-1000 asli/ml-ze, aseT

SemTxvevaSi virusologiuri araefeqturobis momatebuli riskia (79)

(BII).. reJimis SenarCuneba zrdis Semdgomi mutaciebis da meti

medikamentis mimarT ufro gamoxatuli rezistentobis ganviTarebis

risks.

• “Blips” (xanmokle mcire piki) aris vd-s msubuqi mateba ganusazRvreli

donidan 50-200 asli/ml-mde. mas SesaZloa adgili hqondes

rezistentuli Stamis ganviTarebis gareSe (laboratoriuli Secdoma),

Tumca igi aris indikatori reJimis dacvis msjelobisTvis (80) (BII). am situaciaSi SesaZloa, agreTve, damxmare roli Seasrulos

medikamentebis Terapiulma monitoringma (TDM). TiToeuli “blifi”

unda gakontroldes 4 kviraSi.

• Tu virusulogiuri araefeqturobis mizezi ar vlindeba (reJimis

araadeqvaturi dacva, wamlebis suboptimaluri done, wamlebis

urTierTqmedeba da sxv.), unda ganxilul iqnes meore rigis Terapiis

dawyebis SesaZlebloba5.

4.4.2. imunologiuri araefeqturoba

• Tu vd ar aris xelmisawvdomi, CD4 ricxvi gamoyenebul unda iqnes

mkurnalobis warmatebis an araefeqturobis indikatorad.

• imunologiuri araefeqturobaa, Tu CD4 ricxvma ar moimata 50 /mm3-ze

metad arT pirveli wlis ganmavlobaSi. saSualod aranamkurnaleb

pacientebSi mkurnalobis pirveli wlis ganmavlobaSi CD4 ricxvi

imatebs 150 /mm3-iT (81, 82) (AI). • Tu CD4 ricxvi ar imatebs arT dawyebidan pirveli 9 Tvis

ganmavlobaSi, ganxilul unda iqnes meore rigis arT SesaZlebloba.

Tu vd aragansazRvradia, reJimi unda gagrZeldes. Tu igi > 400-1000

asli/ml-ze, unda verificirdes reJimis dacva da daiwyos meore rigis

reJimi.

• Tu CD4 ricxvi ar imatebs 6 Tvis ganmavlobaSi, xelaxla unda

Sefasdes reJimis dacvis xarisxi.

4.4.3. klinikuri araefeqturoba

arT dawyebis Semdeg, oportunistuli infeqciis (oi) an sxva aiv-

asocirebuli daavadebis ganviTareba, klinikuri araefeqturobis

indikatoria. Tumca es SeiZleba iyos imunuri rekonsitituciis sindromi

(irs), gansakuTrebiT, arT-s dawyebidan pirveli 3 Tvis ganmavlobaSi, Tu

igi dawyebul iqna CD4 ricxvi <50 ujredi/mm3-ze. am SemTxvevaSic vd

gadamwyveti roli eniWeba meore rigis Terapiis dawyebis Sesafaseblad.

5 Tu cnobilia, rom qveyanaSi rezistentobis prevalentoba 7%-ze metia, rekomendebulia

rezistentobis testi mkurnalobis araefeqturobis SemTxvevaSi wamlebis miRebisas an

maTi Sewyvetidan 2-4 kviris ganmavlobaSi. mogvianebiT rezistentobis testi ver

gamoavlens rezistentobas mkurnalobis Sewyvetis Semdeg veluri Stamis swrafi zrdis

gamo.

36

cxrili 10

mkurnalobis araefeqturobis kriteriumebi

virusologiuri

araefeqturoba

imunologiuri

araefeqturoba

klinikuri

araefeqturoba

markeri vd CD4 ricxvi oi (aiv-Tan

asocirebuli)

dro 24 kvira; 48 kvira 24-48 kvira

mkurnalobis

dawyebidan 12

kviris Semdeg

zRvari >400asli/ml;

>50asli/ml

50 ujredi/mm3-ze

naklebi mateba

oi (gamoricxeT

irs)

4.5. meore rigis arv reJimi

(rekomendaciebi dozebis Sesaxeb ix. damateba 4)

• meore rigis Terapiad rekomendebulia pi-s Semcveli kombinacia. pi-ebs

gaaCniaT maRali genetikuri barieri.

• meore rigis arT rekomnedebulia mxolod pirveli rigis reJimis

mimarT dadasturebuli araefeqturobis SemTxvevaSi.

• meore rigis arT dawyebasTan erTad unda moxdes reJimis dacvis

xelaxali Sefaseba da maqsimaluri mxardaWera.

• meore rigis reJimis dros sul mcire ori nrti-s Secvlaa saWiro.

arasodes SecvaloT mxolod erTi wamali saeWvo rezistentobis

SemTxvevaSi.

• efavirenzis da nevirapinis xangrZlivi naxevardaSlis periodis gamo,

samive wamlis erTdrouli Sewyveta niSnavs, rom efavirenzi an

nevirapini darCeba sisxlSi nrti-ebze xangrZlivad, rac maT mimarT

rezistentobis gamomwvevi mutaciis ganviTarebis risks zrdis.

• aqedan gamomdinare, nrti+anrti reJimis Sewyvetisas SesaZloa Sewydes

jer anrti da mogvianebiT, daaxloebiT 7 dRis Semdeg, nrti-ebi. Tumca,

am sakiTxTan dakavSirebiT sakmarisi monacemebi ar arsebobs.

4.5.1. nrti komponenti

• Tu pirveli rigis arT Seicavda ZDV + 3TC, maSin meore rigSi

SesaZloa gamoyenebul iqnas ABC ddI–Tan kombinaciaSi (an TDF da

moxdes ddI dozis modifikacia da mWidro monitoringi) (83) (CIII). • Tu pacients pirveli rigis Terapia utardeboda TDF an ABC, maT

mimarT rezistentobis maRali albaTobis gaTvaliswinebiT meore

rigSi sasargeblo iqneba ZDV (84) (BII). K65R mutacia, romelsac iwves

TDF da ABC, zrdis mgrZnobelobas ZDV–s mimarT (85, 86) (BII)..

37

• 3TC agreTve sasargebloa mis mimarT rezistentobis dros, vinaidan

mis mier gamowveuli 184V mutacia amcirebs virusis replikaciis

unars da, agreTve, zrdis mgrZnobelobas ZDV mimarT.

4.5.2 pi komponenti

• Tu pirveli rigis Terapia Seicavda anrti-s, meore rigSi gamoyenebul

unda iqnes pi.

• pi-ebis umravlesoba Zlierdeba (bustirdeba) ritonaviris (RTV an /r) dabali doziT - 100mg 2-jer dReSi. ritonaviri TavisTavad pi-ia.

ritonaviriT ar bustirdeba nelfinaviri, romelic Zlierdeba ara

qimiurad, aramed – sakvebiT. bustirebis meqanizmia ritonaviris mier

citoqrom P450 (CYP) 3A4 izoenzimis inhibireba. Sedegad izrdeba pi

medikamentebis done, garda nelfinavirisa (87) (BII).. ritonaviri

gamoiyeneba mxolod sxva pi-ebis bustirebisTvis da ar aris efeqturi

rogorc damoukidebeli arv medikamenti.

• pi-ebs Soris gansxvaveba mdgomareobs maT mimarT rezistentobis

ganviTarebisTvis saWiro mutaciebis ricxvSi da gverdiTi movlenebis

profilSi.

• yvelaze maRali barieri rezistentobis ganviTarebisTvis aReniSneba

bustirebul lopinavirs (LPV/r) (88). • ritonaviriT bustirebuli atazanaviris (ATV/r), fosamprenviris (FPV/r),

indinaviris (IDV/r) da seqvinaviris (SQV/r) rezistentobis profili

umniSvnelod gansxvavdeba, risi klinikuri efeqtic mcirea an saerTod

ar aris.

• atazanaviri SesaZloa gamoyenebul iqnes ritonaviriT bustirebis

gareSec (400 mg/dReSi).

• nelfinaviri efeqturobiT naklebia sxva pi-ebTan SedarebiT. Tumca

misi gamoyeneba kargad dokumentirebulia orsulebSi. misi

araefeqturobis dros SeirCeva D30N mutacia, romelic ar iwvevs

jvaredin rezistnetobas sxva pi-ebis mimarT (89, 90) (BII).. • arCevis pi-ia LPV/r misi kargad dokumentirebuli efeqturobis gamo

(91). evropaSi registrirda LPV/r axali formulireba, romelic

gamoiyeneba 2-jer dReSi da ar esaWiroeba macivari (92) (AI). • ar aris warmoebuli LPV/r–is pirdapiri Sedareba amprenaviris axal

forma fosamprenavirTan, dReSi erTxel misaReb atazanavirTan (93)

(CIII) da seqvinaviris axal 500mg-ian formasTan, arsebobs mxolod

arapirdapiri monacemebi (94) (DIV). saWiroa damatebiTi kvlevebi.

• pi-s SerCevisas gaTvaliswinebul unda iqnas gverdiTi movlenebi,

Tanmxlebi daavadebebi, wamlebTan urTierTqmedeba da pacientis

individualuri ganwyoba.

38

cxrili 11

rekomendebuli meore rigis arv reJimi mozardebis mozrdilTaTvis

pirveli rigis reJimi meore rigis reJimi

ZDV + 3TC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + (ZDV + 3TC)b

TDF + FTC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV

ABC + 3TC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ZDV + TDF (+ 3TC)b

aLPV/r mocemulia rogorc upiratesi pi bustirebuli ritonaviriT, Tumca sxva pi-ebi

SesaZloa gamoyenebul iqnas programis individualuri prioritetebis mixedviT.

SesaZloa nebismieris gamoyeneba CamoTvlilTagan: ATV/r, SQV/r, FPV/r, da IDV/r. civi

jaWvis ararsebobis SemTxvevaSi SesaZloa nelfinaviris gamoyeneba, Tumca igi

ganixileba, rogorc naklebad potenturi, vidre bustirebuli pi-ebi. bZDV da 3TC gamoyeneba naCvenebia strategiuli mizniT, radgan pirveli rigis

araefeqturobis SemTxvevaSi maT mimarT virusi rezistentuli iqneba. kerZod, ZDV SesaZloa Tavidan agvacilos an Seaferxos K65R mutaciis ganviTareba; xolo 3TC

SeinarCunebs M184V mutacias, romelic amcirebis virusis replikaciis unars da

garkveulwilad zrdis sensitiurobas ZDV mimarT. unda aRiniSnos, rom am strategiis

klinikuri Rirebuleba ar aris dadasturebuli.

• Tu ganviTarda pi-s Semcveli pirveli rigis arT-s araefeqturoba,

meore rigis reJimis SerCeva efuZneba rezistentobis profils. Tu

rezistentobis profili ar aris xelmisawvdomi, navaraudevi unda

iqnas rezistentoba pirveli rigis reJimSi Semavali pi-s mimarT.

pi-s Semcveli pirveli rigis arT-s araefeqturobis dros SesaZlo

arCevania:

ZDV + 3TC + SQV/r (an ATV/r, FPV/r, IDV/r) ➔ ABC + ddI + LPV/r ZDV + 3TC + LPV/r ➔ ABC + ddI + anrti (darunaviri (TMC11)) an bustirebuli tipranaviri (TPV/r)

kidev erTi arCevania ori pi-s kombinacia, magaliTad SQV + ATV/r (95). ar aris rekomendebuli ormagi pi-ebis kombniacaSi TPV/r gamoyeneba.

4.6. gadarCenis (Salvage) reJimebi

dadasturebuli meore rigis araefeqturobis SemTxvevebSi

(virusologiuri, imunologiuri, klinikuri araefeqturobis

kriteriumebiT) ganixileba gadarCenis reJimebi. gadarCenis reJimebSi

igulisxmeba im medikamentebis kombinacia, romlebic SesaZloa muSaobdes

an virusi maT mimarT iyos nawilobriv rezistentuli. yvela reJimi meore

rigis Semdgom garTulebulia da moiTxovs arT-codnis maRal dones da

unar-Cvevebs. genotipuri rezistentobis testis monacemebi am situaciaSi

aucilebelia. zogierT SemTxvevebSi gadarCenis Terapiis dawyebamde

39

umjobesia ramodenime TviT mocda, Tumca es strategia SesaZloa iyos

saSiSi, kerZod, Tu CD4 ujredebis ricxvi dabalia.

• Tu SesaZlebelia, unda CaerTos ori medikamentis efeqturi kombinacia

mag; SeWris inhibitori enfurvitidi (ENF) (96) (CIII), romelic iniSneba

2-jer dReSi kanqveSa aplikaciis saxiT da axali pi TPV (97,90) (CIII), an axali pi TCM114 (99,100) (CIII).

• TPV - genetikuri barieri ufro maRalia, vidre LPV/r da monacemebi gviCveneben mis efeqturobas am ukanasknelTan SedarebiT. dRevandel

dRes TPV gamoiyeneba mxolod gadarCenis Terapiis reJimebSi.

• sxva SesaZleblobaa ori pi kombinacia (102-104) (CIII), gamonaklisia

TPV, romelic ar unda gamoviyenoT sxva pi–sTan kombinaciaSi.

4.7. mkurnalobis dagegmili Sewyveta

bevri ewinaaRmdegeba arT dagegmil Sewyvetas, Tumca dasabuTeba

SesaZlebelia. mag. CD4>500 mm3 mudmivi done da virusis supresia mravali

wlebis ganmavlobaSi abrkolebs oportunistuli infeqciebis

ganviTarebas. mkurnalobis dagegmili Sewyveta, mkurnalobis reJimis

araadeqvaturad dacvis SemTxvevaSi, Tavidan agvacilebs rezistentuli

Stamebis ganviTarebas. mkurnalobis Sewyvetis Semdeg CD4 limfocitebis

ricxvi Camodis pre-arv Terapiis donemde, amdenad aucilebelia pirveli

sami Tvis ganmavlobaSi CD4 limfocitebis ricxvis monitoringi. zogierT

pacientSi limfocitebis ricxvi >350 mm3 da dabali virusuli datvirTva

(1000-5000 asli/ml) Tveebisa da wlebis ganmavlobaSia SenarCunebuli.

mkurnalobis dagegmili Sewyvetis sargebelze arasakmao informaciis

arsebobis gamo janmos mier igi ar aris rekomendebuli.

5. aiv inficirebul pacientTa klinikuri monitoringi

mas Semdeg rac adamians daesmeba aiv infeqciis diagnozi is

uzrunvelyofili unda iyos monitoringiTa da movliT.

5.1. laboratoriuli indikatorebi arT dawyebamde

CD4 ujredebis ricxvi:

• gaimeoreT yovel 6 TveSi, Tu aris amouxsneli Sedegebi (CD4 ujredebis swrafi daqveiTeba an oportunistuli infeqciebis

ganviTareba);

• Tu mimdinareobs msjeloba arT dawyebaze (CD4 ujredebi tolia an

<350 mm3) gaimeoreT yovel 3 TveSi. statistikurad, erTi wlis

ganmavlobaSi CD4 ujredebis ricxvi klebulobs 50 ujrediT, Tumca

Tanmxlebi infeqciebis arsebobis dros SesaZloa daqveiTdes Zalian

swrafad.

• virusuli datvirTva unda gakontroldes drois igive SualediT.

dabali virusuli datvirTva (1000-5000 asli/ml) maniSnebelia

daavadebis duned progresirebis da piriqiT, maRali virusuli

datvirTva (>100 000 asli /ml) miuTiTebs daavadebis swraf

progresirebaze.

40

• ZiriTadi laboratoriuli testebi unda gakontroldes (cxr. 12)

yovel 6 TveSi, Tu ar aris raime sxva mizezi, mag. orsuloba.

5.2. laboratoriuli maCvemeblebis monitoringi arv Terapiaze myof

pacientebSi

arT-s warmatebis pirveli maCvenebelia virusuli datvirTva. imunuri

pasuxi virusuli datvirTvis Sedegia da mogvianebiT viTardeba. arT

monitoringisTvis saukeTesoa orives gakontroleba.

virusuli datvirTva:

• virusuli datvirTva unda ganisazRvros mkurnalobis dawyebidan 4-8

kviraSi reJimis warmatebis SefasebisTvis. virusuli datvirTva

aragansazRvradi unda gaxdes 16-24 kviraSi.

• virusuli datvirTvis monitoringisTvis sasurveli intervalia 3-4-

Tve.

• Tu virusuli datvirTva gaxda aragansazRvradi (< 50 asli/ml), is

unda darCes aragansazRvradi.

• CD4 ujredebis ricxvi unda gakontroldes yovel 6 TveSi, klinikuri

warumateblobis SemTxvevebis garda.

• ZiriTadi laboratoriuli testebi (cxr. 3) unda gakontroldes

yovel 6 TveSi, Tu ar aris raime cvlilebebli arv Terapiis reJimSi.

cxrili 12.

laboratoriuli testebis sixSire ZiriTadad da specifikuri arv-s

reJimis gaTvaliswinebiT

sawyisi

2

kvira

4

kvira 8

kvira 16

kvira 24

kvira 36

kvira 48

kvira virusuli

datvirTva

X

X X X X

CD4 ujredebis ricxvi

X X X (X) X

sisxlis saerTo

analizi

X X X X

(ZDV) X (X) X

RviZlis

funqciuri

sinjebi

X X

(NVP) X X

(NVP, ZDV, PI)

X

(NVP, PI)

X (X) X

qolesterini

triglice-ridebi

X (PI) X (PI) X (PI)

Tirkmlis

funqciebi

X X

(TDF) X

(TDF, IDV)

X (X) X

X: testebi, romlebic unda Catardes arv Terapiisgan damoukideblad;

X (arv): testebi, romlebic unda Catardes mocemuli preparatis arsebobisas

arT reJimSi;

(X): araucilebeli testebi.

41

5.3. mkurnalobis reJimis dacvis monitoringi

yvela pacienti, romelic imyofeba arT-ze mudmivad unda imyofebodnen

meTvalyureobis qveS. sanam isini imyofebian mkurnalobis monitoringis

qveS (ixileT damateba 5), miRebuli meTodia standartuli anketireba 14

dReSi an TveSi erTxel.

virusuli datvirTvis cvlileba yovelTvis saWiroebs eqimis mier

pacientTan erTad mkurnalobis reJimis ganxilvas. gamoiyeneba kiTxvari,

romlis mixedviTac SeiZleba ganvsazRvroT damyoloba mkurnalobisadmi.

mkurnalobis reJimis dacva 4-6 Tvis ganmavlobaSi saSualebas iZleva

miRweul iqnas xangrZlivi imunovirusologiuri pasuxi (110) (AI). sxvadasxvagvari Careva SesaZlebelia, magram prioritetulia is reJimi,

romelic adreul TveebSi iZleva arT-ze ukeTes pasuxs (110-114) (AI).

mkurnalobis reJimis dacva SeiZleba iyos nawili rutinuli klinikuri

dakvirvebisa, romelsac axorcielebs yvela profesionali eqimi. yoveli

vizitis dros eqimi unda darwmundes, rom TiToeul pacients:

aqvs emociuri da fizikuri mxardaWera; dRis ganmavlobaSi icavs wamlebis miRebis reJims;

esmis, rom reJimis darRveva gamoiwvevs rezistentobis ganviTarebas;

gacnobierebuli unda hqondes, rom yvela doza droulad iqnas

miRebuli;

wamlebis miRebis dros Tavs unda grZnobdes komfortulad;

daicvas daniSnuleba;

esmodes arv-s moqmedeba da gverdiTi efeqtebi;

icodes, Tu rodis mimarTos eqims.

sxva strategia moicavs:

depresiis mkurnalobas, raTa amaRldes mkurnalobis reJimis dacva da

miRweul iqnas xangrZlivi Sedegi;

wamlebis urTierTqmedebis da dozirebis menejments;

medikamentebis gacemas mcire raodenobiT da xSiri intervalebiT,

romelic aiolebs:

1. problemebis droul gamovlenas, manam sanam ganviTardeba

rezistentoba;

2. Semcirdes medikamentebis gacema da borotad gamoyeneba;

3. gamoyenebuli iqnas dReSi erTxel misaRebi, erTdoziani

medikamentis kombinacia, rac xels Seuwyobs adreul etapze

mkurnalobis damyolobas;

4. mkurnalobaze uSualo zedamxedveloba, gansakuTrebiT

hospitalSi.

fsiqosocialur daxmarebas;

pacients miewodos saxelmZRvanelo da broSurebi;

pacientebis monawileobas daxmarebis jgufebSi.

5.4. arv toqsiuroba da gverdiTi efeqtebis menejmenti

gverdiTi efeqtebi xSiria arv Terapiis dros, gansakuTrebiT proteazas

inhibitorebis miRebis dros (ix. cxrili 13).

lopinavir/ritonavirs da nelfinavirs SeuZliaT gamoiwvion diarea;

42

lopinaviri/ritonaviris miReba asocirebulia hiperlipidemiasTan

(gansakuTrebiT trigliceridebis momatebasTan);

cximebis metabolizmis darRvevebi SeiZleba gamoiwvios TiTqmis yvela

proteazas inhibitorebma;

erTaderTi proteazas inhibitori, romelic gavlenas ar axdens

lipidur cvlaze aris atazanaviri da atazanavir/ritonaviri. zogierT

qveyanaSi atazanaviri mowodebulia mkurnalobis meore rigis sqemaSi;

kardiovaskularuli garTulebebis riskis momateba saWiroebs Semdgom

Seswavlas.

cxrili 13

arv-s toqsiurobis dadastureba da menejmenti

ARV toqsiuroba menejmenti RviZlis nekrozi

nevirapini (NVP) o cxeleba, gamonayari (50%),

gulisreva, Rebineba,

eozinofilia, alt, ast-s

donis momateba

o Cveulebriv pirvel 6-18

kviraSi, iSviaTad 48

kviris Semdeg

o nevirapinze myofi

pacientebis 1-2%, qalebSi

CD4 > 250 ; kacebSi CD4 > 400-ze

o RviZlis funqciuri

sinjebis monitoringi 2,

4, 8, 16 kviraze da

Semdeg yovel 3 TveSi

o simptomuri mkurnaloba

o RviZlis nekrozis

mkurnaloba, calkeul

klinikur SemTxvevebSi

wamlebis Sewyveta

laqtat-acidozi

maRlidan dabali

riskisken:

o stavudini

didanozinTan

erTad

o didanozini

o stavudini

o zidovudini

o gulisreva, Rebineba,

wonaSi dakleba, sisuste,

pankreatiti,

multiorganuli

ukmarisoba,

respiratoruli distres

sindromi

o yoveli 1000 pacientidan

1-10 weliwadSi

didanozini da stavudini

o laqtat-acidozis

monitoringi Tu eWvia,

inaxos adreuli

indikatorebi

(kreatinkinaza (CK) HCO3)

o acidozis samkurnalod

mowodebulia

bikarbonati

o abakaviriT,

tenofoviriT,

lamivudiniT,

emtricitabiniT Secvla

maRali mgrZnobeloba

abakaviri (ABC )

o xSirad aris cxeleba,

gamonayari, aseve sisuste

da gulisreva

o 5%, iSviaTad 6 kviris

Semdeg

o kanze dakvirveba, ar

SeiZleba dawyeba

gamonayris

sawinaaRmdego

wamlebTan erTad.

o Sewydes abakaviris

miReba da ar ganaxldes

Tu diagnozi saeWvoa

o Seicvalos

zidovudiniT,

tenofoviriT an

stavudiniT

o

43

stivens-jonsis sindromi, epidermisis toqsiuri nekrozi

nevirapini (NVP) efavirenzis dabali

doziT

o cxeleba, buStukovani

gamonayari, mialgia

o nevirapini 1%-Si,

efavirenzi 0,1%-Si

o kanze dakvirveba

o antibiotikebis daniSvna

Wrilobis samkurnalod

pankreatiti

maRlidan dabali

riskisken:

o stavudini

didanozinTan

erTad

o didanozini

o stavudini

o tkivili, lipazas maRali

done

o didanozini 1-7%, dozis

SemcirebiT

o lipazas donis

monitoringi

o simptomuri mkurnaloba,

parenteraluri kveba,

wamlebis Sewyveta

o zidovudiniT an

tenofoviriT an

abakaviriT Secvla

ARV toqsiuroba menejmentinefrotoqsiuroba

tenofoviri TDF

o Tirkmlis ukmarisoba

da fankonis sindromi o ufro xSirad

pacientebSi Tirkmlis

disfunqciiT

o kreatininis monitoringi,

istoria Tirkmlis

daavadebis Sesaxeb

o mkurnaloba simtomuria

o tenofoviris dozis

koreqcia (saWiroa

kreatininis klirensi:

yovel meore dRes

o Seicvalos tenofoviri

zidovudiniT, abakaviriT

an stavudiniT

anemia

zidovudini ZDV

o anemia da neitropenia

(sustad Semcireba

iTvleba normad

zidovudinTan)

o 1-4%, dozaze

damokidebulebiT

o sisxlis saerTo analizis

monitoringi 2, 4, 8, 12

kviraze. makrocitozi

msubuqi anemiiT

(hemoglobini 100 gr/l)

xSiria o mkurnaloba aris

eriTropoetinis

transfuzia (Zalze

Zviria) an Seicvalos

zidovudini sxva nrti

(tenofoviri, abakaviri an

stavudini)

periferiuli neiropaTia

didanozini, stavudini,

zalcitabini

o kidurebis

tkivili,

paresTezia

o 10-30% wlebis

Semdeg

o periferiuli nervuli

sistemis kontroli

o mkurnaloba tkivilis

kupireba, Seicvalos arT.

Sewydes wamlebi an

Seicvalos nrti

(zidovudini, tenofoviri,

abakaviri)

cximovani atrofia

stavudini, da sxva nrti

o loyisa da

o kidurebis cximis

ganleva

o xangrZlivad

gamoyenebis

o monitoringi da sawyis

o mdgom. Sedareba

o Seicvalos stavudini

tenofoviriT an

abakaviriT. Tu atrofia

44

SemTxvevaSi

xSiria

(mitoqondriuli

toqsiuroba)

Seuqcevadia plastikuri

qirurgia naCvenebia

cximovani akumulacia

PI

o matulobs

mucelze

gacximovneba,

mkerdis zoma,

o 20-80%

o Sefaseba da sawyis mdgom.

Sedareba

o Seicvalos NNRTI-iT, Tu lipodistrofia/lipoatr

ofia ar aris

tolerantuli, naCvenebia

plastikuri qirurgia

nrti fosamprenaviri

FPV>abakaviri ABC o makulur-papuluri

gamonayari

o 15% nnrti, APV 20%,

abakaviri 5%

o cxelebis, RviZlis

funqciuri sinjebis da

kreatinkinazas

monitoringi

o sxva alergenebis

gamoricxva

(sulfametoqsazol/trim

etoprimi da sxva

antibi.). gamonayari

SeiZleba spontanurad

gaqres arT-s Semdeg

o Seicvalos nevirapini

efavirenziT an piriqiT.

Tu ar aris

gaumjobeseba scadeT

sxva reJimi

transaminazebis elevacia

anrti (all) da PIs (all)

o auxsneli RviZlis

funqciebis momateba

o 8-15% PI da nnrti o ufro xSirad

pacientebSi

qronikuli HBV da

HCV infeqciiT

o ALT monitoringi yovel

eqvs TveSi,

gaTvaliswinebuli iqnas

sxva faqtorebi (mag.

wamlismieri hepatiti. o momateba xSirad Tan

axlavs nnrti da pi

ganuwyvetel miRebas

o Sewydes nnrti da pi

miReba

45

ARV toqsiuroba menejmenti PIs (all),zidovudini ZDV,didanizini ddI

o gulisreva da Rebineba,

diarea

o xSiria

o gamoiricxos sxva mizezi

(imunuri rekonstituciis

anTebiTi sindromi CMV

kolitiT,

kriptosporidiozi,

mikrosporidiozi, arT-s

dawyebidan kvireebis Semdeg

o mkurnaloba aris

loperamidiT Tu diareis

sxva mizezi ar aris:

metoklopramidi, zofrane

gulisrevis da Rebinebis

dros

centraluri nervuli sistemis (cns) toqsiuroba

efavirenzi EFV

o Ramis SfoTva,

koncentraciis darRveva,

depresia (suicidisken

midrekileba)

o 50%

o pacientebis gafrTxileba,

fsiqiatris konsultacia

o mkurnaloba Cveulebriv

saWiro ar aris. aRniSnuli

movlenebi gaivlis 5-21

dReSi

insulin rezistentoba

PIs (yvela magram ATV)

o glukozis tolerantoba

matulobs, glukoza

matulobs uzmoze

o 5%

o uzmoze glukozis

monitoringi o mkurnaloba dietiT da

metforminis an glitazonis

miReba o Seicvalos pi nnrti-iT

hiperlipidemia

stavudini (d4T)>PIs (all but ATV)

o lipidebis, qolesterolis,

trigliceridebis

momateba( am

ukanasknelisTvis

stavudini SeiZleba iyos

wamyvani)

o 0%

o lipidebis donis

monitoringi arT-s

dawyebidan da Semdeg yovel

eqvs TveSi

o mkurnaloba lipidebis,

qolesterolis da

trigliceridis

gaidlainebiT

o sifrTxilea saWiro

urTierTzemoqmedebisas (ar

SeiZleba simvastatini da

lovastatini)

hiperbilirubinemia

atazanaviri (ATV) >indinaviri ( IDV)

o bilirubinis momateba

(SesaZlebelia qavili,

araprolongirebuli RviZlis

dazianeba, Seqcevadi

o xSiria

o bilirubinis da klinikuri

simtomebis monitoringi

o wamlebis Sewyveta Tu ar

aris tolerantoba.

Seicvalos pi.

nefroliTiazi

indinaviri (IDV)

o muclis tkivili,

hematuria, Tirkmlis

kolika

o 10-20%

o Sardis analizis da

kreatininis monitoringi

o mkurnaloba igivea rac

nefroliTiazis dros

46

ARV toqsiuroba menejmentinefrotoqsiuroba

tenofoviri TDF

o Tirkmlis ukmarisoba da

fankonis sindromi o ufro xSirad

pacientebSi Tirkmlis

disfunqciiT

o kreatininis moni-

toringi, istoria

Tirkmlis daavadebis

Sesaxeb

o mkurnaloba simto-muria

o tenofoviris dozis

koreqcia (saWiroa

kreatininis klirensi:

yovel meore dRes

o Seicvalos tenofoviri

zidovudiniT, abakaviri

an stavudiniT

anemia

zidovudini ZDV

o anemia da neitropenia

(sustad Semcireba

iTvleba normad

zidovudinTan)

o 1-4%, dozaze

damokidebulebiT

o sisxlis saerTo

analizis monitoringi

2, 4, 8, 12 kviraze.

makrocitozi msubuqi

anemiiT (hemoglobini

100 gr/l) xSiria o mkurnaloba aris

eroTropoetinis

transfuzia (Zalze

Zviria) an Seicvalos

zidovudini sxva nrti

(tenofoviri, abakaviri

an stavudini)

periferiuli neiropaTia

didanozini, stavudini,

zalcitabini

o kidurebis tkivili,

paresTezia

o 10-30% wlebis Semdeg

o periferiuli nervuli

sistemis kontroli

o mkurnaloba tkivilis

kupireba, Seicvalos

arT. Sewydes wamlebi an

Seicvalos nrti

(zidovudini,

tenofoviri, abakaviri)

cximovani atrofia

stavudini, da sxva nrti

o xSiria xangrZlivi

gamoyenebis SemTxvevaSi

(mitoqondriuli

toqsiuroba)

o monitoringi da sawyis

mdgom. Sedareba

o Seicvalos stavudini

tenofoviriT an

abakaviriT. Tu atrofia

Seuqcevadia plastikuri

qirurgia naCvenebia

cximovani akumulacia

PIs

o matulobs mucelze

gacximovneba, mkerdis

zoma,

o 20-80%

o Sefaseba da sawyis

mdgom. Sedareba

o Seicvalos NNRTI-iT,

Tu

lipodistrofia/lipoat

rofia ar aris

tolerantuli,

naCvenebia plastikuri

qirurgia

47

ARV toqsiuroba menejmenti

PIs (all),zidovudini ZDV,didanizini ddI

o gulisreva da Rebineba,

o diarea

centraluri nervuli sistemis (cns) toqsiuroba

efavirenzi EFV

o koncentracia depresia

(suicidisken midrekileba)

o 50%

insulin rezistentoba

PIs (all but ATV)

o glukozis tolerantoba

matulobs, glukoza

matulobs

o 5%

hiperlipidemia

stavudini (d4T)>PIs (all but ATV)

o lipidebis qolesterini,

trigliceridebi

o % meryeobs

hiperbilirubinemia

atazanaviri (ATV) >indinaviri ( IDV)

o bilirubinis momateba

(SesaZloa qavili, ar

grZeldeba RviZlis dazianeba,

Seqcevadia)

o xSirad cvalebadobs

nefrolifiazi

indinaviri (IDV)

o muclis tkivili, hematuria,

Tirkmlis kolika

o 10-20%

nnrti>APV/fozamprenaviri FPV>abakaviriABC

o makulur-papuluri

gamonayari

o 15% nnrti, APV 20%,

abakaviri 5%

transaminazebis elevacia

anrti (all) da PIs (all)

o auxsneli RviZlis

funqciebis momateba

o 8-15% PI da nnrti o ufro xSirad

pacientebSi qronikuli

HBV da HCV infeqciiT

48

5.5 imunuri rekontituciis sindromi (irs)

irs adgili aqvs arT sawyis etapze, ufro xSirad rodesac CD4<100mm3. Tu

miZinebuli oportunistuli infeqcia ar diagnostirdeba klinikuri

simtomebis ararsebobis gamo, maSin SesaZlebelia adgili hqondes irs

arT sawyis etapze. saWiroa gamoswordes da gaaqtiurdes imunuri sistema,

rac saSualebas mogvcems diagnostirdes oportunistuli infeqciebi (120-

121) (CIII). oportunistuli infeqciebi sxvadasxvagvarad gamovlindeba,

magaliTad abscesis dros gamomwvevia Mycobacterium avium-intracellulare (MAI) an gulmkerdis kuriozuli rentgenologiuri Sedegi Pneumocystis jirovecii pneumonia (PCP). irs gvxvdeba SemTxvevaTa 10%-Si. MAI da CMV yvelaze

xSiri oportonistuli infeqciebia, magram cudi mkurnalobis SemTxvevaSi

SesaZlebelia PCP ganviTardes (122) (BII). irs ganviTarebis Semdeg arT

unda gagrZeldes oportunistuli infeqciebis mkurnalobasTan erTad.

SesaZlebelia prednizolonis dabali dozebi (20-60 mg dReSi). arT

SesaZlebelia Sewydes Tu adgili aqvs oportunistuli infeqciebis

mkurnalobis gverdiT efeqtebs an gamoxatulia ezofagiti (CMV,

herpesuli infeqcia, kandidozi) tkiviliT.

5.6. wamlebis urTierTqmedeba

wamlebis urTierTqmedeba warmoadgens calke problemas arT-s dros.

aiv/SidsiT inficirebulebi iReben ramdenime saxis medikamentebs, imis

gamo, rom aqvT manifestirebuli daavadeba da/an Tanmxlebi daavadebebi.

medikamentebis urTierTqmedebis miuxedavad, maTi kombinaciis miReba

SesaZlebelia kvlav gagrZeldes. miuxedavad amisa gverdiTi efeqtebis

gamovlenis SesaZlebloba maRalia da saWiroebs monitorings.

kontraceptivebis miReba sariskoa.

cxrilSi 14 da 15 ilustrirebulia aranukleozidis revers

transkriftazas inhibitorebis da proteazas inhibitorebis

urTierTmoqmedeba.

49

cxrili 14.

anrtis zemoqmedeba

nnrti efeqti mniSvneloba

EFV NPV

+ ergotamini ++ (Tavidan

acileba)

+ antiariTmulebi: lidokaini,

amiodaroni da sxva

++ (SeniSvna)

+

+

antikonvulsurebi: karbamazepini,

fenitoini, fenobarbitali

+ +

(+)c + itrakonazoli, ketokonazoli +

+ ciklosporini, takrolizmusi,

rapamicini

+ +

+ + + midazolami, alprazolami,

triazolami

+ +

+ kalciumis arxis blokatorebi + +

+ + sildenafili, vardenafili,

tadalafili

+ +

+ fentanili + +

+ + metadoni + +

+ + kontraceptivebi + +

+ + rifampini, rifabutini + +

+ + stivens jonsis sindromi + +

+ + varfarini + +

cxrili 15.

proteazas inhibitorebis zemoqmedeba

proteazas inhibitorebi efeqti mniSvneloba

APV ATV IDV LPV NFV RTV SQV + fentanili, tramadoli,

hidrokodoni +

+ + kodeini, morfini,

metadoni +

+ + + + + + + amiodaroni, lidokaini,

flekainidi +

+ + + + + + karbamazepini,

klonazepami, fenitoini,

fenobarbitali

++ (Tavidan

acileba)

+ + + + tricikluri

antidepresantebi +

+ + sxva antidepresantebi +

+ loratadini + +

+ atovaqvini +

+ + + ++ + + ++ benzodiazepini + +

+ beta blokatorebi +

+ + + + + + + kalciumis arxis

blokatorebi + +

50

+ + + klaritromicini,

eriTromicini, Tirkmlis + (SeniSvna)

+ + + + + klaritromicini,

eriTromicini +

+ + + + kontraceptivebi + +

+ + + + kortikosteroidebi +

+ + + + + + + ciklosporini +

+ + + + + + + ergot derivatebi ++ (Tavidan

acileba)

+

++

+

+

+

+

+

protonuli dguSis

inhibitorebi (PPIs) + (SeniSvna)

(++, ATV- Tavidan

acileba)

+ ++ + + + + + H2 antagonistebi ++ (SeniSvna)

(++, ATV) + + + + + + + lovastatini,

simvastatini ++ (Tavidan

acileba)

+ irinotekani ++ (Tavidan

acileba)

+ + + + + ketokonazoli,

itrakonazoli +

+ + + + + + + pimozidi ++ (Tavidan

acileba)

+ + + + + + + rifampini ++ (Tavidan

acileba)

+

+

+

+

+

+

+

rifabutini + (SeniSvna,

doze adjustment)

+ + + + + + + sildenafili + +

+ + + + + + + stiven jonsis sindromi ++ (Tavidan

acileba)

+ tenofoviri + + (add RTV)

+ + + Teofilini +

+ + + + varfarini +

cxrilebis wakiTxvis magaliTi

1. cxrili 14 rigi 6: efavirenzi mkacrad zrdis dones: midazolamis,

alfrazolamis da triazolamis, maSin roca nevirapinis doza

amcirebs. zemoT xsenebuli faqtis klinikuri mniSvneloba

mdgomreobs medikamentebis kvlav mowodebaSi.

2. cxrili 15 rigi 4: abakaviri, indinavir/lopinaviri, nelfinaviri,

ritonaviri da seqvinaviri zrdian karbamazepinis, klonazepamis,

fenitoinis da fenobartialis dones, maSin roca es wamlebi

amcireben proteazas inhibitorebis dones. klinikuri Rirebuleba

imaSia, rom aseT kombinacias Tavi unda avaridoT.

51

II. klinikur doneze Sesagrovebeli minimaluri monacemebis CamonaTvali

klinikur doneze Sesagrovebeli minimaluri monacemebis CamonaTvali

mniSvnelovania, rogorc mkurnalobis xelmisawvdomobisa da Sedegianobis

indikatori. aseTi indikatorebi exmareba menejers SesTavazos es servisi

yvelas, vinc saWiroebs.

CamoTvlili monacemebi unda Segrovdes klinikur doneze, rogorc

regularuli sabaziso: (TveSi erTxel, kvartalSi an eqvs TveSi erTxel)

• aiv pacientebis ricxvi, romelTac vxedavT weliwadSi erTxel;

• aiv pacientebis ricxvi, romlebic ganixilebian arT-s kandidatebad

(CD4<350 mm3); • aiv pacientebis ricxvi, romlebic arian arT-s sawyis etapze;

• aiv pacientebis ricxvi, romlebic Rebuloben arv-s;

• aiv pacientebis ricxvi, romlebic I rigis preparatebidan gadavidnen II

rigze;

• aiv pacientebis ricxvi, romlebic II rigis preparatebidan gadavidnen

gadarCenis reJimze;

• aiv pacientebis ricxvi, romlebmac Sewyvites arT, mizezis aRniSvniT

(magaliTad sikvdili, toqsiuroba-gverdiTi efeqtebi, orsuloba, arv

ar aris xelmisawvdomi);

• aiv pacientebis ricxvi, romlebic gardaicvalnen arT-s dros,

sikvdilis mizezis aRniSvniT (magaliTad aiv/SidsTan dakavSirebuli

sikvdilianoba an misgan damoukidebeli, rogoricaa dozis

gadaWarbeba, suicidi da sxva);

• aiv pacientebis ricxvi, romlebic gardaicvalnen arT-s dawyebidan 12

TveSi;

• gardacvlili aiv pacientebis ricxvi, sikvdilis mizezis aRniSvniT

(magaliTad aiv/SidsTan dakavSirebuli sikvdilianoba an misgan

damoukidebeli, rogoricaa dozis gadaWarbeba, suicidi da sxva).

52

damateba 1. ZiriTadi informacia aiv infeqcia/Sidsis mkurnalobis da movlis personaluri istoriisTvis

cxrili 16

ZiriTadi informacia aiv infeqcia/Sidsis mkurnalobis da movlis

personaluri istoriisTvis

TariRi CD4 ujredebi/mm3

%

VL asli/ml

rezistentoba

(genotipi an

fenotipi)

53

damateba 2. jandacvis msoflio organizaciis mier mowodebuli aiv/Sidsis klinikuli klasifikacia mozardebsa da mozrdilebSi

(Sua evropis regionis versia, pacientebisTvis romelTa asaki >15welze,

aiv pozitiuria an saxezea aiv infeqciis sxva laboratoriuli testebi)

mwvave aiv infeqcia

asimptomuri

mwvave retrovirusuli sindromi

klinikuri stadia 1

asimptomuri

persistuli generalizebuli limfadenopaTia

klinikuri stadia 2

seboreuli dermatiti

angularuli heiliti

ganmeorebiTi oraluri ulceracia (ori an meti epizodi eqvsi Tvis

ganmavlobaSi)

herpes zosteri

respiratoruli traqtis ganmeorebiTi infeqcia (ori an meti epizodi

eqvsi Tvis ganmavlobaSi, sinusiti, Sua otiti, bronqiti, faringiti,

traqeiti)

frCxilebis sokovani infeqcia

klinikuri stadia 3

piris Rrus Tmovani leikoplakia

umizezo qronikuli faRaraTi erT Tveze meti

ganmeorebiTi oraluri kandidozi (ori an meti epizodi eqvsi Tvis

ganmavlobaSi

sxva baqteriuli infeqcia (mag. pnevmonia, empiema, piomioziti, Zvlebis

an saxsrebis infeqcia, meningiti, baqteriemia)

mwvave, nekrozuli, ulcerogenuli stomatiti, gingiviti an

periodontiti)

klinikuri stadia 4

filtvis tuberkulozi;

eqstrapulmonuri tuberkulozi (limfadenopaTiis CaTvliT);

wonis umizezo dakargva (eqvsi Tvis ganmavlobaSi 10% meti);

aiv asocirebuli ganlevis sindromi;

pnevmocisturi pnevmonia;

ganmeorebiTi sxva an radiologiurad dadasturebuli baqteriuli

pnevmonia (ori an meti epizodi erT weliwadSi);

CMV retiniti (+koliti); martivi herpes virusuli infeqcia (qronikuli an persistuli bolo

erTi Tvis ganmavlobaSi); encefalopaTia; aiv-Tan asocirebuli kardiomiopaTia;

54

aiv-Tan asocirebuli nefropaTia; progresuli multifokaluri leikoencefalopaTia; kapoSis sarkoma da aiv_Tan dakavSirebuli avTvisebiani daavadebebi: 1. toqsoplazmozi;

2. diseminirebuli sokovani infeqcia (mag. kandidozi, kokcidomikozi,

histoplazmozi);

3. kriptosporidozi;

4. kriptokokuli meningiti;

5. aratuberkulozuri mikobaqteriuli infeqcia.

damateba 3. rezistentobis testi

rezistentobis testis Casatareblad saWiroa virusuli datvirTva

minimum 500-1000 asli/ml. testis Catareba SeuZlebelia, rodesac

aRiniSneba virusis sruli supresia.

genotipis rezistentobis testi damyarebulia virusis rnm-is mutaciis

analizze. mutacia damokidebulia virusis mgrZnobelobis cvlilebaze.

es aris arapirdapiri mtkiceba wamlis rezistentobisa. rezistentuli

virusis populacia ar aris maRali da Seadgens mTeli populaciis 20%-s.

fenotipis rezistentobis testi msgavsad mikrobiologiuri

rezistentobis testisa, ikvlevs virusis replikaciis unars ujredebis

kulturaSi sxvadasxva agentis arsebobisas da adareben virusis veluri

Stamis unarianobas. 50% inhibitoris koncentracia (IC50) aris wamlis

potenciis markeri. testis Sedegi gviCvenebs mgrZnobelobis gansxvavebul

xarisxs.

rezistentobis romeli testi gamoviyenoT?

amJamad arsebuli yvela testi aris Zviri. genotipis testis Rirebuleba

Seadgens 400 E, fenotipis _ 800 E (2005w). drom nimuSis aRebidan Sedegis miRwevamde SeiZleba Seadginos ramdenime kvira. genotipis bazisuri testi

saSualebas iZleva daigegmos mkurnalobis reJimi. pirveli da meore

rigis mkurnalobis sqemebi ar saWiroebs Zvir fenotipis tests. rodesac

gaurkvevelia arT-s istoria, sakmarisad cnobili mutacia, mkurnaloba ar

aris Sedegiani, fenotipuri testis Catareba gamarTlebulia. yvela

testis SemTxvevaSi unda gagrZeldes mkurnalobis arsebuli reJimi, sxva

SemTxvevaSi swrafad ganviTardeba rezistentuli Stamebi. ar arsebobs

standartuli rekomendaciebi romeli rezistentuli testebi ganiviyenoT,

fenotipuri Tu genotipuri.

55

damateba 4. ZiriTadi informacia antiretrovirusuli mkurnalobis Sesaxeb cxrili 17. ZiriTadi informacia antiretrovirusuli mkurnalobis Sesaxeb

arv abreviatura zoma dozebi SeniSvnebi gverdiTi efeqtebi rezistentobis profili

(didi da mcire)

nrti abakaviri ABC 300 mg 300 mg tab. orjer an

600 mg erTxel

ar aris

hipermgrZnobelobis

reaqciis monacemebi

maRalmgrZnobiare reaqcia

(cxeleba, gamonayari,

gripismagvari simptomebi: GI da filtvis simptomi)

65R, 74V, 115F, 184V/I

didanozini ddI 250 mg

400 mg

pacienti >60kg: 400 mg

tab. erTxel

pacienti <60kg: 250 mg

tab. erTxel

Wamidan 2 sT-is Semdeg

dozis koreqcia TDF, ara ribavirinTan

kombinacia

periferiuli polineiropaTia,

pankreatiti, laqtacidozi 65R, 74V

emtricitabini FTC 200 mg 200 mg kaps. erTxel igive, rac lamivudini 65R, 184V/I lamivudini 3TC 300 mg

150 mg

300 mg tab. erTxel an

150 mg tab. orjer

iSviaTi diarea 65R, 184V/I

stavudini d4T 30 mg

40 mg

pacienti >60kg: 40 mg

kaps. orjer

pacienti <60kg: 30 mg

kaps. orjer

zidovudinTan ar

SeiZleba

periferiuli neiropaTia,

lipodistrofia, alt, ast-s

donis momateba

41L, 67N, 70R, 75T/M/S/A, 210W, 215Y/F, 219Q/E

tenofoviri TDF 300 mg 300 mg tab. erTxel didanozinis dozis

koreqcia, ar SeiZleba

stavudinTan

kombinacia; sifrTxile

Tirkmlis ukmarisobis

dros (dozis koreqcia)

Tirkmlis ukmarisoba 41L, 65R, 210W

zidovudini ZDV 300 mg 300 mg tab. orjer ar SeiZleba

stavudinTan; mgrZno-

biarea 65R da 184V

anemia, GI, Tavis tkivili 41L, 67N, 70R,210W, 215Y/F, 219Q/E

ABC + 3TC KVX 600 mg ABC 300 mg 3TC

1 tableti erTxel

TDF + FTC TVD 300 mg TDF 200 mg FTC

1 tableti erTxel

ZDV + 3TC ZDV + 3TC ABC

CBV TZV

300 mg TDF 150 mg 3TC 300 mg ZDV 150 mg 3TC 300 mg ABC

1 tableti orjer

1 tableti orjer

maRali doza

zidovudinis maRalia

riski (gverdiTi

efeqtebis maRali

riski)

ara dReSi erTxel

anrti efavirenzi EFV 600 mg 600 mg tab. erTxel dawyeba saRamos Zilis darRveva, fsiqiuri darRvevebi

(depresia, suicidisken midrekileba,

Tavbruxveva)

100I, 101E, 103N, 106A/M, 108I, 181C, 188L, 190A/S, 225H, 230L

56

arv abreviatura zoma dozebi SeniSvnebi gverdiTi

efeqtebi rezistentobis

profili (didi da mcire)

nevirapini NVP 200 mg 200 mg tab. orjer pirveli 14 dRe 200 mg

erTxel,Semdeg 200 mg

orjer

gamonayari, RviZlis

fermentebis

momateba

100I, 101E, 103N, 106A/M, 108I, 179D/E, 181C/I, 188C/H, 190A/S, 230L

delavirdini DLV 200 mg

100 mg

200 mg x 2 tab. samjer an

100 mg x 4 tab. samjer

ar gamoiyeneba evropaSi gamonayari, gastro-

intestinuri

simptomebi, diarea

K103N/S, Y181C/I, P236L, G190A/S/E/Q/C, Y188L/H/C, V106A/M, K101E/P, M230L, K238T/N, F318L, V179D/E

pi

atazanaviri ATV 300 mg 300 mg erTxel

+

100 mg RTV erTxel

iseTive dozireba, rogorc

mkurnalobaze myofi

pacientebis. gamoiyeneba

ritonavirTan erTad

bilirubinis

momateba

24I, 33F/I/V, 36I/L/V, 46I/L, 50L, 54V/L/M/T, 82A/F/T/S, 84V, 88S, 90M

fozamprenaviri FPV 700 mg 700 mg tab. orjer +

100 mg kaps. RTV orjer

iseTive dozireba, rogorc

mkurnalobaze myofi

pacientebis. gamoiyeneba

ritonavirTan erTad

gamonayari, Tavis

tkivili, diarea,

dislipidemia

32I, 47V, 50V, 54L/M, 82A/F/T/S, 84V

indinaviri IDV 400 mg 400 mg kaps. orjer +

100 mg kaps. RTV orjer

gamoiyeneba ritonavirTan

erTad

Tirkmlis kenWi,

dislipidemia

24I, 32I, 36I, 46I/L, 54V, 82A/F/T/S, 84V, 90M

lopinaviri/

ritonaviri

kombinacia

LPV/r 133 mg/33 mg

200 mg/50 mg

(133 mg/33 mg) x 3 kaps. orjer an

(200 mg/50 mg) x 2 tab. orjer

Zveli monacemebiT

saWiroa gayinva, axali

monac. amis saWi-roeba ar

aris; dReSi erTxel

diarea, meteorizmi,

dislipidemia

10I/R/V, 20M/R, 24I, 32I, 33I/F/V, 46I/L, 53L, 54V/L, 63P, 71V, 82A/F/T, 84V, 90M

nelfinaviri NFV 250 mg

625 mg

625 mg x 2 tab. orjer

an 250 mg x 5 tab orjer

saWmelTan erTad Sewova

izrdeba 270%-iT; ar

Zlierdeba ritonavirTan

erTad

diarea, meteorizmi 30N, 36I, 46I/L, 54V/L/M/T, 82A/F/T/S, 84V, 88D/S, 90M

ritonaviri

seqvinaviri

RTV SQV

100 mg

500 mg

500 mg x 2 kaps. orjer

+ 100 mg kaps. RTV orjer

axali 500 mg tab. 2004

wlamde iyo 200 mg. gamo-

iyeneba ritonavirTan erTad

dislipidemia, RviZlis

funqciebis momateba,

diarea

diarea da sxva

gastrointestinuri

simpromebi,

dislipidemia

48V, 53L, 54V/L, 82A/F/T, 84V, 90M

tipranaviri TPV 250 mg 250 mg x 2 kaps. orjer +

100 mg x 2 kaps. RTV orjer

iseTive dozireba, rogorc

mkurnalobaze myofi

pacientebis. ar gamoiyeneba

pi-Tan erTad, gamoiyeneba

ritonavirTan erTad

dislipidemia,

RviZlis funqciebis

momateba, diarea

13L/V, 20M/R/V, 33F/I, 35D/N, 36I, 45R, 46I/L, 47V, 54A/M/T/V, 58E, 66F 69K, 71I/K, 74P, 82F/L/T, 84C/V, 90M, 91S

ujredSi SeWris inhibitorebi

enfuvirtidi ENF 90 mg 90 mg/ml kanqveSa

ineqcia orjer

ar aris oraluri

miRebisTvis

kanis mxriv reaqcia

(qavili, SeSupeba,

tkivili)

57

damateba 5. mkurnalobis reJimis dacvis monitoringis meTodebi

TviT-angariSi mkurnalobis reJimis kargi markeria, magram ara saukeTeso.

igi ufro gadaWarbebulad afasebs arT-s efeqturobas, vidre sxva meTodi

(128). aucilebelia pacientma gaamJRavnos problemebi pirispir saubrisas.

es meTodi SeiZleba iyos mniSvnelovani mkurnalobis dagegmvaSi

pacientis rolis gaZlierebisTvis, sapirispirod mowodebuli

kontrolirebadi meTodisa.

momwodeblis Sefaseba mwiria (129) da ar aris sasurveli.

wamlis donis monitoringi aris Zviri da SeuZlebelia yvela arT-ze

myofi pacientisTvis. es ar aris rutinuli meTodi mkurnalobis

efeqturobis kontrolisTvis. im SemTxvevaSi, rodesac plazmaSi wamlis

Semcveloba dabalia, mkurnalobis efeqturoba ar ganixileba. plazmaSi

wamlis done aris laboratoriuli markeri, romelic aCvenebs mag.

zidovudinis miRebis reJimis dacvas.

samedicino SemTxvevebis monitoringis sistema (MEMS) xSirad gamoiyeneba kvlevebis dros.

tabletebis raodenoba da farmakologiuri dokumenti SeiZleba

ganxilul iqnas, rogorc arasasurveli mcdeloba jandacvis muSakebis

mxridan akontrolon mkurnalobaze damyoloba. amitom pacients unda

movTxovoT, rom Tan hqondes darCenili medikamentebi.

tabletebis identifikaciis testi (PIT) warmoadgens axal meTods,

romelic korelaciaSia TviTangariSTan (132). pacientebs unda SeeZloT im

tabletebis amocnoba, romlebsac Rebuloben (132). pacientebma unda

gamoarCion is tabletebi, romlebsac Rebuloben sxva msgavsi, magram ara

identuri arv “tyupi tabletebisgan”.

surogati markerebis gamoyeneba realuria, magram dagvianebulia, rodesac

saxezea miRebis reJimis darRveva. pi-s Semcvel reJimebze ganviTarebuli

virusuli araefeqturoba dakavSirebulia miRebis reJimis darRvevasTan

da pi-ze genotipuri rezistentobis ararsebobasTan, rac miuTiTebs, rom

mkurnalobis araefeqturoba gamowveulia reJimis darRveviT (133,134).

mimwodeblebi Zalian frTxilad unda iyvnen am markerebis

interpretaciisas da gaiTvaliswinon sisxlSi medikamentebis dabali

donis sxva SesaZlo mizezebi (131).

58

damateba 6. antiretrovirusuli medikamentebis CamonaTvali

cxrili 18 antiretrovirusuli medikamentebis CamonaTvali

saerTaSoriso

saxeli (INN) mwarmoeblis saxeli farmaceptuli

kompania

nrti

abakaviri (ABC) epzikomi US, Kivexa United Kingdom (lamivudini/abakaviri)

triziviri Europe, United Kingdom, US (zidovudini/lamivudini/abakaviri)

ziageni United Kingdom, United States

GlaxoSmithKline

abaviri Genixpharma viroli

viroli LZ (abkaviri/lamivudini/zidovudini) Ranbaxy

didanozini (ddI) videqsi, videqsi EC Bristol-Myers Squibb dineqsi EC odiviri Kit (didanozini/lamivudini/efavirenzi)

aviro-Z virozini

viro-Z

Ranbaxy (India)

diviri Thai Government emtricitabini

(FTC) atripla (efavirenzi/emtricitabini/tenofoviri) Bristol-Myers Squibb emtriva

truvada (tenofoviri/emtricitabini) Cipla

lamivudini (3TC) kombiviri United Kingdom, United States (lamivudini/zidovuni)

epiviri United Kingdom, United States, zefiqsi United Kingdom epzikomi United Kingdom, kiveqsa United Kingdom (lamivudini/abakaviri)

triziviri United Kingdom, United States (zidovudini/lamivudini/abakaviri)

GlaxoSmithKline

lamivoqsi

staveqsi-L (lamivudini/stavudini)

staveqsi-LN (lamivudini/nevirapini/stavudini)

zidoveqsi-L (lamivudini/zidovudini)

zidoveqsi-LN (lamivudini/nevirapini/zidovudini)

Aurobindo

duoviri (lamivudini/zidovudini)

duoviri-N (lamivudini/nevirapini/zidovudini)

lamiviri

odiviri Kit (didanozini/lamivudini/efavirenzi)

triomuni (lamivudini/nevirapini/stavudini)

Cipla

heptaviri

lamistari 30, lamistari 40 (lamivudini/stavudini)

nevilasti (lamivudini/nevirapini/stavudini)

zidolami (lamivudini/zidovudini)

Genixpharma

virolami

virokombi (lamivudini/zidovudini)

virolansi (lamivudini/nevirapini/stavudini)

virolisi (lamivudini/stavudini)

virol LZ, abak-ALZ (abkaviri/lamivudini/zidovudini)

Ranbaxy

59

saerTaSoriso

saxeli mwarmoeblis saxeli farmaceptuli

kompania

stavudini (d4T) zeriti, zeriti XR Bristol-Myers Squibb staveqsi

sraveqsi-L (lamivudini/stavudini) sraveqsi-LN (lamivudini/nevirapini/stavudini)

Aurobindo

staviri

lamiviri-S (lamivudini/stavudini)

triomuni (lamivudini/nevirapini/stavudini)

Cipla

lamistari (lamivudini/stavudini)

nevilasti (lamivudini/nevirapini/stavudini)

stagi

Genixpharma

staviri GPO (Thailand) avostavi

triviro-LNS (lamivudini/nevirapini/stavudini)

virolansi (lamivudini/nevirapini/stavudini)

virolisi, koviro (lamivudini/stavudini)

virostavi

Ranbaxy

tenofoviri (TDF) truvada (tenofoviri/emtricitabini)

vireadi (tenofoviri) Gilead Sciences

atripla (efavirenzi/emtricitabini/tenofoviri) Bristol-Myers Squibb triple

nukleozidi (TRZ) triziviri United Kingdom, United States (zidovudini/lamivudini/abakaviri)

GlaxoSmithKline

zidovudini (ZDV or AZT)

kombiviri United Kingdom, United States (lamivudini

/zidovudini)

retroviri United Kingdom, United States triziviri United Kingdom, United States (zidovudini/lamivudini/abakaviri)

GlaxoSmithKline

zidoveqsi Aurobindozidoviri

duoviri (lamivudini /zidovudini) Cipla

zido-H (zidovudini) Genixpharmaantiviri GPO (Thailand) aviro-Z virokombi (lamivudini /zidovudini)

viroli LZ (abakaviri/lamivudini/zidovudini)

viro-Z

Ranbaxy

anrti

delavirdini (DLV)

reskriptori Pfizer, Inc.

efavirenzi (EFV) Sustiva Europe, United Kingdom, Stocrin Australia, Europe, Latin America, South Africa atripla (efavirenzi/emtricitabini/tenofoviri)

Bristol-Myers Squibb

viranzi Aurobindoefaviri Cipla estiva Genixpharmaefferveni Ranbaxy

nevirapini (NVP) viramuni Boehringer Ingelheim nevireqsi

staveqsi LN (lamivudini/nevirapini/stavudini) Aurobindo

duoviri-N (lamivudini/nevirapini/zidovudini)

nevimuni

triomuni (lamivudini/nevirapini/stavudini)

Cipla

nevilasti (lamivudini/nevirapini/stavudini) Genixpharma gpoviri GPO (Thailand)

60

saerTaSoriso saxeli mwarmoeblis saxeli farmaceptuli

kompania

nevipani

triviro LNS (lamivudini/nevirapini/stavudini)

virolansi (lamivudini/nevirapini/stavudini)

zidoveqsi-LN (lamivudini/nevirapini/zidovudini)

Ranbaxy

Fusion Inhibitors enfuvirtidi, T-20 fuzeoni Roche

Pharmaceuticals & Trimeris, Inc.

proteazas inhibitorebi

amprenaviri (APV) Agenerase United Kingdom, United States GlaxoSmithKline atazanaviri (ATV) Reyataz Europa, US, Zrevada Bristol-Myers Squibb fosamprenaviri (FPV) leqsiva US, telziri United Kingdom GlaxoSmithKline

and Vertex indinaviri (IDV) kriqsivani Merck & Co.

indiveqsi Aurobinda indiviri Cipla indiviri Genixpharma virodini Ranbaxy

lopinaviri/ritonaviri

kombinacia (LPV/r) kaletra Abbott Laboratories

nelfinaviri (NFV) viracepti Pfizer, Inc., Roche Pharmaceuticals

nelveqsi Aurobinda nelviri Cipla nelfini Genixpharma nefaviri Ranbaxy

ritonaviri (RTV) norviri Abbott Laboratories ritoviri Hetero/Genix

seqvinaviri (SQV) Fortovase europe, United Kingdom, United States Invirase United Kingdom, United States

Roche Pharmaceuticals

61

damateba 7. leqsikoni

mkurnalobis reJimis dacva. rodesac wamlis dozis 95%-ia miRebuli

saubaria mkurnalobisadmi damyolobaze. am maCveneblis qvemoT saubaria

mkurnalobis reJimis darRvevaze.

foni bazisuri nawilia arT mkurnalobisa, romelic Cveulebriv Seicavs

or nrti-s, romelic Tavis mxriv fonia proteazas inhibitoris an pi-s da

SeWris inhibitorisTvis. termini “optimaluri foni” gulisxmobs

problemis regulirebas nrti-sTvis, romelic damyarebulia

rezistentobis testis Sedegze.

medegianoba aris mkurnalobis reJimis dacvis Zveli termini.

genetikuri barieri gamoxatavs virusis mutaciis im raodenobas, romelic

saWiroa wamlebis mimarT rezistentobis ganviTarebisTvis. rezistentoba

erTi mutaciiT niSnavs dabal genetikur bariers. rezistentoba aTi

mutaciiT niSnavs Zalian maRal genetikur bariers, Tumca aseTi

daxasiaTeba SeiZleba Seicvalos.

maRali mutacia warmoadgens cvlilebebs virusis rnm-Si, romelic

ganapirobebs rezistentobas arT-s wamlebze an mTlian klasze.

mcire mutacia muSaobs kombinaciaSi. igi SesaZloa gaxdes wamyvani

rezistentobis ganviTarebaSi, an ewinaaRmdegebodes sxva araxelsayrel

did an mcire mutacias.

nukleozidis analogis mutacia (NAMs) mJRavndeba jvaredini

rezistentobiT umetes nrti-sTvis.

wertilovani mutacia warmoadgens erT cvlilebas rnm-is jaWvSi, risi

Sedegic aris rezistentobis ganviTareba wamlis an wamlebis mTeli

klasis mimarT. magaliTad: arT-s mkurnalobis dros 103 wertilovani

mutacia niSnavs mutacias mTeli nrti-is mimarT.

rezistentoba aris Sedegi rnm-is jaWvSi aminomJavebis Tanamimdevrobis

cvlilebis, rac xdeba aiv-is “Raribi” replikaciis mizezi. cvlilebaTa

umravlesoba ganapirobebs virusis sikvdils, zogierTi cvlilebis

Sedegad ki virusi iZens unars gaumklavdes arT-s da gadarCes.

mkurnalobis warmatebisTvis sasurvelia arT-s dawyebamde virusuli

replikaciisa da rezistentobis testis Catareba. rezistentobis

zogierTi Sedegi saboloo jamSi gamosadegia.

Timidinis analogebis mutacia (TAMs) aris zidovudiniT mkurnalobis

Sedegi.

62

damateba 8. horizonts miRma

arT-s kvleva grZeldeba. virusis axal mutacias da rezistentobas

adgili aqvs regularulad _ rac qmnis axal warmodgenas wamlebisa da

virusis urTierTobis Sesaxeb.

qvemoT moyvanilia zogierTi ukanaskneli antiretrovirusuli

preparatebi, romlebic mowonebulia an gadis gamocdas kombinaciaSi Zvel

medikamentebTan.

• dReSi erTxel fiqsirebuli doza kombinaciiT _ tenifoviri +

emtricitabini + efavirenzi ufro efeqturia, vidre

standartuli kombinacia zidovudini + lamivudini + efavirenzi

(40).

• etravirini warmoadgens axal nnrti-s, romelsac aqvs didi

potenciali, miuxedavad mutaciisa, ramac SeiZleba ganapirobos

nnrti-s klasis rezistentobis ganviTareba (135).

• darunaviri (TMC 114) axali proteazas inhibitoria, romelsac

gaaCnia maRali genetikuri barieri, vidre

lopinavir/ritonavirs, rezistentobis ganviTareba ufro nela

xdeba, vidre nelfinaviris, APV, an lopinavir/ritonaviris

SemTxvevaSi. darunaviri xelmisawvdomia farTod xelmisawvdomi

programisTvis (EAP) (136). is axlaxan damtkicebul iqna FDA-s

mier.

• kapravirini warmoadgens meore Taobis nnrti-s, romelic bevrad

efeqturia miuxedavad nnrti-s klasikuri rezistentobisa.

• axali koreceptoris inhibitorebi kvlevis meore fazaSia.

CXCR4 da CCR5, romlebic gamoxataven virusebs, brZoloben

wamlebTan, romlebsac SeuZliaT gamiowvion erTis an orives

inhibicia. axali testi koreceptorebis eqspresiisa saWiroa

mkurnalobis dros. gverdiTi efeqtebi amJamad SezRudulia,

Tumca sawyisi gamocdilebiT am axal klasisTvis aRmoCenilia

kardiotoqsiuri efeqti. aRiareba SeiZleba moxdes 2007 wels.

63

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67

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99. Arasteh K et al. TMC114/ritonavir substitution for protease inhibitor(s) in a non-suppressive antiretroviral regimen: a 14-day proof-of-principle trial. AIDS, 2005, 19(9):943–947.

100. Kovalevsky AY et al. Effectiveness of nonpeptide clinical inhibitor TMC-114 on HIV-1 protease with highly drug resistant mutations D30N, I50V, and L90M. Journal of Medicinal Chemistry, 2006, 49(4):1379–1387.

101. Turner D et al. The influence of protease inhibitor resistance profiles on selection of HIV therapy in treatment-naive patients. Antiviral Therapy, 2004, 9(3):301–314.

102. Stephan C et al. Saquinavir drug exposure is not impaired by the boosted double protease inhibitor combination of lopinavir/ritonavir. AIDS, 2004, 18(3):503–508.

103. Eron JJ et al. A phase II trial of dual protease inhibitor therapy: amprenavir in combination with indinavir, nelfinavir, or saquinavir. Journal of Acquired Immune Deficiency Syndromes, 2001, 26(5):458–461.

68

104. Boffito M et al. Atazanavir enhances saquinavir hard-gel concentrations in a ritonavir-boosted oncedaily regimen. AIDS, 2004, 18(9):1291–1297.

105. Ananworanich J et al. CD4-guided scheduled treatments interruptions compared to continuous therapy: results of the Staccato trial. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 102).

106. Skiest D et al. Predictors of HIV disease progression in patients who stop ART with CD4 cell counts>350 cells/mm3. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 101).

107. Marchou B et al. Structured treatment interruptions in HIV-infected patients with high CD4 cell counts and virologic suppression: results of a prospective, randomized, open-label trial (Window - ANRS 106). 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 104).

108. Danel C et al. CD4-guided strategy arm stopped in a randomized structured treatment interruption trial in West African adults: ANRS 1269 Trivacan trial. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 105LB).

109. El-Sadr W et al. Episodic CD4-guided use of art is inferior to continuous therapy: results of the SMART study. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 106LB).

110. Carrieri MP et al. Impact of early versus late adherence to highly active antiretroviral therapy on immuno-virological response: a 3–year follow-up study. Antiviral Therapy, 2003, 8(6):585–594.

111. Safren SA et al. Two strategies to increase adherence to HIV antiretroviral medication: life-steps and medication monitoring. Behaviour Research and Therapy, 2001, (10):1151–1162.

112. Simoni JM et al. Antiretroviral adherence interventions: a review of current literature and ongoing studies.Topics in HIV Medicine, 2003, 11(6):185–198.

113. Golin CE, Smith SR, Reif S. Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina. Journal of General Internal Medicine, 2004, 19(1):16–27.1-39 patient evaluation and antiretroviral treatment for adults and adolescents

114. Weber R et al. Effect of individual cognitive behaviour intervention on adherence to antiretroviral therapy: prospective randomized trial. Antiviral Therapy, 2004, 9(1):85–95.

115. Kerr T et al. Psychosocial determinants of adherence to highly active antiretroviral therapy among injection drug users in Vancouver. Antiviral Therapy, 2004, 9(3):407–414.

116. Tyndall MW et al. Attendance, drug use patterns, and referrals made from North America’s first supervised injection facility. Drug and Alcohol Dependence, 2005, December.

117. Yun LW et al. Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients. Journal of Acquired Immune Deficiency Syndromes, 2005, 38(4):432–438.

118. Zimmermann AE et al. Tenofovir-associated acute and chronic kidney disease: a case of multiple drug interactions. Clinical Infectious Diseases, 2006, 42(2):283–290.

119. Bartlett JG. Pocket guide to adult HIV/AIDS treatment. Baltimore, John Hopkins University AIDS Service, 2006 (http://hopkins-aids.edu/publications/pocketguide/pocketgd0106.pdf, accessed 11 September 2006).

120. Jacobson MA et al. Cytomegalovirus retinitis after initiation of highly active antiretroviral therapy. The Lancet, 1997, 349(9063):1443–1445.

121. Race EM et al. Focal mycobacterial lymphadenitis following initiation of protease-inhibitor therapy in patients with advanced HIV-1 disease. The Lancet, 1998, 351(9098):252–255.

122. Koval CE et al. Immune reconstitution syndrome after successful treatment of Pneumocystis carinii pneumonia in a man with human immunodeficiency virus type 1 infection. Clinical Infectious Diseases, 2002, 35(4):491–493.

123. Sande MA, Eliopoulos GM. The Sanford guide to HIV/AIDS therapy, 13th ed. Hyde Park, VT, Antimicrobial Therapy, 2004.

69

124. Gilbert DN, Moellering RC, Eliopoulos GM. The Sanford guide to antimicrobial therapy, 35th ed. Hyde Park, VT, Antimicrobial Therapy, 2005.

125. Antoniu T, Tseng AL. Interactions between recreational drugs and antiretroviral agents. The Annals of Pharmacotherapy, 2002, 36(10):1598–1613.

126. WHO/EURO report of the technical consultation on clinical staging of HIV/AIDS and HIV/AIDS case definition for surveillance. Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro. who.int/document/E87956.pdf, accessed 5 April 2006).

127. 2006 antiretroviral drug guide. IAPAC Monthly, 2006, 12 Suppl. 1 (http://www.iapac.org/home. asp?pid=7288, accessed 11 September 2006).

128. Liu H et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Annals of Internal Medicine, 2001, 134(10):968–977.

129. Bangsberg DR et al. Provider assessment of adherence to HIV antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 2001, 26(5):435–442.

130. Hugen PW et al. Assessment of adherence to HIV protease inhibitors: comparison and combination of various methods, including MEMS (electronic monitoring), patient and nurse report, and therapeutic drug monitoring. Journal of Acquired Immune Deficiency Syndromes, 2002, 30(3):324–334.

131. Paterson DL et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine, 2000, 133(1):21–30.

132. Parienti JJ et al. The pills identification test: a tool to assess adherence to antiretroviral therapy. JAMA, 2001, 285(4):412.

133. Descamps D et al. Mechanisms of virologic failure in previously untreated HIV-infected patients from a trial of induction-maintenance therapy. JAMA, 2000, 283(2):205–11.

134. Havlir DV et al. Drug susceptibility in HIV infection after viral rebound in patients receiving indinavircontaining regimens. JAMA, 2000, 283(2):229–234.

135. Vingerhoets J et al. Effect of baseline resistance on the virologic response to a novel NNRTI, TMC 125, in patients with extensive NNRTI and PI resistance: analysis of study TMC 125–233. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 154).

136. De Meyer et al. Effect of baseline susceptibility and on-treatment mutations on TMC 114 and control PI efficacy: preliminary analysis of data from PI-experienced patients from POWER 1 and POWER 2. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 157).

70

III. oportunistuli infeqciebis marTva cxrili 19. oportunistuli infeqciebi da sxva daavadebebi, romlebic

dakavSirebulia aiv infeqciasTan

baqteriuli

infeqciebi

sokovani

infeqciebi

virusuli

infeqciebi

parazituli

infeqciebi

sxva

daavadebebi

tuberkulozi

baqteriuli

respiratoruli

infeqciebi

nawlavTa

baqteriuli

infeqciebi

atipiuri mikobaqteriozebi

bartonelozi

ezofaguri

kandidozi

kriptokokozi

histoplazmozi

pnevmocisturi

pnevmonia

kokcidioidozi

infeqciebi,

romelsac

iwvevs:

_martivi herpes

virusi;

_varicela-

zosteris

virusi

_citomegalo-

virusi

_adamianis

herpes virusis

8 tipi;

_adamianis

papilomavirusi

progresuli

multifokaluri

leikoencefalop

aTia

_hepatiti B da C

toqsoplazmozi

kriptospori-diozi

mikrospori-diozi

izosporiazi leiSmaniozi

kapoSis sarkoma

arahojkinsis

limfoma

saSvilosnos

yelis simsivne

encefalopaTia

vakuoluri

mielopaTia

evropis regionisTvis yvelaze xSiri oportunistuli infeqciebia:

tuberkulozi

baqteriuli infeqciebi

pnevmocisturi pnevmonia

herpesuli infeqciebi (VZV, HSV 1 da 2, CMV)

kandidozuri ezofagiti

kriptokokuli meningiti

toqsoplazmozi

SederebiT iSviaT oportonistul infeqciebs da simsivneebs miekuTvneba;

atipiuri mikobaqteriozebi

kapoSis sarkoma

arahojkinis limfoma

citomegalovirusuli infeqciebi (retina, kuW-nawlavis traqti,

encefalitebi).

71

cxrili 20. oportunistuli infeqciebis profilaqtika aiv inficirebul

pacientebSi

gamomwvevi maCveneblebi pirveli rigis

preparatebi

Aalternatiuli

sqemebi

Pneumocystis jirovecii

CD4< 200mkl-1

an

orofaringeuli

kandidozi

ko-trimoqsazoli 160/800

mg/dReSi yovel dRe

- ko-trimoqsazoli 80-

400 mg/dReSi yovel

dRe

- ko-trimoqsazoli

160/800 mg/dReSi

kviraSi samjer

- dapsoni 50 mg dReSi

orjer

- 100 mg dReSi

erTxel (2)

- pirimetamini 50 mg +

dapsoni 50 mg

+ foliumis mJava 15

mg erTxel dReSi

-pentamidis

inhalaciebi 300 mg 3

kviraSi erTxel (3)

-aseve SesaZlebelia:

klindamicini an

atovaqvoni (4,5,)

M.tuberkunosis PPD reaqcia >

5mm an

kontaqti

tuberkulozis

aqtiuri formis

mqone pacientTan

izoniazidi 300mg/dReSi +

piridoqsini 50

mg/dReSi 6 Tvis

ganmavlobaSi (6)

saWiroa damatebiTi

kvlevebis Catareba

alternatiuli

profilaqtikuri

mkurnalobis

SemuSavebisTvis

izoniazidze

rezistentobis

SemTxvevebSi

Toxoplasma gondii, primary

CD4< 100 mm3 ko-trimoqsazoli 160/800

mg/dReSi yovel dRe

- ko-trimoqsazoli,

80-400 mg/dReSi yovel

dRe (7,8)

- dapsoni 50 mg yovel

dRe +

pirimetamini 50 mg

kviraSi erTxel +

foliumis mJava 25 mg

kviraSi erTxel

Toxoplasma gondii, secondary

CD4< 100 mm3 ko-trimoqsazoli 160/800

mg/dReSi yovel dRe

-dapsoni 50 mg yovel

dRe +

pirimetamini 50 mg

dReSi +

foliumis mJava 15- 25

mg dReSi

M. avium complex

CD4< 50mkl-1 azitromicini 1200 mg

kviraSi erTxel

klariTromicini 500

mg orjer dReSi (9,10)

Criptococcus neoformans

CD4< 50mkl-1 flukonazoli 100-200

mg/dReSi (11)

72

3.1. sasunTqi gzebis infeqciebi

filtvebis morecidive infeqciur daavadebebs erT-erTi pirveli adgili

uWiravs aiv inficirebulebSi da xSirad uqmnis safrTxes maT sicocxles.

etiologiis mixedviT igi SeiZleba iyos baqteriuli, virusuli da

sokovani.

aiv infeqciis adreul stadiaze viTardeba baqteriuli pnevmoniebi,

romlebic advilad eqvemdebareba antibaqteriul mkurnalobas. aiv

inficirebulebSi xSiria inkafsulirebuli baqteriebiT mag. Streptococcus pneumoniae da Haemophilus influenzae-Ti gamowveuli infeqciebi. mogvianebiT,

imunodeficitis fonze aiv inficirebulebs uviTardebaT filtvis

oportunistuli infeqciebi, romelTa Soris yvelaze did problemas

warmoadgens tuberkulozi. ujreduli imunitetis daqveiTebasTan erTad

SeiZleba ganviTardes sicocxlisaTvis saSiSi oportunistuli

infeqciebi, maT Soris pnevmocisturi, mikozuri da virusuli pnevmoniebi.

21-e cxrilSi CamoTvlilia filtvis daavadebebi, romlebic arTuleben

aiv infeqciis mimdinareobas.

cxrili 21. respiraciuli daavadebebi aiv/SidsiT daavadebul pacientebSi

infeqciis tipi SesaZlo garTulebebi a

baqteriuli

pnevmokokuri pnevmonia empiema b, plevruli gamonaJoni,

filtvis abscesi

H. influenza pnevmonia plevruli gamonaJoni b, filtvis

abscesi, empiema

klebsielaTi gamowveuli pnevmonia empiema b, plevruli gamonaJoni

stafilokokuri pnevmonia filtvis abscesib, empiema, plevruli

gamonaJoni

M. tuberkulosis pnevmonia perikarduli gamonaJoni, filtvis

abscesi, empiema, plevruli gamonaJoni

MAC pnevmonia iSviaTi garTuleba: abscesi,

gansakuTrebiT imunuri rekonstituciis

sindromis dros

virusuli

citomegalovirusi pnevmoniti b (maRalia letaloba)

martivi herpesis virusi pnevmoniti b (maRalia letaloba)

sokovani

pnevmocisturi pnevmonia pnevmoToraqsi

kriptokokozi

histoplazmozi

aspergilozi filtvis abscesi

sxva mdgomareobebi

kapoSis sarkoma plevruli an perikardiuli gamonaJoni

limfoma plevruli an perikardiuli gamonaJoni

karcinoma (ara SidsTan asocirebuli) perikardiuli gamonaJoni

a SesaZlo garTulebebi CamoTvlilia maTi ganviTarebis sixSiris

mixedviT. b mdgomareobebi, romlebic yvelaze xSirad viTardeba

73

3.1.1. baqteriuli respiratoruli infeqciebi

aiv inficirebulebs imunodeficitis fonze xSirad uviTardebaT

baqteriuli pnevmoniebi, romelTac axasiaTebT mZime mimdinareoba.

yvelaze xSirad pnevmonias iwvevs Streptococcus pneumoniae. pnevmoniis sxva baqteriuli gamomwvevebi mocemulia 21-e cxrilSi. klinikuri

gamovlinebebia: xvela, cxeleba, tkivili gul-mkerdis areSi, qoSini da

taqipnoe. gulmkerdis rentgenogramaze SeiZleba gamoCndes wilovani

pnevmoniis an bronqopnevmoniis klasikuri niSnebi, atipuri cvlilebebi an

cvlilebebis ararseboba.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi efuZneba klinikur gamovlinebebsa da rentgenologiur

cvlilebebs. rentgenogramaze SeiZleba aRmoCndes:

filtvis parenqimis wilovani an kerovani daCrdilva

filtvis difuzuri infiltraciebi an

atipiuri cvlilebebi, kavernozuli daavadebis CaTvliT.

mkurnaloba

Tu pacientis mdgomareoba saSualo simZimisaa, mkurnaloba SeiZleba

Catardes binaze 22-e da 23-e cxrilebSi mocemuli sqemebis mixedviT.

cxrili 22. baqteriuli pnevmoniis mkurnalobis pirveli rigis sqemebi

antibiotiki doza MmiRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

amoqsicilini

(penicilinisa da

ampicilinis mimarT

SesaZlo rezistentobis

SemTxvevaSi gamoiyeneT

penicilini beta

laqtamazas inhibitorebTan

kombinaciaSi)

500-1000mg 3X

dReSi

PO 7 dRe an

ufro

xangrZlivad

morCenamde

Aan

eriTromicini 500mg 4X dReSi PO 7 dRe

an

klaritromicini 500mg 2X dReSi PO 7 dRe

Aan

azitromicini 500mg erTxel

dReSi

PO 3-4 dRe

an

qinoloni pnevmokokis sawinaaRmdego

aqtivobiT (mag: moqsifloqsacini)

400 mg

erTxel

dReSi

PO 7 dRe

an

doqsiciklini 100 mg

2X dReSi

PO 7 dRe

74

Tu pirveli rigis sqemiT mkurnalobis fonze mdgomareoba 72 sT-Si

ar gaumjobesda (cxelebis normalizeba, C reaqtiuli cilis

matebis SeCereba, leikocitozis donis Semcireba), aucilebelia

pacientis hospitalizacia da mkurnalobis Secvla II rigis sqemiT

(cxrili 23), saWiroebis SemTxvevaSi _ JangbadiT inhalacia (am

SemTxvevaSi unda vivaraudoT pnevmocisturi pnevmonia).

mZime mdgomareobaSi myofi avadmyofebis hospitalizacia unda

moxdes dauyonebliv.

cxrili 23. baqteriuli pnevmoniebis mkurnalobis meore rigis sqemebi

antibiotiki doza M miRebis

sixSire

MmiRebis

gza

mkurnalobis

xangrZlivoba

ceftriaqsoni

+

eriTromicini

2g

500mg

dReSi erTxel

4X dReSi

i/v

7 dRe

an

ampicilin/

sulbaqtami

+

eriTromicini

1500mg

500mg

3X dReSi

4X dReSi

i/v

7 dRe

an

qinoloni

pnevmokokuri

aqtivobiT

(mag:

moqsifloqsacini)

400 mg erTxel dReSi IV/PO 7 dRe

an

qloramfenikoli (mxolod sxva pre-

paratebis ar arse-

bobis dros)

12,5 mg/kg

4X dReSi

i/v

7 dRe

Tu mkurnalobis fonze mdgomareoba ar gaumjobesda, eWvi unda

mivitanoT pnevmocistur pnevmoniaze an tuberkulozze.

antibiotikebiT mkurnalobis dawyebamde paTogenis identifikaciis

oqros standarts miekuTvneba lavaJi bronqoskopiiT (14) (AI). damxmare meTodia sisxlis kulturebi, romelsac aqvs maRali done

pnevmokokis identifikaciisvis da SesaZloa Catardes swrafad.

3.1.2. atipuri mikobaqteriozebi

Mycobaqterium avium complex (MAC an MAI) gamowveuli infeqciebi ufro

iSviaTad gvxvdeba, vidre sxva oportunistuli infeqciebi. klinikuri

gamovlinebebia:

cxeleba

wonaSi kleba

Ramis oflianoba

diarea

ganleva.

75

mikobaqteriebis aRmoCena SesaZlebelia avadmyofis sisxlsa da

eqskrementebSi.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

sisxlis specialur niadagze daTesva.

pacientebs klinikurad gamovlinebuli infeqciiT mikobaqteriebis

intensivoba imgvari aqvT, rom gamomwvevis aRmoCena SesaZlebelia

daTesili sisxlis TiTqmis yvela ulufaSi.

vinaidan, diseminirebuli infeqciis dros xSirad ziandeba RviZli

da Zvlis tvini, mikobaqteriebis aRmoCena SesaZlebelia mJavagamZle

baqteriebze SeRebil preparatebSi, romlebic damzadebulia am

organoebidan aRebuli bioptatebisgan.

RviZlis bioptatis mikroskopuli gamokvlebis gziT winaswari

diagnozis dasma saSualebas iZleva mkurnaloba daviwyoT

droulad.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

cxrili 24. atipuri mikobaqteriozebis mkurnaloba (AI)

antibiotiki doza MmiRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis preparatebi (15,16)

klariTromicini 500-1000 mg 2-jer dReSi PO 6 Tve ;

damokidebulia

klinikur

mdgomareobaze

+

etambutoli 15 mg/kg dReSi

erTxel

PO 6 Tve ;

damokidebulia

klinikur

mdgomareobaze

+

rifabutini 300-450 mg dReSi

erTxel

PO 6 Tve ;

damokidebulia

klinikur

mdgomareobaze

sxva preparatebi, rimlebic moqmedeben atipiur mikobaqteriebze a

azitromicini 500-1200 mg dReSi

erTxel

PO 6 Tve

6 Tve

ara umetes 4

kvirisa

ciprofloqsacini 500 mg 2-jer dReSi PO

amikacini 15 mg/kg/dR dReSi 1X i/v

an 7,5

mg/kg/dR

2-jer dReSi i/v

a rifampicini ar aris efeqturi atipiruri mokibaqteriis mimarT.

76

Tu atipiuri mikobaqteriozebis mkurnalobis fonze mdgomareoba

gaumjobesda da preparatebi kargad gadaitaneba unda daiwyos arT.

atipiuri mikobaqteriozebis mkurnalobidan 4-6 kviraSi iwyeba arT.

6 Tvis Semdeg imunuri pasuxis gaumjobesebis Semdeg (CD4

ricxvi>100mm3) Cerdeba atipiuri mikobaqteriozebis mkurnaloba da

gamoiyeneba meoradi profilaqtika.

meoradi profilaqtikis Sewyveta SesaZlebelia, rodesac imunuri

sistema stabiluria 3-6 Tvis manZilze.

atipiuri mikobaqteriozebis mkurnaloba da meoradi profilaqtika

grZeldeba 6 Tve, rac aris mkurnalobis warmatebis da relapsis

Tavidan acilebis sawindari.

didi mniSvneloba aqvs atipiuri mikobaqteriozebis mkurnalobis

dawyebas arv Terapiis dawyebamde.

arsebobs albaToba imunuri rekonstituciis anTebiTi sindromis

ganviTarebis arT-s dawyebis Semdeg.D

3.1.3. pnevmocisturi pnevmonia

pnevmocisturi pnevmonia erT-erTi gavrcelebuli oportunistuli

infeqciaa aiv inficirebulebSi. misi gamomwvevia Pneumocystis jiroveci (adre moixseniebdnen Pneumocystis carinii–is saxeliT).

tipiuri klinikuri gamovlinebebia: xvela, qoSini da cxeleba.

zogjer pnevmocisturi pnevmonia mimdinareobs filtvismieri

gamovlinebebis gareSe.

xSirad aRiniSneba sunTqvis ukmarisobis niSnebi, qoSini da cianozi.

daavadebis mimdinareoba SeiZleba iyos mZime da, Tu droulad ar

dainiSneba mkurnaloba, SeiZleba damTavrdes sikvdiliT.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi ismeba klinikuri suraTis mixedviT. aiv inficirebul

pacients uviTardeba respiratoruli distresi cianoziT an mis

gareSe.

SesaZloa aRiniSnebodes mSrali xvela, Tumca ufro

mniSvnelovania, rom filtvebSi fizikaluri gamokvlevebiTAD

mciredi cvlilebebia an saerTod ar aris.

gul-mkerdis rentgenologiuri gamokvleva:

orive filtvis qvemo wilSi gamWvirvalobis Rrubliseburi

daqveiTeba_yvela pacients ar aReniSneba.

SesaZlebelia orive filtvSi aRmoCndes kerovani daCrdilva,

romelic waagavs baqteriuli pnevmoniis an tuberkulozis suraTs.

pacientebis umetesobas, romelTac daudginda pnevmocisturi

pnevmonia, rentgenologiuri cvlilebebi ar aReniSnebaT.

diagnozis oqros standarts warmoadgens bronquli lavaJi (14).

diagnozi dasturdeba gamomwvevis cistis aRmoCeniT amonaxvelSi an

bronquli lavaJis aspiratSi.

Tu bronqoskopiis Catareba SeuZlebelia, maSin pnevmocisturi

pnevmoniis diagnozisTvis SesaZlebelia gamoyenebul iqnes filtvis

darRveuli funqciuri testebi an sisxlis airTa analizi, rogorc

indikatorebi

diagnozis dasmisTanave dawyebul unda iqnas mkurnaloba.

77

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

pnevmocisturi pnevmoniis mkurnaloba tardeba stacionarSi. aucilebelia

damxmare Terapia JangbadiT inhalaciis CaTvliT. mkurnalobis detaluri

sqema mocemulia cxrilSi N#25 da #26 qvemoT.

cxrili 25. pnevmocisturi pnevmoniis pirveli rigis mkurnaloba (AI)

antimikrobuli

agenti

doza M miRebis

sixSire

M miRebis

gza

mkurnalobis

xangrZlivoba

timetoprimi/

sulfametoqsazoli

400/80 mg 4X dReSi PO/IV

21 dRe

cxrili 26. pnevmocisturi pnevmoniis meore rigis mkurnaloba (AI)

Kklindamicini

+

primaqini

600mg

15 mg

4X dReSi

2X dReSi

PO/IV

PO

21 dRe (17)

an

pentamidini (farTo

speqtris

antibiotikTan

kombinaciaSi

baqteriuli

superinfeqciis

profilaqtikisTvis

mag. ampicilin+

sulbaqtami 10 dRe)

4 mg/kg IV

dReSi. doza

mcir 2 mg/kg

5 dRis

mkurnalobis

Semdeg (18)

dReSi

erTxel

IV 21 dRe

mZime mdgomareobaSi myof avadmofebSi iniSneba prednizoloni, 80-

250 mg PO/IV dReSi 1-2 kvira (amcirebs intersticiul SeSupebas).

mZime SemTxvevebSi ganixileba kombinirebuli mkurnaloba, mag. ko-

trimoqsazoli da pendamidini mxolod erTeuli Setyobinebuli

SemTxvevebis mixedviT dakavSirebulia toqsiurobis maRal riskTan.

pnevmocisturi pnevmoniis mZime SemTxvevebi moiTxovs xelovnur

ventilacias an oqsigeniT saturacias (SO2)<92%.

unda moxdes gverdiTi efeqtebis monitoringi, gansakuTrebiT Tirkmlebis,

parkreasis (pendamidiniT mkurnalobisas), Zvlis tvinis (ko-

trimoqsazoliT mkurnalobisas). laboratoriuli gamokvlevebi

aucilebelia 2 kviraSi erTxel.

pnevmocisturi pnevmoniis mwvave SemTxvevis warmatebiT mkurnalobis

Semged :

meoradi profilaqtikis mizniT aiv inficirebulma pacientebma unda

miiRon trimetoprim/sulfametoqsazoli 160/800 mg doziT erTxel

dReSi xangrZlivad ;

aRniSnuli preparatebis miReba pacientma SeiZleba Sewyvitos Tu

CD4 limfocitebis raodenoba stabilurad aRemateba 200 mm3-s sul

mcire sami Tvis ganmavlobaSi.

78

3.1.4. sxva etiologiis pnevmoniebi imunodeficitis mqone pacientebSi

pnevmoniebi SeiZleba iyos sokovani da virusuli etiologiis. aseT

SemTxvevebSi Znelia diagnozis dazusteba rTuli laboratoriuli

gamokvlevebis gareSe da rTulia maTi mkurnaloba.

pnevmoniis gamomwvev virusebs miekuTvneba: martivi herpesis virusi,

varicela-zosteris virusi an citomegalovirusi.

sokovan pnevmoniebs Pneumocystis-jiroveci (Pneumocystis carinii) –is garda iwveven Histoplazma capsulatum, Cryptococcus neoformans da Aspergillus.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

pnevmoniis mqone pacientebSi, romlebic Znelad eqvemdebarebian

standartul mkurnalobas, unda vivaraudoT tuberkulozis an

virusuli, sokovani an protozouli etiologiis pnevmoniis

arseboba.

sokovani an sxva etiologiis pnevmoniebis specifikuri

diagnostikisTvis aucilebelia rTuli laboratoriuli

gamokvlevebi:

pp65 adreuli CMV antigeni periferiuli sisxlSi an bronqul

lavaJSi;

polimerazuli jaWvuri reaqcia (pjr) herpesis jgufis

virusebisTvis (CMV, HSV 1/2/; VZV, EBV, HHV8, HHV6) ; specialuri kulturebi nela-mzardi paTogenebisTvis mag: nokardia.

aucilebelia mWidri TanamSromloba eqimebsa da mikrobiologebs

Soris.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

mkurnaloba damokidebulia daavadebis etiologiaze mag: foskarneti CMV

infeqciisTvis an xangrZlini antibiotikoTerapia (8 kvira) nokardiisTvis.

3.2. kuW-nawlavis traqtis infeqciebi

kuW-nawlavis traqtis dazianeba aiv inficirebulebSi SeiZleba iyos:

rogorc aiv infeqciis uSualo gamovlineba, aseve

baqteriuli;

virusuli;

sokovani;

protozouli an

parazituli etiologiis.

zog SemTxvevaSi kuW-nawlavis aSliloba ganpirobebulia Sewovis

unaris darRveviT, rac nawlavTa xaoebis atrofiiTaa gamowveuli

(malabsorbcia).

yvelaze xSirad viTardeba diarea, romelic SeiZleba iyos mwvave,

qronikuli an qronikuli - gamwvavebebiT.

SidsiT avadmyofebSi diarea persistuli an qronikulia da xSirad

aris maTi sikvdilis mizezi.

mwvave diarea saWiroebs dehirdatacias mkurnalobis Sedegis

miRebamde.

ganavali sisxliani minarevebiT damaxasiaTebelia dizenteriis an

nawlavTa amebiazisTvis.

79

aiv inficirebulebs xSirad aReniSnebaT kuW-nawlavis traqtis dazianebis

iseTi simptomebi, rogoricaa:

madis dakargva;

gulisreva;

pirRebineba da

wonaSi progresirebadi kleba.

aiv inficirebulebSi yvelaze gavrcelebuli kuW-nawlavis infeqciebi da

maTi mkurnalobis Sesaxeb rekomendaciebi mocemulia cxrilSi #27.

cxrili 27. aiv inficirebulebSi gavrcelebuli kuW-nawlavis traqtis

infeqciebi

infeqcia klinikuri

gamovlinebebi da

diagnostika

mkurnaloba

ara-tifoiduri

salmonelozebi

cxeleba, tkivili muclis

areSi, diarea (SesaZlebelia

ganavalSi sisxlis aRmoCena),

wonaSi kleba, anoreqsia,

hepatosplenomegalia.

diagnostika _ sisxlis an

ganavlis kultura

ciprofloqsacini, 500mg

2-jer dReSi PO 2 kviris

ganmavlobaSi (19)

Sigelozebi cxeleba, tkivili muclis

areSi, sisxliani diarea.

diagnostika _ sisxlis an

ganavlis kultura.

ciprofloqsacini 500mg

2-jer dReSi PO 7-10 dRe

an

nalidiqsis mJava 500mg

dReSi 4-jer PO 7-10DdRe

an

ko-trimoqsazoli

160/800mg 2-jer dReSi PO7-10 dRe

kriptosporidozi wylisebri ganavali, madis

dakargva, cxelebis ar

arseboba.

diagnostika _ ganavlis

mikroskopulia.

paromomicini 1g 2-jer

dReSi PO +

azitromicini 600mg

dReSi erTxel PO 4

kviris ganmavlobaSi;

Semdeg:

mxolod paromomicini 8

kvira (20,21).

mkurnaloba xSirad

warumatebelia (22).

mikrosporidozi wylisebri ganavali, madis

dakargva, cxelebis

ararseboba.

diagnostika _ ganavlis

mikroskopulia.

albendazoli 400mg 2-

jer dReSi PO 4kvira Tu

es ar muSaobs scadeT:

mebendazoni 500mg 3-jer

dReSi PO (albendazoli

metad efeqturia) (23).

80

3.3. kandidozebi

Candida albicans pirveladad kolonizdeba qalTa da mamakacTa kuW-

nawlavia traqtSi. Candida albicans aRmoCndeba janmrTeli qalebis 1/3

saSos mikrofloraSi.

qalebSi kandidozuri vulvovaginiti gamovlindeba saSodan

gamonadeniTa da vulvisa da saSos qaviliT.

mamakacebSi sasqeso organoebis kandidozi mimdinareobs, rogorc

balaniti an balanopostiti, amasTan erTad aRniSnaven CuCidan

gamonadens da asosa da CuCis qavils.

piris Rrus kandidozi gamovlindeba lorwovani garsis anTebiTa da

mis zedapirze TeTri balTebis warmoqmniT.

kandida ainficirebs kansac da iwvevs qavana dermatits.

imunodeficitis gaRrmavebasTan erTad piris Rrus kandidozi

SeiZleba gavrceldes saylapavze da gamoiwvios ezofagiti.

iSviaT SemTxvevebSi SeiZleba ganviTardes bronqebis dazianeba da

diseminirebuli kandidozi.

simptomebiAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

piris Rrus kandidozi moicavs:

loyis lorwovan garss;

enas;

pir-xaxas;

RrZilebs;

rbil da magar sasas.

avadmyofs SeiZleba ar hqondes Civilebi an aRniSnavdes Wamis dros wvis

SegrZnebas.

zogierTi avadmyofi uCivis pirSi TeTri nadebis arsebobas.

roca kandidozi vrceldeba saylapavze pacienti uCivis:

tkivils ylapvis dros;

retrosternalur tkivils;

hipersalivacias.

pacientebi, romlebSic kandidozi yvelaze xSirad viTardeba:

orsuloba da peroraluri kontraceptivebis miReba;

axalSobilobis periodi, gansakuTrebiT dRenaklul bavSvebSi;

farTo speqtris antibiotikebis xangrZlivi miReba;

glukokortikoidebis sistematiuri miReba;

Saqriani diabeti;

Tandayolili an SeZenili imunodeficiti;

mZime qronikuli daavadeba;

gamofitva, kaxeqsia;

onkologiuri daavadebebi, qimioTerapia an sxivuri Terapia.

diagnostika

orofaringeuli kandidozis diagnostika efuZneba klinikur niSnebs,

gasinjvas da dazianebuli ubnebidan aRebuli masalis mikroskopul

daTvalierebas.

81

piris Rrus daTvalierebisas vnaxulobT balTis formis TeTr

nadebs SewiTlebul da anTebad lorwovan garsze.

anTeba SeiZleba gavrceldes sasaze, xaxaze, RrZilebze, enasa da

loyis lorwovanze. ena dazianebisas xdeba gluvi, wiTeli da

dvrilebi swordeba.

kandidozuri ezofagitis da filtvebis aspergilozis SemTxvevebSi

diagnozis dadasturebisTvis aucilebelia qsovilis bioftatis

histologiuri gamokvleva.

aiv inficirebulebs erTxel mainc uviTardebaT piris Rrusa da xaxis

kandidozi. is sicocxlisTvis saSiSi ar aris, magram iwvevs:

ylapvis gaZnelebas;

mkerdis tkivils, romelic Zlierdeba ylapvisas;

diseminirebuli kandidozis klinikuri gamovlinebebia: cxeleba da

dazianebul organoebTan dakavSirebuli simptomebi (mag: Tvalis

dazianebisas_sibrmave).

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

piris Rrus kandidozisa da kandidozuri vulvovaginitis

mkurnaloba iwyeba adgilobrivi araZviradRirebuli antimikozuri

preparatebiT. mag.: nistatini, mikonazoli, klotrimazoli.

diseminirebuli kandidozisa da aseve, adgilobrivi mkurnalobis

araefeqturobis dros, iniSneba sistemuri antimikozuri agentebi,

mag: ketokonazoli, flukonazoli, itrakonazoli an amfotericin

B. im pacientebSi, romlebic imyofebian metadoniT, rogorc opioid-

CanacvlebiT Terapiaze gasaTvaliswinebelia metadonis

urTierTqmedeba flukonazolTan, itrakonazolTan an

ketokonazilTan.

rekomendaciebi kandidozis mkurnalobis Sesaxeb mocemulia 28_29-

30-e cxrilebSi.

cxrili 28. piris Rrus kandidozis mkurnaloba (AI)

antimikozuri

agenti

doza

M miRebis

sixSire

miRebis gza

mkurnalobis

xangrZlivoba

mkurnalobis pirveli rigis sqemebi (24)

mikonazoli tabletebi

gasawovad

dReSi

erTxel

adgilobrivad 7 dRe

an

flukonazoli 100 mg 2-jer dReSi

3 dRe

Semdeg

erTxel

dReSi 4 dRe

PO 7 dRe

mkurnalobis meore rigis sqemebi (25)

itrakonazoli 200-400 mg dReSi

erTxel

PO 7 dRe

82

cxrili 29. vaginaluri kandidozis mkurnaloba (AI)

antimikozuri

agenti

doza M miRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

flukonazoli 100 mg erTjeradad PO erTjeradad

klotrimazoli 500 mg erTjeradad vaginalurad erTjeradad

meore rigis sqemebi

ketokonazoli 200 mg 2-jer dReSi PO 3 dRe

ketokonazoli 200 mg dReSi

erTxel

PO 7 dRe

SemanarCunebeli Terapia

nistatini 2-4 mln IU 2-jer dReSi PO 10 dRe

Aan

flukonazoli 50-200 mg dReSi

erTxel

PO yoveldRe

mesame rigis sqemebi

ketokonazoli 200 mg dReSi

erTxel

PO damokidebuli

pasuxze,

Cveulebriv 7-

10 dRe

itrakonazoli 100 mg dReSi

erTxel

PO damokidebuli

pasuxze,

Cveulebriv 7-

10 dRe

cxrili 30. ezofaguri da diseminirebuli kandidozebis mkurnaloba (AI)

antimikozuri

agenti

doza M miRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

ketokonazoli 200-400 mg 2-jer dReSi PO 21 dRe

Aan

flukonazoli

(ketokonazolze

efeqturia)

200-400 mg

Semcirdes

klinikuri

Sedegis

mixedviT 3

dRis Semdeg

100 mg/dReSi

dReSi

erTxel

PO/IV

14 dRe

meore rigis sqemebi

amfotericini B 0,3-0,5 mg/kg IV 10-14 dRe

Aan

itrakonazoli 200-400 mg dReSi

erTxel

PO 2 kvira

83

kandidozuri ezofagitis mkurnalobis Semdeg saWiroa xangrZlivi

SemanarCunebeli Terapia flukonazoliT 50-100 mg/dReSi yoveldRe,

an itrakonazoliT 100 mg/dReSi yoveldRe, an ketokonazoliT 200

mg/dReSi yoveldRe.

Tu mkurnaloba araefeqturia unda gamoiricxos virusuli

(citomegalovirusuli an herpesuli) ezofagiti ezofagoskopiiT.

Candida glabrata. C. krusei da C. tropicalis rezistentulia flukonazolis

mimarT zogierT SemTxvevebSi. saWiroa nimuSebis kultivireba,

SesaZlebelia savaraudo testireba da amfotericin B daniSvna.

vorikonazoli, posakonazoli da kaspofungini axali antimikozuri

medikamentebia, romelTa mimarT arcerTi gamomwvevi ar aris

rezistentuli, maT Soris Aspergillus; yvela maTgani

ZviradRirebulia. vorikonazoli ar unda dainiSnos efavirenzTan

da ritonavirTan erTad. pacientebi, romlebic Rebuloben

proteazas inhibitorebs vorikonazolTan erTad saWiroeben

gverTiTi efeqtebis mWidro monirtorings (26).

3.4. kriptokokuli meningiti

kriptokokozi xSirad mimdinareobs meningitis formiT, ufro

iSviaTad viTardeba pnevmonia da diseminirebuli infeqcia.

kriptokokuli meningiti erT-erTi gavrcelebuli sistemuri

mikozia aiv/SidsiT daavadebulebSi.

avadmyofTa sicocxlis xangrZlivoba mkurnalobis gareSe Tveze

naklebia.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

kriptokokozis diagnostireba SedarebiT advilia. pacienti uCivisL Tavis

tkivils, cxelebas, saxezea kefis kunTebis rigidoba, Tavis qalis

nervebis dazianeba, cnobierebis darRveva, komatozuri mdgomareoba.

meningitis niSnebi, maT Soris, cxeleba da kefis kunTebis rigidoba

xSirad ar aRiniSneba. liqvors acentrifugireben, miRebul naleqs

ikvleven mikroskopis qveS tuSis wveTis India ink damatebis Semdeg. preparatSi naxuloben sqeli kafsuliT dafarul safuaris

ujredebs.

SesaZlebelia kriptokokis kulturis gamoyofa Tavzurgtvinis

siTxidan

gamoiyeneba Sratis da Tavzurgtvinis siTxis gamokvleva

kriptokokul antigenze.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

rekomendacibi kriptokokuli meningitis mkurnalobis Sesaxeb mocemulia

31-e cxrilSi.

84

cxrili 31. kriptokokuli meningitis mkurnaloba (AI)

antimikozuri

agenti

doza M miRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi (27)

amfotericini B + 5-flucitozini

0,7-1,0 mg/kg

25 mg/kg

erTxel

dReSi

4X dReSi

IV

14 dRe

Semdeg

flukonazoli 400 mg erTxel

dReSi

PO sul mcire 10

kvira

Semdeg

flukonazoli 200mg erTxel

dReSi

PO mTeli

cxovreba

meore rigis sqemebi

amfotericini B + 5-flucitozini

0,7-1,0 mg/kg

25 mg/kg

erTxel

dReSi

4X dReSi

IV 6-10 kvira

an

amfotericini B 0,7-1,0 mg/kg erTxel

dReSi

IV 6-10 kvira

an (msubuq SemTxvevebSi)

flukonazoli 400-800 mg erTxel

dReSi

PO 10-12 kvira

Semdeg

flukonazoli 200 mg erTxel

dReSi

PO mTeli

cxovreba

meoradiAqimioprofilaqtikaAan SemanarCunebeli Terapia

aucilebelia mTeli cxovrebis manZilze Catardes kriptokokozis

meoradiAqimioprofilaqtika. am mizniT iniSneba flukonazoli 200

mg/dReSiAyoveldRe.

itrakonazoli 200 mg/dReSiAyoveldRe.

SemanarCunebeli Terapiis aucilebloba pacientebSi, romelTa

imunuri sistema aRdga (CD4 ricxvi >200 mm3) ar aris damxmare da ar arsebobs raime sawinaaRmdego mosazreba am konkretuli

SemTxvevisTvis.

3.5. histoplazmozi

am araxSiri mwvave an qronikuli infeqciis gamowvevia soko Hispoplasma capsulatum inhalaciuri sporebi.

eqspoziciis Sedegad daavadebis ganviTareba damokidebulia rogorc

maspinZlis imunur sistemaze, aseve gamomwvevis raodenobaze.

diseminaciis aRkveTaze pasuxismgebelia intaqturi ujred-damokidebuli

imuniteti. mwvave daavadeba gripismagvaria da axasiaTebs:

85

cxeleba;

anoreqsia;

arTralgia;

mialgia;

mSrali xveleba;

tkivili gul-mkerdis areSi.

diseminacia imunosupresiul avadmyofSi swarfad viTardeba da

axasiaTebs:

wonaSi dakleba;

oraluri da kanis dazianebuli ubnebi;

mkerdis niSnebi;

RviZlis, elenTis da limfuri kvanZebis gadideba;

oraluri ubnebisTvis damaxasiaTebelia nekruzuli wylulebi.

SesaZlebelia ganviTareds sasis perforacia da rbili qsovilis

destruqcia.

diagnostika

diagnostika efuZneba klinikur suraTs da dasturdeba sokos kulturiT

an qsovilis bioftatis histologiuri gamokvleviT.

mwvave daavadebisas gul-mkerdis rentgenologiuri gamokvleva gviCvenebs:

Suasayaris limfadenopaTias

mravlobiT infiltratebs

qvemo wilis kvanZebs.

histoplazmozis diagnostisTvis unda Catardes sisxlis da kanis

testebi, Tumca isini ar aris farTod gamoyenebuli.

mkurnaloba

imunokompetentur adamianSi histoplazmozi TviTgankurnebadia da ar

sWirdeba mkurnaloba. imunosupresiis SemTxvebSi mkurnaloba unda

Catardes 32-e cxrilSi mocemuli sqemebis mixedviT.

cxrili 32. histoplazmozis mkurnaloba (28) (AI)

antifunfaluri

agenti

dozireba miRebis

sixSire

miRebis gza xangrZlivoba

amfotericni B 0.7-1 mg/kg erTxel

dReSi

IV 10 dRe

sawyis mkurnalobas mohyveba 3 Tviani mkurnaloba imunorekonstituciamde

>100 CD4 ujrediT, Sedegi medikamentebiT:

itrakonazoli 200 mg 2X dReSi PO flukonazoli 200 mg 2X dReSi PO amfotericini B 1 mg/kg IV kviraSi erTxel.

alternatiul reJims warmoadgens itrakonazoli 200 mg samjer dReSi - 3

dRe, Semdeg 200 mg 2X dReSi 12 kvira (sakvebTan erTad).

86

3.6. kapoSis sarkoma

kapoSis sarkomas iwvevs me-8 tipis herpes virusi (HHV8), romelic

aseve cnobilia kapoSis sarkomasTan asocirebuli herpes virusis

saxeliT (KSHV).

nebismieri pacienti kapoSis sarkomis savaraudi diagnioziT unda

gaigzavnos onkologTan.

imunodeficitis mqone aiv inficirebulebSi daavadeba mimdinareobs

mZimed, diseminaciis tendenciiT da ufro male progresirebs, vidre

daavadebis endemuri formis mqone arainficirebul adamianebSi.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

kapoSis sarkomis winaswari diagnozi ismeba klinikuri suraTis

safuZvelze da dasturdeba kanis dazianebuli ubnebidan aRebuli

bioptatis histologiuri gamokvleviT.

klinikuri niSnebi moicavs Semdegs:

kapoSis sarkomis elementebi SeiZleba aRmovaCinoT kanisa da

lorwovanis nebismier areze. kanze elementebi warmodgenilia

cisferi an mewamuli feris papulebiT an kvanZebiT, araiSviaTad

garSemo arsebuli kanis limfuri SeSupebiT. xSirad ziandeba sasa,

filtvebi, kuW-nawlavis traqti da limfuri kvanZebi.

piris RruSi kapoSis sarkomis elementebi yvelaze xSirad

ganlagebulia magar sasaze, iSviaTad enaze, xaxaze, nuSura

jirkvlebsa da RrZilebze. isini warmoadgenen mewamuli feris

papulebs, romlebic Cveulebriv ar aris mtkivneuli. xandaxan

SeiZleba Segvxvdes msxvili elementebic da elementebi kanze.

filtvis parenqimis dazianeba atarebs infiltraciul xasiaTs.

xSirad viTardeba sunTqvis ukmarisoba. filtvis infiltraciuli

dazianebis mqone avadmyofebs arakeTilsaimedo prognozi aqvT da

maTSi maRalia sikvdilianoba.

aucilebelia ganvasxvavoT kapoSis sarkoma baqteriuli

angiomatozisagan, romelic warmoadgens infeqciur daavadebas

(gamomwvevi: Bartonella spp.) da aseve gvxvdeba aiv inficirebulebSi.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

kapoSis sarkomis mkurnaloba tardeba onkologis mier.

kapoSis sarkoma avTvisebiani simsivnea. lokaluri formis

samkurnalod gamoiyeneba sxivuri Terapia, generalizirebuli

formis samkurnalod iniSneba citotoqsiuri qimioTerapia.

efeqturobis sxvadasxva xarisxiT gamoiyeneba simsivnis

sawinaaRmdego preparatebis Semdegi kombinaciebi:

liposomuri doksorubiciniT monoTerapia (saukeTeso Sedegebi) (29-

31) (BII) bleomicini;

vinkristini;

daunorubicini;

vinblastini;

etopozidi.

87

remisiis miRweva Zalian Znelia da pacientebis umetesobas

uviTardebaT recidivi.

calkeuli elementebi SeiZleba moSordes qirurgiulad an

lazeris, Txevadi azotis (relapsis maRali done) da dasxivebis

zemoqmedebiT. demonstrirebuli iyo uSualod kapoSis

sarkomatozul kvanZSi bleomicinis Seyvanis efeqturoba.

kapoSis sarkoma SesaZloa daeqvemdebaros mxolod arT-s da nel-

nela alagdes.

3.7. saSvilosnos yelis kibo

saSvilosnos yelis kibo erT-erTi xSiri saxea simsivneebis,

romelic mizezia qalTa sikvdilianobis mTels msoflioSi.

savaraudo ricxvi axali SemTxvevebisa msoflioSi Seadgens 500 000

weliwadSi (32) (AI). saSvilosnos yelisa da vulvis kiboswinare mdgomareobisa da

kibos ganviTarebaSi wamyvan etiologiur faqtors warmoadgens

adamianis papilomavirusi.

aiv inficirebul qalebSi cervikaluri intraepiTeluri neoplaziis

(cin) riski 5-10-jer maRalia, maTi Pap nacxi paTologiuria

SemTxvevaTa 20-40%-Si (33,34) (BII).

diagnostika

aiv inficirebul qals unda Cautardes ginekologiuri gasinjva da

saSvilosnos yelis nacxis citologiuri gamokvleva Pap papanikolaus SeRebvis meTodiT. ginekologiuri da citologiuri

gamokvleva unda ganmeordes eqvi Tvis Semdeg da yovelwliurad.

saSvilosnos yelis kiboze eWvis SemTxvevaSi pacienti unda

gasinjos ginekolog-onkologma da saWiroebis SemTxvevaSi

gaigzavnos onkodispanseris ginekologiur ganyofilebaSi.

3.8. sxva avTvisebiani warmonaqmnebi

imunodeficitis mqone aiv inficirebul pacientebSi maRalia limfomiT

avadoba, maT Soris arahojkinis, cns-is pirveladi da berkitis

limfomebiT, aseve brtyelujredovani kiboTi. yvela aiv inficirebuli

simsivneze eWvis SemTxvevaSi unda gaigzavnos onkologiur klinikaSi.

3.8.1. arahojkinis limfoma

imunodeficitis mqone aiv inficirebulebSi xSirad gvxvdeba arahojkinis

limfomebi B ujredovani, ufro iSviaTad T ujredovani. misi ganviTareba

ar aris damokidebuli CD4 ujredebis ricxvze. varaudoben, rom am

daavadebis paTogenezSi did rols TamaSobs epStein-baris an romelime

sxva virusi.

simsivnuri arahojkinis limfomis ujredebis deteqcia SesaZlebelia

limfur kvanZebSi, kunTebSi, RviZlSi, elenTaSi, gulSi, TvinSi da kuW-

nawlavis traqtSi da SedarebiT iSviaTad ZvlebSi.

88

simptomebi mravalferovania.

SeSupebuli limfuri kvanZebi SesaZlebelia palpirdebodes

sxvadasxva adgilze.

cxeleba, wonaSi kleba da sisuste xSiria, Tumca ara aucilebeli.

daavadebis stadiis gansazRvrisTvis (I-IV) aucilebelia Semdegi

gamokvlevebi – cerebruli, cervikaluri, Torakaluri da

abdominaluri kompiuteruli aqsialuri tomografia (CAT) skanireba, Zvlis tvinis da Tav-zurg-tvinis siTxis biofsia da

gastroskopia. diagnozi dasturdeba hiperplazirebuli limfuri

kvanZis biofsiiT, histologiuri gamokvleviT.

3.8.2. berkitis-tipis limfoma aiv inficirebulebSi

berkitis limfoma ara-hojkinis limfomis erT-erTi subtipia. berkitis

limfoma asocirebulia aiv infeqciasTan da SeiZleba ganviTardes

gamoxatuli imunodeficitis ganviTarebamde. dadgenilia kavSiri am

daavadebasa da epStein-baris viruss Soris.

diagnostika

berkitis –tipis limfomis diagnozi ismeba limfuri kvanZis da simsivnis

bioptatebis histologiuri gamokvleviT.

ara hojkinis, berkitis-tipis da cns-is lomfomebis mkurnaloba

ara-hojkinis limfomebis samkurnalod efeqturia CHOP reJimi, unda Catardes 6 kursi (ganmeorebebi aucilebelia sruli remisiis

misaRebad);

prednizoloni 100 mg/dReSi erTxel 5 dRe;

vinkristini (onkovini) 1,4 mg/m2 (maqsimum 2 mg/dReSi) erTi doza

mkurnalobis pirvel dRes;

ciklofosfamidi 750 mg/m2/dReSi erTi doza mkurnalobis pirvel

dRes;

doqsorubicini (hidroqsidaunomicini) 50 mg/m2/dReSi erTi doza

mkurnalobis pirvel dRes.

meore cikli iwyeba yovel 21-e dRes (dRe 22-e mohyveba I dRes)

EPOCH reJimi, romelic moicavs etopozids, prednozolons,

vinkristins, ciklofisfamids da daunorubicins an diqsirubicins

efeqturia arT-sTan kombinaciaSi. igi efuZneba gagrZelebiT

infuzias 96 saaTis ganmavlobaSi, romelic moicavs:

etopozidi 50 mg/m2 dReSi (centraluri venuri xaziT)

doqsorubucuni 10 mg/m2/dReSi (centraluri venuri xaziT)

vinkristini 0,4 mg/m2/dReSi (maqs 2 mg/kviraSi) (centraluri venuri

xaziT)

ciklofosfamidi 375 mg/m2 me-5 dRes mxolod, bolusiT

(centraluri venuri xaziT)

prednizoloni 100 mg/dReSi pirveli 5 dRe erTxel dReSi.

reJimi unda ganmeordes yovel 21 dReSi sanam ar Catardeba 6 cikli.

89

berkitis–tipis limfomis menejmenti ar gansxvavdeba sxva

limfomebis mkurnalobisgan da pasuxobs CHOP da EPOCH reJimebs (BII). swrafad mzardi limfomis mkurnaloba ufro agresiuli

qimioTerapiiT (mag: B-ALL reJimi) diskusiis Temas warmoadgens da

specifikuri rekomendaciebi dRevandeli dRisTvis ar arsebobs

(35,36) (Va). berkitis–tipis limfomebis SemTxvevebSi qimioTerapias Tan unda

axldes dasxiveba savaraudo pirveladi keris.

SesaZlebelia ara hojkinis limfomebis mkurnaloba CD4 ujredebis

ricxvisgan damoukideblad, Tumca mkurnalobis efeqturobisTvis

arT unda dainiSnos ufro adre. qimioTerapiis ganmavlobaSi CD4 ujredebis ricxvi >350 mm3 dakavSirebulia relapsis maRal

maCveneblebTan arT gareSe (37) (BII). intakranilauri limfomebis (metastazebi) sasurvelia Tavis

dasxiveba, simsivnis sawinaaRmdego preparatebTan da

glukokortikoidebTan erTad (38) (BII).

cns-is pirveladi limfomis dros erTaderTi efeqturi mtkicebulebaze

dafuZnebuli Terapiaa sxivuri Terapia. dauyonebliv unda daiwyos arT

(39,40) (AI).

3.9. centraluri nervuli sistemis infeqciebi

adamianis imunodeficitis virusis nervul sistemaze pirdapiri

zemoqmedeba iwvevs encefalopaTiis, mielopaTiis da periferiuli

neiropaTiis ganviTarebas. aiv infeqcias ukavSireben iseT nevrologiur

darRvevebs, rogoricaa :

Tavis tvinis nivTierebis atrofia da degeneracia,

Sids-demenciis kompleqsi,

naTxemis atrofia,

vakuoluri mielopaTia,

saxis nervis dambla,

gien-baris sindromi da

sensorul-motoruli periferiuli neiropaTia tkivilis sindromiT.

cns-is darRvevebi aseve SeiZleba gamoiwvios aqteriulma, virusulma da

sokovanma oportunistulma infeqciebma (mag: kriptokokulma meningitma).

3.10. toqsoplazmozi

ganviTarebul qveynebSi toqsoplazmozi farTod aris gavrcelebuli.

toqsoplazmozi iwvevs Tavis tvinSi mravlobiTi anTebadi ubnebis

warmoqmnas. aiv inficirebulebSi toqsoplazmozi ZiriTadad

gamovlindeba encefalitis an diseminirebuli daavadebis saxiT.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

toqsoplazmozze eWvi SeiZleba gamoiTqvas Semdegi klinikuri suraTis

mixedviT:

cnobierebis darRveva;

cxeleba;

90

krunCxvebi;

Tavis tkivili;

kerovani nevrologiuri simptomatika motoruli deficitis,

kraniuli nervis parezis, moZraobis SezRudvis, dismetriis,

mxedvelobis dakargvis da afaziis CaTvliT;

Tavis tvinis MAC an MRI skanirebiT aRmoCenili mravlobiTi

rgoliseburi kerebi;

Tu es meTodebi ar aris xelmisawvdomi diagnozis dadgenaSi

gvexmareba serologiuri testebi toqsoplazmis sawinaaRmdegod

gamomuSavebul antisxeulebze (IgG klasis);

cerebraluri toqsoplazmozis mqone pacientebis umravlesobas

aReniSneba Toxoplasma gondii-iT gamowveuli infeqciis gadatanis

serologiuri niSnebi;

toqsoplazmozze eWvis dros iniSneba sacdeli mkurnaloba;

2 kviris manZilze mkurnalobis araefeqturobis SemTxvevebSi dgeba

sakiTxi Tavis tvinis biofsiis Sesaxeb;

diagnozs adasturebs Tavis tvinis qsovilis histologiuri

gamokvleva.

mkurnalobaA

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

cxrili 33. toqsoplazmozis mkurnaloba (41-43) (AI)

preparati doza M miRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

mkurnaloba

pirimetamini 200 mg erTjeradad (gajerebiTi doza)

PO erTjeradad

Semdeg

pirimetamini 25 mg

an 50 mg

3-jer dReSi

2-jer dReSi

PO 6-8 kvira

+

foliumis

mJava

15 mg dReSi

erTxel

PO 6-8 kvira

+

sulfadiazini 1 g 4-jer dReSi PO 6-8 kvira

am sqemaSi sulfadiazini SeiZleba Seicvalos:

klindamiciniT 600 mg i/v an PO dReSi 4-jer 6 kvira

azitromiciniT 1200 mg PO dReSi erTxel 6 kvira

klariTromiciniT 1 g PO 2-jer dReSi 6 kvira

atovakvoniT 750 mg PO 4-jer dReSi 6 kvira.

zogierT pacients sWirdeba xangrZlivi mkurnaloba

toqsoplazmozis gamo. gadawyvetileba efuZneba klinikur

mdgomareobas da ganmeorebiT CAT skanirebas. meoradi profilaqtika grZeldeba efeqturi reJimis ganaxevrebuli

dozebiT manamde, sanam CD4 ujredebs ricxvi sami Tvis ganmavlobaSi

stabulurad ar moimatebs (200 ujredi da meti).

91

3.11. martivi herpesiT gamowveuli infeqciebi

klinikur praqtikaSi xSiria martivi herpesiT gamowveuli

infeqciebi;

herpesis pirvelad epizods xSirad axlavs recidivi.

imunodeficitis mqone pacientebSi dazianeba SeiZleba iyos vrceli

da persistuli, aseve SesaZlebelia moxdes infeqciis diseminacia.

martivi herpesi aris meningitisa da meningoencefalitis gamomwvevi.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi ZiriTadad ismeba tipiuri klinikuri gamovlinebebiT.

herpesuli gamonayari Cveulebriv warmodgenilia vezikulebiTa da

mtkivneuli eroziebiT, romlebic ganlagebulia piris irgvliv,

cxviris nestoebze, tuCebsa da sasqeso organoebze.

diseminirebuli martivi herpesiT gamowveuli infeqciis diagnozis

dasma xSirad Znelia. amisaTvis saWiroa laboratoriuli kvlevebi,

rogoricaa virusis kulturis gamoyofa, radio-imunoblotingis

meTodi, imunofluoroescencia da monoklonuri antisxeulebiT

testireba.

herpesul encefalits mivyavarT Tavis tvinSi dazianebis

mravlobiTi kerebis ganviTarebamde, romelic TvalsaCinoa CAT skanirebiT.

mkurnaloba

mkurnalobis sqemebi mocemulia 34 – 37-e cxrilebSi.

cxrili 34. martivi herpesvirusuli infeqciis msubuqi formis

mkurnaloba (44-47(AI)

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

acikloviri 400 mg 3-jer dReSi PO 7-10 dRe

an

famcikloviri 250 mg 3-jer dReSi PO 7-10 dRe

an

valacikloviri 1 g 2-jer dReSi PO 7-10 dRe

cxrili 35. martivi herpesvirusuli infeqciis recidivis

mkurnaloba (44-47) (AI) antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

acikloviri 800 mg 5-jer dReSi PO 7-10 dRe

an

famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe

an

valacikloviri 1 g 2-jer dReSi per os 7-10 dRe

92

cxrili 36. martivi herpesvirusuli infeqciis mZime formis

mkurnaloba (44-47) (AI)

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe

an

valacikloviri 1 g 2-jer dReSi PO 7-10 dRe

cxrili 37. martivi herpesvirusuli infeqciis mZime visceraluri

formebis mkurnaloba (44-47) (AI)

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

acikloviri 10 mg/kg 3-jer dReSi IV 14-21 dRe

meore rigis sqema

foskarneti

(aciklovirze

rezistentobis

SemTxvevebSi)

40-60 mg/kg 3-jer dReSi IV 14 dRe

3.12. sartyliseburi liqeni (Herpes zoster) (48) (AI)

varicella-zoster-is virusiT gamowveuli pirveladi infeqcia

mimdinareobs diseminirebuli formiT.

bavSvebSi viTardeba Cutyvavilas klinikuri suraTi, Tumca

adamianTa umravlesobas es infeqcia gadaaqvs subklinikuri formiT. pirveladi infeqciis Semdeg virusi wlebis ganmavlobaSi latentur

mdgomareobaSi rCeba zurgis tvinis gangliebSi.

imunitetis daqveiTebasTan erTad virusi mravldeba da viTardeba

kanis dazianebuli ubnebiT nervis an dermatomis gaswvriv.

SesaZloa moxdes infeqciis diseminacia kanis, nervuli sistemis,

filtvebis da lorwovani garsebis CarTviT paTologiur procesSi.

imunodeficitis fonze zosteri multidermatulia, persistirebs,

axasiaTebs Zlieri tkivili da sisuste.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi Cveulebriv ismeba klinikuri suraTis mixedviT.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

mkurnalobis sqemebi mocemulia 37-e da 38-e cxrilebSi.

93

cxrili 37 sartyliseburi liqenis (kanis formis) mkurnaloba (AI)

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

acikloviri 800 mg 5-jer dReSi PO 7-10 dRe an

vezikulis

gaSrobamdeE

an

famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe

an

valacikloviri 1 g 3-jer dReSi PO 7-10 dRe

cxrili 38. Tvalis sartyliseburi liqenis, infeqciis diseminirebuli

da visceruli formebis mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe

an

valacikloviri 1 gr 3-jer dReSi PO 7-10 dRe

an

famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe

meore rigis sqema

foskarneti 60 mg/kg

an

40 mg/kg

2-jer dReSi

an

3-jer dReSi

IV 7-10 dRe

post-herpesuli nevralgia xSiri da seriozuli problemaa.

dazianebul dermatomebSi viTardeba Zlieri tkivili.

tkivilis kontroli mniSvnelovania da tkivilis kupirebis mizniT

iniSneba arasteroidul anTebis sawinaaRmdego preparatebi.

Tu tkivili gaxangrZlivda iniSneba amitriptilini, karbamazepini an

fenitoini.

3.13. citomegalovirusuli infeqcia

imunodeficitis fonze citomegalovirusma SeiZleba daazianos

sxvadasxva organoebi da sistemebi. simptomebi moicavs:

cxeleba da diarea citomegalovirusuli kolitis Ddros;

dispnoe - pnevmoniis dros;

sibrmave - retinitis dros;

citomegalovirusulma infeqciam SeiZleba gamoiwvios piris Rrus

lorwovanis mtkivneuli wylulebi, rac iwvevs kvebis reJimis

darRvevas.

94

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

pacientebs, romelTa CD4<100mm3 yovel 3 TveSi unda CautardeT

ofTalmoskopia, raTa droulad gamovlindes citomegalovirusuli

retiniti.

citomegalovirusuli infeqciis sxva lokalizaciis SemTxvevbSi

diagnozis dasadgenad saWiroa ZviradRirebuli gamokvlevebis

Catareba, maT Soris dazianebuli organoebis bioptatis gamokvleva,

dnm-is hibridizaciis meTodis gamoyeneba.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

rekomendaciebi citomegalovirusuli infeqciis mkurnalobis Sesaxeb

mocemulia 39-e, 40-e da 41-e cxrilebSi.

cxrili 39. citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis

traqtisa da cns-is dazianebebis da retinitis mkurnaloba (49-53) (AI)

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqema

gancikloviri 5 mg/kg 2-jer dReSi IV 2-3 kvira

meoradi profilaqtikisTvis aucilebelia gancikloviriT 5 mg/kg IV

dReSi mkurnaloba.

cxrili 40. citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis

traqtisa da cns-is dazianebebis mkurnaloba (49-53) (AI)

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

meore rigis sqemebi

foskarneti 90 mg/kg 2-jer dReSi IV 3 kvira

meoradi profialqtikisTvis aucilebelia foskarnetiT mkurnalobis

xangrZlivi kursi doziT 90mg/kg IV erTxel dReSi.

cxrili 41. citomegalovirusuli retinitis meoradi profilaqtika (49-53)

(AI)

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

meore rigis sqemebi

Tvalis implantanti, romelic gamoyofs ganciklovirs

+

valgancikloviri 900 mg erTxel

dReSi

PO manamde sanam CD4ujredebi ricxvi ar

moimatebs 100-150 mm3

minimum 3 Tvis

ganmavlobaSi

95

meoradi profilaqtikis Sewyveta SesaZlebelia 6 Tvis Semdeg da

imunorekonstituciisas - CD4 100-150 mm3.

3.14. epStein-baris virusiT gamowveuli infeqciebi

epStein-baris virusi miekuTvneba herpesvirusebis ojaxs. am virusiT

gamowveuli infeqciebi gavrcelebulia, rogorc aiv inficirebul,

ise arainficirebul adamianebSi.

aiv inficirebulTa orofaringealur sekretSi gvxvdeba virusuli

nawilakebis momatebuli raodenoba da antisxeulebis ufro maRali

titri, vidre arainficirebulebSi.

varaudoben, rom epStein-baris virusi iwvevs ramdenime daavadebas,

maT Soris:

• oraluri Tmovani leikoplakia;

• limfoiduri intersticiuli pnevmoniti (LIP); • arahojkinis limfomebi;

• berkitis-tipis limfoma;

• nazofaringeuli karcinoma;

oraluri Tmovani leikoplakia

• oraluri Tmovani leikoplakia viTardeba, rogorc aiv

inficirebulebSi, aseve pacientebSi, romelTac utardebaT

transplantaciis Semdgomi imunosupresiuli Terapia.

• dazianebul kerebs aqvs zedapiridan wamoweuli balTiseburi

TeTri nadebis saxe, romelic ganlagebulia piris RruSi,

upiratesad ki enis kideze. igi lorwovani garsis epiTelis

keTilTvisebiani gadagvarebaa.

• rTulia diferencialuri diagnostika oralur Tmovan

leikoplakiasa da piris Rrus kandidozs Soris; araiSviaTia am

daavadebaTa erTdrouli arseboba.

• specifikuri mkurnaloba ar arsebobs. pacientebisaTvis

rekomendebulia piris Rrus higienis dacva.

limfoiduri intersticiuli pnevmoniti

• limfoiduri intersticiuli pnevmoniti upiratesad uviTardebaT

aiv inficirebul bavSvebs, magram mozrdilebSic gvxvdeba.

• damaxasiaTebelia difuzuri intersticiuli infiltratebis

arseboba filtvebSi, romelic SeiZleba miviCnioT tuberkulozis

an pnevmocisturi pnevmoniis gamovlinebad.

• xSirad limfoiduri intersticiuli pnevmoniti mimdinareobs

filtvis mZime paTologiis niSnebis gareSe.

• specifikuri mkurnaloba ar arsebobs.

96

3.15. ZiriTadi simptomebi

3.15.1. persistuli generalizirebuli limfadenopaTia (pgl) mozrdil

aiv inficirebulebSi

aiv infeqciis yvelaze adreul klinikur gamovlinebas warmoadgens

limfuri kvanZebis simetriuli gadideba;

gadidebuli limfuri kvanZi, rogorc wesi umtkivneulo,

elastiuri konsistenciis moZravi warmonaqmnia. yvelaze advilad

isinjeba kisris, ybisqveSa, iRliisa da sazardulis limfuri

kvanZebi;

persistuli generalizirebuli limfadenopaTia SeiZleba

warmoadgendes aiv infeqciis erTaderT gamvlinebas;

persistuli generalizirebuli limfadenopaTia _ es aris limfuri

kvanZebis (1sm diametrze meti) or an meti jgufis gadideba

(sazardulis garda), romelic SenarCunebulia 1 Tveze met xans;

pgl–s dros limfuri kvanZis biofsiiT Ghistologiurad saxezea

“reaqtiuli hiperplazia” an “folikuluri hiperplazia”.

hiperplaziis mizezis gasarkvevad aucilebelia kimfuri kvanZis

biofsia.

diagnostika

gamokvleva aucileblad unda moicavdes limfuri kvanZebis Semdegi

jgufebis palpacias:

• kisris wina da ukana;

• ybisqveSa;

• kefisukana;

• yuris irgvlivi (yuriswina da ukana);

• iRliis orive;

• idayvis are;

• sazardulis (am jgufis jirkvlebis gadideba janmrTel

pirebSic gvxvdeba).

persistuli generalizebuli limfadenopaTiis mqone aiv

inficirebulebSi SeiniSneba aiv infeqciis sxva gamovlinebebic. maT

Soris:

piris Rrus kandidozi;

oraluri Tmovani leikoplakia;

qavana dermatitis;

frCxilebis gamuqeba;

oraluri da genitaluri herpesi;

umizezod wonaSi kleba;

ucnobi etiologiis cxeleba.

generalizebuli limfadenopaTia damaxasiaTebelia sxva

daavadebebisaTvisac, kerZod, tuberkulozis, leikozis, limfomis,

kapoSis sarkomis, veneriuli limfogranulomis, sifilisis,

97

citomegalovirusuli infeqciis, toqsoplazmozis, epStein-baris virusiT

gamowveuli infeqciis, kriptokokozis, histoplazmozisa da kanis

Cirqovani infeqciebisaTvis, Savi Wirisa da B hepatitisaTvis.

limfuri kvanZebis biofsiis Cvenebebi:

persistiuli generalizebuli limfadenopaTiis mqone pacientebi

aucilebelia gagzavnil iqnas biofsiaze, Tu maT aReniSnebaT:

limfuri kvanZebis asimetriuli gadideba;

limfuri kvanZebis gamoxatuli gadideba (3 sm diametris mqone

erTi limfuri kvanZi mainc);

dakvirvebebis fonze limfuri kvanZebis gadideba;

tuberkulozis raime niSnebi;

gulmkerdis rentgenogramaze filtvis karis limfuri kvanZebis

gadideba;

nebismieri likalizaciis kapoSis sarkoma; cxeleba, Ramis oflianoba, wonaSi kleba erT kviraze

xangZlivad.

aiv asocirebuli limfadenopaTia ar aris seriozuli daavadebis, mag;

lomfomis maniSnebeli. miuxedavad amisa, mdgomareobis cvlilebisas, mag:

persistuli cxelebis damatebisas sasurvelia limfadeneqtomia da

kvanZis histologiuri gamokvleva.

3.15..2. cxeleba aiv inficirebulebSi

cxelebis mizezi SeiZleba iyos infeqcia, anTebiTi procesi an

avTvisebiani simsivne. mozrdilebSi persistulad iTvleba cxeleba, Tu

38°C–ze maRali temperatura grZeldeba or kviraze gangrZlivad.

aiv inficirebul pacientebSi cxeleba SeiZleba iyos infeqciis

erTaderTi klinikuri niSani. amitom persistuli cxelebis mqone

avadmyofebis mkurnalobisas unda gvaxsovdes, rom misi mizezi

SeiZleba iyos aiv infeqcia.

aiv /SidsiT pacientebSi persistul cxelebas SeiZleba Tan axldes

misi gamomwvevi daavadebis simptomebi, magaliTad, pnevmoniis,

tuberkulozis, kuW-nawlavis traqtis infeqciis an limfomis.

persistuli cxelebis mqone mozrdil pacientebSi aiv infeqciaze

migviTiTebs Semdegi mdgomareobebi:

• anamnezSi mravlobiTi daucveli sqesobrivi kontaqtebi;

• aiv inficirebuli sqesobrivi partniori;

• aiv inficirebuli Svili;

• aiv infeqciisaTvis damaxasiaTebeli tipuri klinikuri niSnebis

arseboba, rogoricaa:

_ persistuli generalizirebuli limfadenopaTia;

_ oraluri an genitaluri kandidozi da/an herpesi;

_ oraluri Tmovani leikoplakia;

_ qavana dermatitis;

_ wonaSi umizezod kleba;

_ frCxilebis gamuqeba (melanonixia);

_ tuCebis hipopigmentacia da

98

_ Tmebis gaTxeleba da cvena.

3.15.3. aiv inficirebul mozrdilebSi wonis umizezo kleba

mozrdilebSi wonaSi kleba xSirad dakavSirebulia aiv

infeqciasTan;

wonis mniSvnelovan klebad iTvleba sxeulis sawyisi masis 10% -iT

an metiT daqveiTeba umizezod;

gamoxatuli wonis kleba aiv inficirebulebSi atarebs “aiv-

kaxeqsiis” an ganlevis sindromis saxels;

ganlevis mizezi jer-jerobiT kargad ar aris Seswavlili. SesaZlebeli

mizezebia:

qronikuli da morecidive infeqciebi;

qronikuli diarea;

Sewovis darRveva (malabsorbcia);

aiv inducirebuli miopaTia;

aiv inducirebuli madis daqveiTeba.

klinikuri niSnebiAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

pacienti uCivis wonaSi umizezod klebas da madis daqveiTebas,

rasac Tan axlavs an ar axlavs cxeleba da diarea;

aiv kaxeqsiis mqone pacientebi uCivian zogad saerTo diskomforts,

gamofitvas, mousvenrobas, gauwyloebas;

aseT pacientebSi xSiria piris Rrus kandidozi;

aseT pacientebSi xSiria Sidsis sxva klinikuri gamovlinebebi, maT

Soris nevrologiuri, mag. encefalopaTia da Sids-demenciis

kompleqsi.

3.15.4. mozrdilTa qronikuli diarea

qronikuli diarea ewodeba 28 dRis ganmavlobaSi arsebul xSir

(sami an meti), Txier defekacias. qronikuli diareis fonze

pacientebs SeiZleba ganuviTardeT mwvave diareis epizodebi.

Tu ar aris dizenteria, ganavalSi sisxlis minarevebis arseboba

iSviaTia.

avadmyofebs aReniSnebaT cudi mada da ikleben wonaSi.

gamokvlevisas gamovlindeba gauwyloebis, anemiisa da gamofitvis

niSnebi.

qronikuli diareis mqone pacientebSi aRiniSneba:

kanisa da Tmebis distrofiuli cvlilebebi tipurad asocirebuli

arasrulfasovan kvebasTan;

tuCebis gafermkrTaleba;

frCxilebis gamuqeba;

piris Rrus kandidozi, oraluri Tmovani leikoplakia da

limfadenopaTia.

99

3.15.5. piris Rrus dazianebebi

kandidozis garda aiv inficirebulebs xSirad aReniSnebaT piris Rrus

sxva saxis dazianebebic. zogierTi maTgani ganxilulia 42-e cxrilSi.

cxrili 42. piris Rrus yvelaze xSiri dazianebebi aiv inficirebulebSi

mdgomareoba aRweriloba mkurnaloba

gingiviti hiperemia, SeSupeba da

sisxldena RrZilebidan

metronidazoli 400 mg 2-jer

dReSi 7 dRe PO

an

eriTromicini 500 mg 4-jer

dReSi 7 dRe PO

piorea Cirqis dagroveba

kbilbudeSi

piris Rrus higiena: yoveli

Wamis Semdeg pirSi Tbili

marilwylis gamovleba da

kbilebis dReSi 2-jer gamoxexva

periodontiti damaxasiaTebelia

kbilebis garSemo

Zvlebisa da rbili

qsovilebis swrafi da

mtkivneuli rRveva.

kbilebi iryeva da

Zvreba, RrZilebi

sisxlmdenia.

SesaZlebelia

dawyluleba

infeqciis kerebis sanacia,

pirSi qlorheqsidinis xsnaris

gamovleba. aseve iniSneba

amoqsicilini 500 mg 3-jer

dReSi 5 dRis ganmavlobaSi PO

an

metronidazoli 200 mg samjer

dReSi 5 dRe PO.

afTozuri

wylulebi

lorwovanze aRiniSneba

mtkivneuli wylulebi

swori kideebiT.

Cveulebriv dafarulia

Cirqovani nadebiT da

Sexebisas sisxlmdenia.

piris Rrus higiena da

glukokortikoidebi

adgilobrivad

stomatiti piris Rrus lorwovanis

anTeba. viTardeba piris

Rrus cudi higienis

pirobebSi; SeiZleba

gamoiwvios anaerobebma.

piris Rrus higiena: Wamis

Semdeg marilwyalsnaris

gamovleba da kbilebis dReSi

2-jer gamoxexva.

qeiliti tuCebis SeSupeba da

SewiTleba, romelic

icvleba sifermkrTaliT;

xSirad aReniSnebaT

gamaxatuli

imunodeficitis mqone

pirebs

specifikuri mkurnaloba ar

arsebobs. iniSneba A, B da C vitaminebi da piris Rrus

higiena.

meoradi

sifilisi

sifilidebi loyis

lorwovanze (sveli

papulebi da wylulebi,

mogvagonebs lokokinis

nakvalevs) da farTe

pirveladi sifilisi:

benzatinbenzilpenicilini 2,4

mln. erT. kunTebSi erTjeradad

meoreuli sifilisi:

100

kondilomebi tuCis

kuTxeebsa da nestoebis

garSemo. meoradi

sifilisis dros yvela

serologiuri testi

dadebiTia.

benzatinbenzilpenicilini 2,4

mln. erT. kunTebSi kviraSi

erTxel 3 kvira

an

doqsiciklini 100mg 2-jer

dReSi 28 dRe PO

an eriTromicini 500mg 4-jer

dReSi 28 dRe PO.

3.15.6. kanisa da frCxilebis dazianebebi

dermatomikozebi

kanis sokovani dazianeba (dermatomikozebi) xSirad gvxvdeba

rogorc aiv inficirebul, ise arainficirebul pacientebSi.

gamonayars xSirad Tan axlavs qavili, elementi mSralia da

aqercvladi.

dazianeba SeiZleba gaCndes sxeulis nebismier adgilze.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

gamomwvevi SeiZleba aRmovaCinoT dazianebuli kanis anafxekis

mikroskopuli gamokvleviT.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

rogorc wesi efeqturia antimikozuri sacxebis adgilobrivi aplikacia.

rekomendaciebi dermatomikozis mkurnalobis Sesaxeb mocemulia 43-e

cxrilSi.

cxrili 43. dermatomikozebis mkurnaloba (AI)

antifungaluri

preparati

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

Mmikonazoli

(adgilobrivad

gamoyenebisTvis)

3-jer dReSi Aadgilobrivad 21 dRe

an

klotrimazoli

(adgilobrivad

gamoyenebisTvis)

3-jer dReSi adgilobrivad 21 dRe

meore rigis sqemebi

ketokonazoli 200 mg dReSi

erTxel

PO 1-3 Tve

an

itrakonazoli 100 mg dReSi

erTxel

PO 1-3 Tve

101

oniqomikozebi

frCxilebis sokovani dazianebebi (oniqomikozebi) iwveven frCxilis

firfitebis deformaciasa da rRvevas.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi ismeba klinikuri suraTiT.

gamomwvevi SeiZleba aRmoCnes frCxilis firfitis qvevidan aRebuli

da kaliumis hidroqsidiT damuSavebuli masalis mikroskopuli

gamokvleviT.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

cxrili 44. oniqomikozebis mkurnaloba (AI)

pirveli rigis sqemebi

antifungaluri

preparati

doza MmiRebis

sixSire

MmiRebi

gza

mkurnalobis

xangrZlivoba

terbinafini 250 mg dReSi

erTxel

PO 6 kvira xelis

TiTebis

dazianebisas an

12 kvira fexis

TiTebis

dazianebisas

an

itrakonazoli 200 mg 2-jer dReSi PO yoveli Tvis I

kviris

ganmavlobaSi 2

Tvis manZilze

(xelis TiTebis

dazianebisas),

3-4 Tve (fexis

TiTebi

dazianebisas)

3.15.7. seboreuli dermatiti

aiv inficirebulebs xSirad uviTardebaT seboreuli dermatiti.

varaudoben, rom mas iwvevs soko Pityrosporum ovale (aseva cnobilia,

rogorc Malassezia furfur). elementi warmoadgens wiTeli feris laqas, romelic iqercleba. aiv

inficirebulebSi dazianeba vrcelia, elementebi xangrZlivad rCeba

da xSirad iZleva recidivs.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi ismeba klinikuri suraTiT. Cveulebriv gamonayari gvxvdeba:

saxeze;

cxviris nestoebis irgvliv;

cxvir-tuCis naoWze;

102

warbebze;

Tavis Tmian nawilze;

gul-mkerdis areSi;

iRliebSi;

tanis zeda nawilsa da

sazardulis areSi.

diagnozi dasturdeba sokos aRmoCeniT kanis dazianebuli ubnidan

anafxeki masalis mikroskopuli gamokvlevisas.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

rekomendebulia dazianebuli ubnebis xSirad dabana qerclis

mosaSoreblad,

karg Sedegs iZleva selenis sulfidis Semcveli samkurnalo

Sampunebis gamoyeneba.

SesaZloa yvelaze efeqturi aRmoCndes hidrokortizonis 1%-ani

mazis aplikaciebi. aseve karg Sedegs iZleva ketokonazolis 2%-ani

kremi.

3.15.8. muni

muns iwvevs tkipa Sarcoptes scabiei. mdedr tkipas kanSi gahyavs gasasvleli,

romelsac aqvs ramodenime sm sigrZis zedapiridan wamoweuli wiTeli

nawiburis Sesaxedaoba. mdedri tkipa gayvanil gasasvlelSi debs

kvercxebs da Semdeg gadaadgildeba sxeulis sxva nawilSi. kvercxebidan

gamodis tkipebis axali Taoba, romlebic izrdebian, jvardebian, gahyavT

axali gasasvlelebi da deben axal kvercxebs.

parazitis pirveladi SeWridan daaxloebiT erT Tvis ganmavlobaSi

(2-6 kvira) simptomebi TiTqmis ar aRiniSneba.

ganmeorebiTi invaziis Semdeg ki viTardeba alergiuli reaqcia da

simptomebi gamovlindeba 1-4 dRis ganmavlobaSi.

kanqveSa gasasvlelis gayvanisas viTardeba gamonayari, romelic

xSirad gvxvdeba:

• xelebze - mtevnebze (gansakuTrebiT TiTebs Soris);

• majis, idayvis, muxlismomxrel zedapirebze;

• winamxris idayviskena zedapirze;

• sasqeso asoze;

• sarZeve jirkvlebsa da

• beWebze.

tkipebi da maT mier gayvanili gasasvlelebi SeiZleba iyos Zalian

mcire raodenobiT da gagviWirdes maTi danaxva.

avadmyofs ZiriTadad awuxebs tanis Zlieri qavili, gansakuTrebiT

RamiT.

imunodeficitis mqone pacientebs xSirad uviTardebaT munis mZime

forma, romelsac uwodeben norvegiuls. misTvis damaxasiaTebelia

vezikuluri gamonayari da sqeli fufxebis warmoqmna mTel

sxeulze. munis am formis dros qavili ar aris gamoxatuli.

qavilis gamo muni xSirad rTuldeba meoradi infeqciebiT.

103

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi ismeba klinikuri gamovlinebebisa da dazianebuli keris

anafxekis mikroskopuli gamokvlevis safuZvelze.

mikroskopiisas aRmoCndeba tkipebi an/da maTi kvercxebi.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

SerCevis preparats warmoadgens adgilobrivad gamosayenebeli 1%-

ani gamabenzen heqsaqloridi, romelic ismeba mTels tanze, Tavis

garda. mozrdilebSi Camoibaneba 24 sT-Si, xolo bavSvebSi _ 8sT-Si.

sakmarisia erTjeradi damuSaveba.

aseve SesaZlebelia kanis damuSaveba 1%-ani permetriniT an 1%-ani

lindaniT; es preparatebic ismeba mTels tanze da Camoibaneba 8 sT-

Si. permetrinisa da lindanis gamoyeneba ar SeiZleba

orsulebisaTvis, meZuZuri dedebisa da bavSvebisaTvis.

norvegiuli munis samkurnalod, imunodeficitis mqone pacientebSi,

efeqturia ivermeqtini, 200 mg/kg PO erTjeradad.

tansacmeli, TeTreuli da pirsaxocebi unda gamoixarSos da

dauTovdes gaSrobis Semdeg.

munis mkurnaloba unda Cautardes sqesobriv partniors da yvelas

vinc sayofacxovrebo kontaqtSi iyo avadmyofTan.

3.15.9. stafilokokuri folikuliti

folikuliti _ kanis infeqciaa, romlis drosac procesi Tmis

folikulSia lokalizebuli.

aiv inficirebulebs xSirad uviTardebaT pustularuli

perifolikuliti.

folikulits, rogorc wesi, iwvevs Staphylococcus aureus, magram sxva mikroorganizmebsac SeuZlia misi gamowveva.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi ismeba klinikuri gamovlinebebis safuZvelze.

gamonayari warmodgenilia mravlobiTi wvrili (5 mm diametris),

hiperemiuli folikulebiT, romlebic centrSi daCirqebulia.

xSirad elementebs aqvT midrekileba gaerTianebisaken. kanis

dazianebas Tan axlavs qavili.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

iniSneba antibiotiki, magaliTad cefaleqsini an kloksacilini 500 mg PO 4-jer dReSi 7-21 dRe.

3.15.10. kontagiozuri moluski

kontagiozuri moluski _ kanis zedapiruli infeqciaa, romelsac

iwvevs kontagiozuri moluskis virusi;

104

infeqcia gadadis avadmyofTan mWidro kontaqtiT an saerTo

moxmarebis nivTebiT da sqesobrivi gziT;

inkubaciuri periodi meryeobs 1-2 kviridan ramodenime Tvemde;

elementebis mocilebam an moqavebam SeiZleba gamoiwvios axali

gamonayrebis ganviTareba;

kontagiozuri moluski ufro xSiria imunodeficitis mqone aiv

inficirebulebSi;

aiv inficirebulebSi aiv negatiurebisgan gansxvavebiT:

• elementebi raodenobrivad bevria;

• xangrZlivad persistirebs;

• ufro msxvilia da

• Znelad eqvemdebareba mkurnalobas.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi ismeba damaxasiaTebeli elementis aRmoCenisas.

kanSi SeRwevisas virusi iwvevs 2-5 mm diametris kanisferi mkvrivi

papulebis ganviTarebas. papulebi Seicavs TeTr cximovan sekrets.

gamonayaris elementebi SeiZleba ganviTardes sxeulis nebismier

adgilas, xSirad rCeba ucvlelad mravali Tvis manZilze da/an

SeiZleba gaqres da Semdeg kvlav gaCndes.

specifikuri diagnostikuri testi virusis aRmosaCenad ar arsebobs.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

mkurnaloba mdgomareobs papulis rbili SigTavsis mocilebaSi, romlis

Semdeg papula qreba. mkurnalobis taqtika yvela SemTxvevaSi

individualuria. arsebobs kanis dazianebuli ubnis damuSavebis

sxvadasxva meTodi. elementebs damuSaveba SesaZlebelia Semdegi

meTodebis gamoyenebiT:

_ kiuretaJi

_ qimiuri destruqcia fenolis koncentrirebuli xsnariT

_ krioTerapia

_ eleqtrokoagulacia

cnobilia, rom aiv inficirebulebSi arT-s dawyeba xels uwyobs

kontagiozuri moluskis eliminacias. naCvenebi iyo, rom antivirusuli

preparati – cidofoviri, romelsac aqvs Zlieri antiretrovirusuli

moqmedeba, aseve efeqturia kontagiozuri moluskis samkurnalod.

105

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IV. aiv infeqcia/SidsiT daavadebulTa imunizaciis ZiriTadi principebi

ramdenadac aiv infeqcia iwvevs imunuri sistemis progresirebad

dazianebas, SesaZloa aiv inficirebul pirebSi zogierTi vaqcina gaxdes

mniSvnelovani gverdiTi reaqciis mizezi.

imunobiologiuri produqti ar aris sruliad usafrTxo; amis

gaTvaliswinebiT, axalSobilTa, bavSvTa da mozrdilTa vaqcinaciis

ZiriTadi principebi efuZneba Semdegs:

• imunobiologiuri produqtis maxasiaTeblebi;

• aqtiuri da pasiuri imunizaciis principebis mecnieruli codna;

• infeqciis epidemiologia;

• infeqciis sawinaaRmdego proteqciis miRwevis dadebiTi da uaryofiTi

mxareebi.

aRniSnuli dadebiTi da uaryofiTi mxareebis zust Sefasebamde, rasac

Semdgomi kvlevebi gviCvenebs, aiv infeqcia SidsiT daavadebul pirebSi

nebismieri vaqcinacia unda tardebodes sifrTxiliT klinikuri da

prevenciuli medicinis eqspertebis SefasebiT.

terminebi – vaqcinacia da imunizacia xSirad moiazreba sinonimebad.

vaqcinacia es aris procesi, rodesac adamianis organizmSi Segvyavs

imunobiologiuri produqti (vaqcina an anatoqsini) da gulisxmobs

aqtiur imunizacias. imunizacia ufro farTo mcnebaa da gulisxmobs

imunitetis xelovnur induqcias, romelic SeiZleba iyos pasiuri an

aqtiuri.

aiv infeqcia/SidsiT daavadebulTa vaqcinaciis ZiriTadi principebia.

• daxocili an inaqtivirebuli vaqcina ar warmoadgens safrTxes

imunokompromitirebulTaTvis da ZiriTadad gamoiyeneba iseve, rogorc

janmrTel populaciaSi.

• rac Seexeba cocxali virusis an baqteriis Semcvel vaqcinebs,

rogoric aris BCG, oraluri poliovirusis, tifis(Ty21a), Cutyvavilas

da yviTeli cxelebis vaqcinebi, maTi gamoyeneba aiv inficirebul

pirebSi SesaZloa dakavSirebuli iyos garkveul riskTan da, amitom,

unda tardebodes dadebiTi da uaryofiTi mxareebis zedmiwevniT

SefasebiT, aiv infeqciis stadiisa da imunuri sistemis supresiis

xarisxis gaTvaliswinebiT.

4.1. vaqcinebisa da imunoglobulinebis gamoyeneba

aiv infeqcia/SidsiT daavadebulTa imunizaciisas gaTvaliswinebuli unda

iyos aRniSnuli vaqcinebis imunogenurobis ZiriTadi aspeqtebi.

miuxedavad imisa, rom aiv inficirebul axalSobilebSi ujreduli

da humoruli imunitetis daqveiTeba iwyeba dabadebisTanave, maT

umravlesobaSi imunuri pasuxis unari sicocxlis pirveli 2 wlis

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ganmavlobaSi SenarCunebulia. rekomendebuli vaqcinebis1 imunogenu-

robis Seswavlam gamoavlina serokonversiis damakmayofilebeli

xarisxi aiv infeqciis adreul stadiaze. aRsaniSnavia, rom

TiToeuli vaqcina xasiaTdeba serokonversiis gansazRvruli doniT.

vaqcinaciaze mopasuxeTa wili aiv infeqciis Sidsis stadiaSi

progresirebasTan erTad mcirdeba.

aiv inficirebul simptomur bavSvebsa da mozrdilebSi vaqcinaciaze

aRiniSneba suboptimaluri imunologiuri pasuxi. imunuri pasuxi

cocxal da daxocil antigenebze mcirdeba, ramdenadac aiv infeqcia

progresirebs. Tumca, maRali doziT vaqcinaciis SemTxvevaSi

imunuri pasuxi da antisxeulebis persistencia aiv inficirebul

pirebSi sistemurad Seswavlili ar aris. aRniSnul kontigentSi,

SesaZlebelia gamoyenebul iqnas vaqcinaciis gazrdili doza, an

xSiri bustireba. Tumca am etapze myari rekomendaciebi ar

arsebobs.

konkretuli vaqcinisa da imunoglobulinis usafrTxoebisa2 da

efeqfturobis Sefaseba moicavs aRniSnuli daavadebis epidemiologiisa

da recipientis imunosupresiis xarisxis gansazRvras. es ukanaskneli

unda Sefasdes eqimis mier jandacvis msoflio organizaciis klinikuri

stadiebis sistemis3 da/an asakobrivi jgufisTvis damaxasiaTebeli CD4+ ujredebis ricxvisa da procentis mixedviT.

4.2. cocxali atenuirebuli vaqcinebi

4.2.1 BCG vaqcina

BCG vaqcina icavs 2 wlamde asakis bavSvebs diseminirebuli da mZime

formis tuberkulozisgan, maT Soris tuberkulozuri meningitisa da

miliaruli tuberkulozisgan (AI). filtvis tuberkulozis sixSiris

Semcirebis TvalsazrisiT zrdasrul populaciaSi BCG vaqcinacia

araefeqturia an xasiaTdeba mcire efeqtiT (AI).

ar aris cnobili mcirdeba Tu ara vaqcinis efeqturoba aiv inficirebul

bavSvebSi. arsebobs garkveuli monacemebi, rom BCG vaqcinaciis Semdgom tuberkulinis dadebiTi testi naklebad xSiria aiv inficirebul

bavSvebSi. Tumca aRniSnuli mtkicebulebis sarwmunoeba naTeli ar aris

(Vb). aRwerilia lokaluri garTulebebisa da diseminirebuli BCG infeqciis SemTxvevebi aiv inficirebuli bavSvebis vaqcinaciidan

ramdenime wlis Semdegac. Tumca prospeqtuli kvlevebiT aiv inficirebul

da janmrTel axalSobilebSi BCG imunizaciis Semdgomi garTulebebis

riskis mxriv gansxvaveba ar gamovlinda (CIII). BCG infeqciis tubrekulo-

1 BCG vaqcina; difTeriis, tetanusisa da yivanaxvelas vaqcina (DTP); OPV; MMR vaqcina;

B hepatitis vaqcina; HiB vaqcina. 2aiv infeqcia/SidsiT daavadebulTa vaqcinirebis usafrTxoebis Sesaxeb informacia

mcirea (Va); vaqcinaciasTan dakavSirebuli nebismieri gverdiTi reaqciis Sesaxeb

informacia unda miewodoT Sesabamis samsaxurebs; gasaTvaliswinebelia, rom zogierTi

gverdiTi movlena SesaZlebelia gamovlindes xangrZlivi latenturi periodis Semdeg

(DIV). 3klinikuri stadiis Sefasebisas SeiZleba ixelmZRvaneloT antiretrovirusuli

mkurnalobis protokolebiT mozrdilebisa da bavSvebisaTvis.

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zuri infeqciisagan gansasxvaveblad saWiroa gverdiTi reaqciebis mWidro

monitoringi aiv infeqciis maRali prevalentobis areebSi. Semdgomi

kvlevebiT dadebiTi da uaryofiTi mxareebis zust Sefasebamde BCG vaqcinacia unda Catardes mxolod asimptomur aiv inficirebul bavSvebSi

(ramdenadac arsebobs disiminirebuli daavadebis albaToba). romelTac

aqvT tuberkulozuri infeqciis ganviTarebis maRali riski, rac Tavis

mxriv damokidebulia tuberkulozis lokalur gavrcelebaze.4 maRali

riskis SemTxvevaSi sasurvelia BCG imunizacia (CIII).

rekomendaciebi

tuberkulozis dabali gavrcelebis arealSi5 aiv inficirebul

bavSvebSi, miuxedavad klinikuri stadiisa da imunodeficitis

xarisxisa, ar unda Catardes BCG vaqcinacia. infeqciis maRali

gavrcelebis arealSi BCG vaqcinacia unda Catardes mxolod aiv

dadebiT asimptomur bavSvebSi. bavSvebi aiv infeqcia/Sidsis

simptomebiT ar unda iyvnen BCG vaqcinirebuli (BII). BCG vaqcina rekomendirebuli ar aris mozardebsa da mozrdilebSi,

maT Soris aiv inficirebul pirebSi. ramdenadac is araefeqturia an

umniSvnelod amcirebs mozrdilTa filtvis tuberkulozis

SemTxvevebs.

prevenciuli antituberkulozuri mkurnaloba mkacrad

rekomendebulia im aiv infeqcia/SidsiT daavadebulebisaTvis,

romlebic savaraudod inficirebulebi arian tuberkulozis

mikobaqteriiT an imyofebian tuberkulozis ganviTarebis riskis

qveS (AI).

4.2.2. qoleris vaqcina (CVD 103-HgR)

miuxedavad imisa, rom cocxali atenuirebuli oraluri vaqcina farTod

gamoiyeneboda aiv infeqciis endemur kerebSi da seriozuli gverdiTi

reaqciebi ar dafiqsirebula, usafrTxoebis Sesaxeb sakmarisi monacemebis

ar arsebobis gamo is ukunaCvenebia aiv inficirebul pirebSi (CIII). daxocili WC/rBs vaqcina rekomendebulia aiv inficirebulTaTvis (BII). 4.2.3. wiTelas, ybayurasa da wiTuras vaqcinebi (MMR, MR, M, R vaqcinebi6)

aiv inficirebul asimptomur bavSvebs, aseve bavSvebs zomieri

imunosupresiiT arainficirebuli bavSvebis msgavsad rutinulad unda

CautardeT MMR da wiTelas Semcveli sxva vaqcinaciebi (AI). mniSvnelovania gvaxsovdes, rom wiTelas vaqcinis imunogenuroba

mcirdeba, Tu vaqcinacia Catardeba adamianis normaluri

imunoglobulinis gamoyenebidan 6 Tveze nakleb periodSi.

4aRsaniSnavia, rom im qveynebSic ki, sadac tuberkulozis gavrceleba dabalia,

zogierTi subpopulacia SeiZleba gamoirCeodes daavadebis maRali prevalentobiT. 5

janmos evropis regionis qveynebi, sadac SemTxvevaTa raodenoba 100 000 mosaxleze 20-

ze naklebia.

5 janmos evropis regionis qveynebi, sadac SemTxvevaTa raodenoba 100 000 mosaxleze 20-

ze naklebia.

6 MMR:wiTela, wiTura, ybayura; MR:wiTela da wiTura; M:wiTela; R:wiTura.

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miuxedavad imisa, rom aiv inficirebul asimptomur da simptomur

pirebSi MMR-sa da wiTelas Semcveli sxva vaqcinebis gamoyenebisas

Catarebuli kvlevebiT mniSvnelovani gverdiTi reaqciebi ar

dafiqsirebula, es vaqcinebi rekomendebuli araa mniSvnelovani

imunosupresiis mqone aiv inficirebulTaTvis. rekomendaciis ar

arsebobis mizezebia:

wiTelas vaqcinaciis Semdgomi pnevmoniis SemTxveva mZime

imunosupresiis mqone recipientSi;

monacemebi wiTelas vaqcinaciaze gansxvavebuli imunuri pasuxis

Sesaxeb mZime imunosupresiis mqone pirebSi;

monacemebi wiTelas vaqcinaciis Semdgomi virusuli infeqciiT

gamowveuli letalobis Sesaxeb sul mcire 6 imunokom-

promitirebul pirSi.

rekomendaciebi

MMR da wiTelas Semcveli sxva vaqcinebi saSualo an mkveTri

imunosupresiis mqone bavSvebsa da mozrdilebSi ar gamoiyeneba (13

wlamde CD4+ <15%, 13 wlis asakis zeviT CD4+ <14%7);

MMR da wiTelas Semcveli sxva vaqcinebi unda gamoviyenoT

asimptomer an zomierad imunosupresirebul aiv inficirebulebSi;

axalSobilebSi, romlebic gamoirCevian wiTelas virusTan

eqspoziciis maRali riskiT rekomendebulia wiTelas antigenis

damatebiTi doziT vaqcinacia 6-11 Tvis asakSi, ris Semdegac

rutinulad Catardeba MMR an wiTelas Semcveli sxva vaqcinacia 12

Tvis asakSi an mogvianebiT (vaqcinaciebs Soris intervali sul

mcire 1 Tvea);

aiv inficirebul simptomur pacientebs, romelTac aReniSnaT

eqspozocia wiTelas virusTan, unda mieceT adamianis

imunoglobulini miuxedavad vaqcinaciis imunostatusisa (AI); imunokompromitirebulebTan mWidro kontaqtSi myof pirebs aseve

unda CautardeT vaqcinacia (AI).

4.2.4. poliovirusis oraluri vaqcina (pov)

miuxedavad imisa, rom SesaZlebelia aiv inficirebuli asimptomuri

bavSvebis vaqcinacia poliovirusis oraluri vaqciniT, rogorc

simptomuri, aseve asimptomuri aiv inficirebuli bavSvebisaTvis

rekomendebulia inaqtivirebuli poliovirusis vaqcina (ipv) (BII).

aiv inficirebulebs ar unda CautardeT vaqcinacia pov-iT, radgan

aRniSnul pirebSi vaqcinis virusis replikacia SesaZlebelia ver

daiTrgunos efeqturad. Tandayolili imunodeficitis mqone bavSvebSi

pov-is gamoyeneba iwvevs progresirebad nevrologiur darRvevebs

(paralizur daavadebas) (AI).

7 bavSvebs zomieri an Zlieri imunosupresiiT aReniSnebaT CD4+ ujredebis Semdegi maCveneblebi:

• <750 ujredi/mm3, rodesac asaki<12w.

• <500 ujredi/mm3, rodesac asaki 1-5w.

• <200 ujredi/mm3, rodesac asaki 6w. an metia

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Tu pov gamoyenebul iqna aiv inficirebulis ojaxis wevrTan an aiv

inficirebulTan mWidro kontaqtSi myof sxva pirTan8, mas da aiv

inficirebuls unda aekrZaloT mWidro kontaqti vaqcinaciidan erTi

Tvis ganmavlobaSi, rac vaqcinis virusis maqsimaluri eqskreciis

periodia.

rekomendacia

pov ar unda iqnas gamoyenebuli aiv inficirebul/SidsiT

daavadebulebSi, rogorc bavSvebSi, aseve zrdasrulebSi,

imunodeficitis statusis miuxedavad; aseve maTi ojaxis wevrebsa

da maTTan mWidro kontaqtSi myof sxva pirebSi (AI).

4.2.5. rotavirusis vaqcina

rekomendacia

Semdgomi samecniero mtkicebulebebiT aiv inficirebul bavSvebSi

vaqcinis usafrTxoebisa da imunogenurobis profilis

dadasturebamde aRniSnul kategoriaSi rotavirusis vaqcina ar

unda iqnas gamoyenebuli damoukideblad imunodeficitis statusisa

(CIII).

4.2.6. muclis tifis (Ty21a) vaqcina

miuxedavad imisa, rom asimptomur aiv inficirebul pirebs 200/mm3-ze

maRali CD4+ limfocitebis absoluturi ricxviT SesaZlebelia

CautardeT vaqcinacia muclis tifis cocxali atenuirebuli vaqciniT

(Ty21a jaWvis gamoyenebiT), parenteraluri inaqtivirebuli vaqcina

Teoriulad ufro usafrTxo alternativaa (DIV).

rekomendacia

Ty21a vaqcina ar unda iqnas gamoyenebuli aiv inficirebul/SidsiT

daavadebulebSi, rogorc bavSvebSi, aseve zrdasrulebSi,

imunodeficitis statusis miuxedavad.

4.2.7. Cutyvavilas vaqcina

miuxedavad imisa, rom mcire zomis axalma kvlevam ar gamoavlina

mniSvnelovani gverdiTi reaqciebi 10 aiv inficirebul bavSvSi, aiv

infeqcia/SidsiT gamowveuli zomieri an mZime imunodeficitis mqone

pirebs Cutyvavilas vaqciniT vaqcinacia ar unda CautardeT.

Tumca asimptomur da msubuqad gamoxatuli simptomatikis mqone aiv

inficirebul bavSvebs, romelTa CD4 ujredebis ricxvi 25% an metia

pirveli vaqcinacia unda CautardeT 12-15 Tvis asakSi, xolo ganmeorebiTi

8 igulisxmeba piri, romelsac aReniSneba poliomielitis vaqcinis virusis gadacemis

riski aiv inficirebul pirze fekaluri an oraluri gziT.

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4-8 kviris Semdeg. virusuli infeqciis SesaZlo diseminaciis gamo

Cutyvavilas vaqcina ar unda iqnas gamoyenebuli im aiv inficirebul

bavSvebSi, romelTa CD4 ujredebis ricxvi 25%-ze naklebia.

aiv inficirebuli bavSvebi da mozrdilebi, romlebic gamoirCevian

maRali mimReblobiT Cutyvavila-zosteris virusis mimarT _ pirebi,

romlebsac ar gadautaniaT Cutyvavila (pirveladi infeqcia), aReniSnebaT

zosteri (rekurentuli infeqcia) an arian seronegatiurni _ sasurvelia

moeridon eqspozicias CutyvaviliT an zosteriT daavadebul pirebTan.

aiv inficirebul/SidsiT daavadebulebTan mWidro kontaqtSi myof pirebs

(gansakuTrebiT bavSvebs), romlebsac ar gadautaniaT Cutyvavila da arian

aiv seronegatiurebi, unda CautardeT Cutyvavilas vaqcinacia, raTa ar

moxdes virusis transmisia am pirebidan im aiv inficirebulebze,

romlebic Cutyvavila-zosteris virusis mimarT maRali mimReblobiT

gamoirCevian.

rekomendaciebi

Cutyvavilas vaqcina ar unda iqnas gamoyenebuli aiv inficirebul

mozrdilebSi imunodeficitis statusis miuxedavad, aseve aiv

inficirebul bavSvebSi zomieri an mZime imunosupresiiT.

Cutyvavilas vaqcina unda gamoviyenoT mxolod asimptomur da

msubuqad gamoxatuli simptomatikis mqone aiv inficirebul

bavSvebSi (CD4>=25%) (BII). aiv inficirebul/SidsiT daavadebulebTan mWidro kontaqtSi myof

pirebs, romlebic gamoirCevian virusis mimarT maRali mimReblobiT,

unda CautardeT vaqcinacia Cutyvavila-zosteris virusis SesaZlo

transmisiis prevenciis mizniT.

4.2.8. yviTeli cxelebis vaqcina

yviTeli cxelebis vaqcinis virusi Teoriulad warmoadgens encefalitis

ganviTarebis risk-faqtors aiv inficirebul pirebSi, ris gamoc is

aRniSnul kategoriaSi ar gamoiyeneba. yviTeli cxeleba endemuri

daavadebaa ekvatoruli afrikis 33 da samxreT amerikis 11 qveyanaSi.

aRniSnul teriatoriaze mogzaurobisas mkurnalma eqimma pacients unda

miawodos informacia arsebuli riskisa da moskitebisagan Tavdacvis

meTodebis Sesaxeb. zogierTi klinika pirovnebis CD4+ ujredebis ricxvis

gaTvaliswinebiT iRebs vaqcinaciis gadawyvetilebas.

Tu aiv inficirebuli piri ver aridebs Tavs yviTeli cxelebis virusTan

potenciur eqspozicias mas unda SevTavazoT vaqcinacia. saWiroa

vaqcinaciasTan dakavSirebuli SesaZlo gverdiTi reaqciebis monitoringi.

ramdenadac aiv negatiur pirebTan SedarebiT aiv pozitiur adamianebSi

vaqcinacia SesaZloa iyos naklebad efeqturi, sasurvelia

maneitralizebeli antisxeulebis titris gansazRvra endemur keraSi

mogzaurobamde. yviTeli cxelebis sawinaaRmdego vaqcinacia unda

CautardeT imunosupresirebuli pirebis ojaxis wevrebsac, Tu maT ar

aReniSnebaT winaaRmdegCvenebebi.

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rekomendacia

yviTeli cxelebis vaqcina ar unda iqnas gamoyenebuli aiv

inficirebulebSi, rogorc bavSvebSi, aseve zrdasrulebSi,

imunodeficitis statusis miuxedavad, garda im SemTxvevebisa,

rodesac mosalodneli dadebiTi Sedegi aWarbebs arsebul risks

(DIV).

4.3. daxocili da inaqtivirebuli vaqcinebi

daxocili da inaqtivirebuli vaqcinebi ar warmoadgens safrTxes

imunokompromitirebuli pirebisaTvis da, ZiriTadad, gamoiyeneba iseve,

rogorc janmrTel populaciaSi. xSirad imunokompromitirebul

pacientebSi daxocili da inaqtivirebuli vaqcinis antigenis Sesabamisi

imunuri pasuxi imunokompetentur pirebTan SedarebiT naklebad

srulyofilia; SesaZloa saWiro gaxdes vaqcinaciis maRali doza an

xSiri bustireba, Tumca aRniSnuli modifikaciebis SemTxvevaSic

SesaZloa imunuri pasuxi optimalurze susti iyos (DIV).

4.3.1. qoleris vaqcina (WC/rBs)

Zveli parenteraluri vaqcina (fenoliT inaqtivirebuli daxocili

srulujredovani qoleris vibrioni 01) dabali efeqturobisa da

xanmokle dacviTi periodis gamo rekomendebuli ar aris, Tumca zogierT

qveyanaSi mainc iwarmoeba.

daxocili srulujredovani qoleris vibrionisa da qoleris toqsinis

rekombinantuli B fraqciis kombinaciis Semcveli vaqcina (WC/rBs) usafrTxoa orsulobisa da ZuZuTi kvebis periodSic, aseve aiv pozitiur

pirebSic.

oraluri vaqcinis 2 doza 10-14 dRis SualediT ainducirebs sawyis

proteqcias vaqcinirebulTa 86%-Si. saSualod vaqcinacia efeqturia 50-

60%-Si sul mcire 3 wlis ganmavlobaSi.

aiv pozitiur pirebSi kombinirebuli vaqcinis (WC/rBs) efeqturobis

damadasturebeli specifikuri monacemebi dRemde cnobili ar iyo, Tumca

im populaciis magaliTze, romlis 25%-s aiv pozitiuri pirebi

warmoadgendnen, mozambikSi Catarebulma uaxlesma kvlevam gamoavlina

damaimedebeli Sedegebi. imunitetis xangrZlivoba aiv inficirebulebSi

cnobili ar aris. aiv inficirebul mozrdilebSi 100mm3-ze naklebi CD4+ ujredebis ricxviT imunizaciis Semdgomi pasuxi SesaZloa iyos susti,

xolo im pirebSi, romelTa CD4+ ujredebis ricxvi 100mm3-ze metia

imunuri pasuxi umjobesdeba ori dozis Semdeg. aRniSnuli monacemebi

gviCvenebs vaqcinaciis efeqturobas adreuli an Sualeduri aiv

daavadebisas (DIV).

vaqcinacia seleqtiurad unda CautardeT im aiv inficirebulebs,

romelTac uwevT mogzauroba endemur kerebSi an miekuTvnebian erT-erT

risk-jgufs (isini vinc xangrZlivi periodiT mogzauroben, iReben

Seumowmebel wyals an arasaTanadod momzadebul sakvebs an cxovroben

arasanitarul pirobebSi daavadebis endemur keraSi) (DIV).

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4.3..2 difTeriis, tetanusisa da yivanaxvelas vaqcinebi (DTP, DTaP, DT, TT, Td9)

aiv inficirebul bavSvebSi imunuri statusis miuxedavad DTP da DT vaqcinebi rekomendebulia janmrTeli populaciisaTvis gankuTvnili

reJimiT, maT Soris yivanaxvelas araujreduli formis (DTaP) gamoyenebis SemTxvevaSic rogorc bustirebis, aseve pirveli dozirebisaTvis (AI).

TT da Td vaqcinebi imunuri statusis miuxedavad SesaZloa gamoyenebul

iqnas aiv inficirebul mozrdilebSi janmrTeli populaciisaTvis

gankuTvnili reJimiTa da dozirebiT (BII). gansakuTrebuli mniSvneloba

unda mieniWos narkotikebis ineqciuri gziT momxmarebelTa vaqcinacias

TT da Td vaqcinebiT, raTa nemsebis gacvlis programebis ararsebobis

SemTxvevaSi SevZloT tetanusis prevencia.

4.3.3. B tipis hemofilus influencas vaqcina (HiB)

5 wlis asakis zeviT bavSvebs daavadebisadmi asakobrivad ganpirobebuli

mgrZnobelobis gaTvaliswinebiT HiB vaqcinacia ar esaWiroebaT. zogierT

adamianSi gamomwvevi iwvevs invaziur infeqcias. mikroorganizmis sisxlis

nakadSi moxvedris zusti gza ucnobia, Tumca ganmsazRvreli faqtori

SeiZleba iyos zemo sasunTqi gzebis winmswrebi virusuli an

mikoplazmuri infeqcia. sisxlis nakadis gziT baqteria gadainacvlebs

sxeulis sxvadasxva nawilebisaken, ZiriTadad ki tvinis garsebisaken. aiv

inficirebuli bavSvebi da mozrdilebi imunosupresiis gamowarmoadgenen

HiB daavadebis ganviTarebis maRal risk-jgufs da SesaZloa CautardeT

vaqcinacia. 5 wlis asakis zeviT aiv inficirebulebma, romlebic

imyofebian HiB daavadebis ganviTarebis riskis qveS, unda miiRon vaqcinis

sul mcire erTi doza. imunokompromitirebuli bavSvebis vaqcinacia unda

Catardes janmrTeli populaciisaTvis gankuTvnili dozirebiTa da

reJimiT.

TiToeuli pacientis magaliTze individualurad unda Sefasdes

daavadebis ganviTarebis riski da vaqcinaciis mosalodneli efeqturoba,

ris mixedviTac gadawydeba imunizaciis sakiTxi. zogierTi monacemis

mixedviT aiv negatiur pirebTan SedarebiT aiv inficirebulebSi HiB daavadebis ganviTarebis riski ufro maRalia.

4.3.4. A hepatitis vaqcina

A hepatitis virusiT gamowveuli simptomuri daavadebis ganviTarebis

riski pirdapir korelaciaSia asakTan. 6 wlamde asakis bavSvebSi A hepatitis virusiT infeqcia Cveulebriv asimptomuria, simptomuri

daavadeba ki ZiriTadad gvxvdeba mozrdilebSi. daavadebis gadatanis

Semdeg imuniteti mTeli sicocxlis manZilze narCundeba. dabal-endemur

kerebSi A hepatiti erTeuli an mcire jgufuri SemTxvevebis saxiT

gvxvdeba. maRal-endemur kerebSi daavadeba ZiriTadad gvxvdeba

asimptomuri formiT bavSvTa asakSi. dabali an saSualo donis endemur

9 DTP: difTeriisa da tetanusis anatoqsini da yivanaxvelas vaqcina; DTaP: difTeriisa

da tetanusis anatoqsini da yivanaxvelas araujreduli vaqcina; DT:difTeriisa da

tetanusis anatoqsini (pediatriuli gamoyenebisaTvis); TT: tetanusis anatoqsini; Td: tetanusisa da difTeriis anatoqsini (mozrdilebisaTvis).

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areebSi mozrdilTa daavadeba SedarebiT xSiria da A hepatiti SesaZloa

warmoadgendes samedicino da ekonomikur tvirTs.

A hepatitis vaqcinacia (erTjeradi doza 6-12 Tvis Semdgomi bustirebiT)

mkacrad rekomendebulia aRniSnuli daavadebis an misi garTulebebis

ganviTarebis riskis mqone pirebSi miuxedavad imunuri da aiv statusisa

(AI). risk-jgufs miekuTvnebian:

• pirebi RviZlis qronikuli daavadebiT;10

• homoseqsuali mamakacebi (MSM); • narkotikebis momxmareblebi;11

• Sededebis faqtorTan dakavSirebuli darRvevebis mqone pirebi;

• daavadebis profesiuli riskis mqone pirebi (mag: laboratoriis

muSakebi);

• 1 wlis an ufrosi asakis pirebi araendemuri qveynebidan, romlebic

gegmaven mogzaurobas A hepatitis virusiT gamowveuli infeqciis

maRali an saSualo endemurobis keraSi12.

A hepatitis vaqcina gamoirCeva maRali imunogenurobiT. mozrdilTa 95%-

ze mets pirveli vaqcinaciidan 4 kviraSi ganuviTardeba proteqtoruli

antisxeulebi. rac Seexeba bavSvebsa da mozardebs, pirveli vaqcinaciidan

1 TveSi seropozitiuri aRmoCndeba 97%-ze meti. klinikur kvlevebSi

vaqcinaciis ori dozis yvela recipients ganesazRvra antisxeulebis

proteqtoruli done. aRniSnulis gamo, vaqcinaciis Semdgomi testireba

naCvenebi ar aris. A hepatitis virusis sawinaaRmdego antisxeulebis

dabali koncentraciis ganmsazRvreli testirebis meTodebi rutinuli

diagnostikisaTvis vaqcinaciis Semdgom periodSi rekomendebuli ar aris

(AI). monacemebi antisxeulebis persistenciisa da imunuri mexsierebis

xangrZlivobis Sesaxeb mcirea, ramdenadac dReisaTvis xelmisawvdom

vaqcinebze dakvirveba warmoebs 12 welze naklebi periodis ganmavlobaSi.

busteruli dozis damatebis saWiroebas gansazRvravs Semdgomi kvlevebi.

4.3.5. B hepatitis vaqcina

B hepatitis vaqcina rekomendebulia B virusiT gamowveuli infeqciis

maRali riskis mozrdilebisTvis miuxedavad imunuri da aiv statusisa

(AI).

10 RviZlis qronikuli daavadebis mqone pirebi inficirebis SemTxvevaSi arian

fulminanturi A hepatitis ganviTarebis gazrdili riskis qveS. aiv inficirebul pirebs

Tanmxlebi qronikuli hepatitiT B an C, unda CautardeT vaqcinacia A hepatitis vaqciniT. 11 A hepatitis virusi daavadebis sawyis stadiaze aRmoCndeba avadmyofis sisxlSi da

iSviaTad transmisia SesaZloa moxdes transfuziis gziT; virusi advilad vrceldeba

antisanitariisa da personaluri higienis dabali donis pirobebSi, rac xSirad

aRiniSneba narkotikebis momxmarebelTa Soris. 12 vaqcinacia unda Catardes gamgzavrebamde 2-4 kviriT adre. maRali an saSualo

endemurobis keras miekuTvneba msoflios yvela qveyana garda kanadis, aSS-s, dasavleT

evropisa, skandinaviis, iaponiis, axali zelandiis da avstraliisa.

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maRali riskis jgufebia:

• homoseqsuali mamakacebi (MSM);

• mravlobiTi heteroseqsualuri sqesobrivi kontaqtebis mqone pirebi;

• sqesobrivi gziT gadamdebi infeqciebiT daavadebuli pacientebi;

• komerciuli seqs-muSakebi;

• B hepatitis virusis mtarebelTa sqesobrivi partniorebi da ojaxis

wevrebi;

• narkotikebis ineqciuri gziT momxmareblebi; • patimrebi _ rogorc mamakacebi, aseve qalebi; • hemodializze myofi pirebi (miuxedavad imisa, rom B hepatitis vaqcina

aRniSnul kategoriaSi naklebad efeqturia, is mainc rekomendebulia);

• jandacvis muSakebi.13

B hepatitis vaqcina rekomendebulia yvela axalSobilisTvis

dabadebisTanave da 18 wlamde asakis bavSvebSi, miuxedavad imunuri da aiv

statusisa (AI). miuxedavad imisa iTvaliswinebs Tu ara vaqcinaciis reJimi

erT Tvemde asakis bavSvTa vaqcinacias, maTi efeqturoba erTnairia.

aiv inficirebul bavSvebSi vaqcinaciis Semdgomi proteqciis

xangrZlivoba cnobili ar aris, rac Seexeba arainficirebul bavSvebs,

dadgenilia, rom vaqcinaciiT ganpirobebuli antisxeulebis done droTa

ganmavlobaSi mcirdeba, Tumca bavSvebSic da mozrdilebSic imunuri

mexsiereba srulyofilad narCundeba vaqcinaciidan 15 wlis manZilze.

normaluri imunuri sistemis mqone bavSvebsa da mozrdilebs ar

esaWiroebaT damatebiTi dozebi bustirebisaTvis, arc rutinuli

serologiuri testirebaa naCvenebi. gamonaklisia bavSvebi, romelTa

dedebic HBsAg pozitiurebi arian. isini gamokvleul unda iqnen HBsAg-sa da mis sawinaaRmdego antisxeulebze vaqcinaciis mesame dozis Semdeg. Tu

zedapiruli antisxeulebis titri 10mIU/ml-ze naklebia, naCvenebia

vaqcinaciis sruli kursis gameoreba. aRniSnul kategoriaSi pasiurad

gadmocemuli dediseuli core antisxeulebi SeiZleba ganisazRvros 24

Tveze maRal asakSic, ris gamoc aRniSnuli testireba ukunaCvenebia.

SesaZlebelia xangrZlivi periodis Semdeg saWiro gaxdes damatebiTi

dozebis gamoyeneba bustirebisaTvis (BII).14

4.3.5.1. B hepatitis vaqcinaciis reJimi aiv inficirebul pacientebSi (AI)

aiv inficirebuli pacientebs, romelTac ar aReniSnebaT HBV infeqciis

markerebi an arian HBsAg negatiurebi,unda CautardeT vaqcinacia.

• B hepatitis vaqcinacia unda daiwyos gansazRvruli doziT (20µg 0, 1, 2 da 12 Tveze an 0, 1 da 6 Tveze) im pacientebisaTvis, romelTa CD4+ limfocitebis ricxvi >500/mm3.

• B hepatitis vaqcinis pediatriuli dozaa 10µg.

13 riski maRalia staJirebis periodSi; vaqcinacia unda Catardes staJirebaze myofi

medicinis, stomatologiis, saeqTno saqmis, laboratoriuli teqnologiebisa da

jandacvis sxva profesiebis dargSi. 14 hemodializze myof pacientebSi yovelwliurad unda ganisazRvros antisxeulebis

titri, ris mixedviTac Sefasdeba vaqcinaciis damatebiTi dozis saWiroeba

bustirebisaTvis; damatebiTi doza saWiroa, Tu antisxeulebis titri < 10 mIU/ml.

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• pacientebisaTvis 200-500/mm3 CD4+ ujredebis ricxviT rekomendebulia

intensiuri reJimi (20µg 0, 1, 2 da 12 Tveze).

• armopasuxe pacientebSi rekomendebulia damatebiTi dozebi

bustirebisaTvis an vaqcinaciis axali kursi 40µg doziT. • pacientebs 200/mm3-ze naklebi CD4+ limfocitebis ricxviT jer unda

daewyoT arv mkurnaloba; vaqcinacia unda gadavdoT klinikurad

SesamCnevi imunuri rekonstituciis miRwevamde, sasurvelia CD4 ujredebis 200/mm3-ze metad momatebamde (BII).

4.3.5.2. imunologiuri pasuxi B hepatitis vaqcinaciis mimarT

• pasuxi vaqcinaze damokidebulia vaqcinaciis periodSi CD4+ ujredebis

ricxvze; pasuxi SeiZleba daqveiTdes pacientebSi CD4+ ujredebis

500mm3-ze naklebi ricxviT.

• B hepatitis vaqcinaciis sruli kursis Catarebisas imunologiuri

pasuxis albaToba aiv inficirebul pacientebSi 500/mm3-ze maRali CD4+

ujredebis ricxviT 87%-ia, xolo 200-500mm3 CD4+ ujredebis ricxviT _

mxolod 33%.

• C hepatitisa da adamianis imunodeficitis virusebiT koinfeqciam

SesaZloa gamoiwvios B hepatitis vaqcinaciis Semdgomi imunologiuri

pasuxis daqveiTeba, aseve B virusis zedapiruli antigenis

sawinaaRmdego antisxeulebis titris Semcireba aiv monoinfeqciiT

pacientebTan SedarebiT.

4.3.5.3. aiv inficirebul pacientTa B hepatitis vaqcinaciis Semdgomi monitoringi da strategia

• B virusis zedapiruli antigenis sawinaaRmdego antisxeulebis titri

unda ganisazRvros vaqcinaciis damTavrebidan 4 kviraSi.

proteqtoruli antisxeulebis ganuviTareblobis SemTxvevaSi

(HBsas<10mIU/ml) unda Catardes damatebiTi vaqcinacia bustirebisaTvis

an revaqcinacia (1-3 damatebiTi doza). Tumca maRali dozebiT

vaqcinaciis imunogenuroba cnobili ar aris da dozirebis Sesaxeb

myari rekomendaciebis gacema am etapze SeuZlebelia.

• vaqcinaciaze armopasuxe pirebi rCebian hepatitis virusiT inficirebis

riskis qveS da maT yovelwliurad unda CautardeT gamokvleva

aRniSnuli infeqciis serologiur markerebze (HBsAg da HBcTotal). • pirebi, romelTac vaqcinaciis 6 dozis Semdeg ar ganuviTardaT anti-HBs

antisxeulebis deteqtabeluri titri, gamokvleul unda iqnen HBsAg -ze.

• HBsAg pozitiur pirebs unda CautardeT konsultacia.

• vaqcinaciaze armopasuxe HBsAg negatiur pirebi ganixileba B hepatitis virusiT infeqciis mimarT mgrZnobiare jgufad da isini

konsultirebuli unda iqnen prevenciuli RonisZiebebisa da

parenteraluri Tu sqesobrivi eqspoziciis SemTxvevaSi B hepatitis

sawinaaRmdego imunoglobuliniT (HBIg) profilaqtikis Sesaxeb.

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4.4. gripis vaqcina15

gripi SeiZleba gaxdes seriozuli avadmyofobisa da garTulebebis

mizezi imunokompromitirebul pirebSi. aseTi pirebis did nawilSi

vaqcinacia uzrunvelyofs proteqtoruli antisxeulebis gamomuSavebas.

miuxedavad imisa, rom aiv infeqcia/SidsiT daavadebulebSi informacia

gripiT avadobis sixSirisa da simZimis Sesaxeb dReisaTvis mwiria, gripis

sezonis dawyebis win rekomendebulia yvela aiv inficirebulis

vaqcinacia. vaqcinaciis sapasuxo antisxeulebis titri aiv infeqciis

Sorswasul stadiaze SeiZleba iyos dabali, Tumca imunuri pasuxis

gasaZliereblad damatebiTi dozis efeqturoba dadgenili ar aris (CIII).

4.5. meningokokuri vaqcina

gansazRvruli serotipebis16 Semcveli meningokokuri vaqciniT rutinuli

imunizacia rekomendebulia meningokokuri daavadebis epidemiis arealSi

wamsvlelTaTvis aiv statusis miuxedavad, aseve risk-jgufebisaTvis,

magaliTad pirebisaTvis anatomiuri an funqciuri aspleniiT (AI).

4.6. pnevmokokuri vaqcina

pnevmokokuri vaqcina rekomendebulia iseTi qronikuli daavadebis mqone

pirebSi, romlebic asocirebulia pnevmokokuri daavadebis an misi

garTulebebis gazrdil riskTan (BII). aseTi qronikuli daavadebebia

imunosupresiasTan asocirebuli mdgomareobebi, maT Soris aiv infeqcia.

arsebobs pnevmokokuri vaqcinis ori tipi: polisaqariduli pnevmokokuri

vaqcina (ppv) da SekavSirebuli pnevmokokuri vaqcina (Spv).

4.6.1. polisaqariduli pnevmokokuri vaqcina (ppv)

ppv-s erTi doza gamoyenebul unda iqnas rutinulad 65 wlis asakis

zeviT pirebSi imunuri da aiv statusis miuxedavad (AI); 2 wlis asakis

zeviT17 qronikuli daavadebis mqone (kardiovaskularuli daavadeba,

filtvis paTologia, diabeti, alkoholizmi, cirozi, cerebrospinaluri

siTxis siWarbe) imunokompetentur pirebSi; 2 wlis asakis zeviT

imunokomprometirebul (maT Soris aiv infeqcia/SidsiT daavadebulebi)18

pirebSi, romlebic imyofebian pnevmokokuri daavadebis ganviTarebis ris-

15 mas Semdeg, rac gripis cocxali vaqcina aiv infeqcia/SidsiT daavadebulebSi

ukunaCvenebia, aRniSnul kategoriaSi gamoiyeneba gripis inaqtivirebuli vaqcina

16 meningokokuri vaqcina unda moicavdes Sesabamis geografiul arealSi daavadebis

epidemiis gamomwvev serotipebs. meningokokuri serojgufebi A, B da C aRmoCenila mTel

msoflioSi; serojgufi Y aRmoCenilia aSS-is zogierT nawilSi; serojgufi A dafiqsirebulia “meningitis sartyelSi” senegalidan eTiopiamde; serojgufi W125

nanaxia saudis arabeTSi. 17 2 wlamde asakis bavSvebSi ppv-s umetesi serotipebis sapasuxo antisxeulebis titri

dabalia. 18 aiv infeqcia/SidsiT daavadebulebTa garda pirebi anatomiuri an funqciuri

aspleniiT (romelime daavadebis arsebobisas an qirurgiuli gziT mocilebisas),

hojkinis daavadebiT, limfomiT, mravlobiTi mielomiT, Tirkmlis qronikuli

ukmarisobiT, an imunosupresiasTan asocirebuli sxva mdgomareobiT (mag.: organos

transplantaciisas).

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kis qveS. pacientebs simptomuri an asimptomuri aiv infeqciiT vaqcinacia

unda CautardeT diagnozis dadasturebisTanave. Tu aiv inficirebuli an

zogadad imunosupresirebuli (magaliTad, kortikosteroidebis xangrZivi

kursis recipientebi) piris vaqcinaciis statusi ucnobia, aseT

SemTxvevaSi vaqcinacia tardeba (BII).

janmrTel mozrdilTa 80%-ze mets ppv-s miRebidan 2-3 kviraSi

ganuviTardeba antisxeulebi vaqcinis serotipebis mimarT. antisxeulebis

maRali titri janmrTel mozrdilebSi narCundeba sul mcire 5 wlis

ganmavlobaSi, xolo SedarebiT ufro swrafad qveiTdeba fonuri

daavadebebis mqone, maT Soris aiv inficirebul pirebSi.

65 wlamde asakis imunokompetenturi pirebis rutinuli revaqcinacia

rekomendebuli araa.

65 wlis pirebsa da ufro xandazmulebs ganmeorebiTi doza unda mieceT

im SemTxvevaSi, Tu pirveli dozis gamoyenebidan gasulia 5 weliwadze

meti da im periodisTvis maTi asaki iyo 65 welze naklebi. aiv

infeqcia/SidsiT daavadebulebsa da sxva imunokompromitirebul pirebs,

romlebic miekuTvnebian maRali riskis jgufs ganmeorebiTi vaqcinacia

unda CautardeT 5 wlis Semdeg.

revaqcinacia aseve rekomendebulia 2 wlisa da Semdgomi asakis bavSvebSi,

romlebic imyofebian infeqciis ganviTarebis maRali riskis qveS; aseve im

pirebSi, romlebSic fonuri daavadebis gamo mosalodnelia pnevmokokuri

antisxeulebis titris swrafi Semcireba. revaqcinacia unda Catardes

pirveli dozis gamoyenebidan 3-5 wlis Semdeg.

4.6.2. SekavSirebuli pnevmokokuri vaqcina (Spv)

Spv imunogenuria Cvilebsa da bavSvebSi, maT Soris aiv inficirebulebSi

imunuri statusis miuxedavad. Spv-s oTxi dozis Semdeg yvela janmrTel

axalSobils uviTardeba vaqcinis TiToeuli serotipis sawinaaRmdego

antisxeulebi (AI).19

• vaqcinacia rutinulad tardeba 2, 4 da 6 Tvis asakSi, damatebiTi doza

bustirebisaTvis rekomendebulia 12-15 Tvis asakSi.

• aravaqcinirebul 7-11 Tvis asakis bavSvebs, maT Soris aiv

inficirebulebs, Spv-s pirveli ori doza unda mieceT 6-8 kviris

intervaliT, damatebiTi doza bustirebisaTvis rekomendebulia 12-15

Tvis asakSi.

• aravaqcinirebul 12-23 Tvis asakis bavSvebs unda mieceT Spv-s ori doza

6-8 kviris intervaliT.

• aravaqcinirebul 24-59 Tvis asakis janmrTel bavSvebs unda mieceT Spv-s

erTjeradi doza.

• 24-59 Tvis asakis bavSvebs aiv infeqciiT, namglisebrujredovani anemiiT,

aspleniiT, qronikuli daavadebebiTa da imunomakompromitirebuli

mdgomareobebiT unda mieceT Spv-s ori doza 6-8 kviris intervaliT.

efeqtis bustirebisTvis rekomendebulia Spv-s damatebiTi doza meore

vaqcinaciidan 6-8 kviris Semdeg.

19 dReisaTvis aiv infeqcia/SidsiT daavadebulebSi Spv-s gamoyenebis Sesaxeb monacemebi

mcirea, Catarebulia kvlevebi mxolod samxreT afrikaSi, aseve mcire gamokvlevebi aSS-

Si.

121

• rutinuli Spv vaqcinacia 5 wlis asakis zeviT bavSvebSi rekomendebuli

araa aiv statusis miuxedavad.

Spv-s pirveladi kursis Semdeg revaqcinacia dReisaTvis rekomendebuli

araa. Tumca 2 wlisa da Semdgomi asakis bavSvebSi, Spv-s pirveladi

kursis bolo vaqcinaciidan 6-8 kviris Semdeg rekomendebulia damatebiTi

doza efeqtis bustirebisTvis.

4.7. inaqtivirebuli poliovirusis vaqcina (ipv)

Tu polioimunizacia naCvenebia, ipv gamoyenebul unda iqnas aiv

inficirebul Cvilebsa da bavSvebSi imunuri statusis miuxedavad, aseve

momvlel personalsa da ojaxis im wevrebSi, romlebic mWidro kontaqtSi

arian aiv inficirebul/SidsiT daavadebulebTan, raTa moxdes vaccine an vaccine-derived poliovirusis transmisiis prevencia am ukanasknelebSi (AI). aravaqcinirebuli aiv inficirebuli mozrdilebisaTvis, romelTac

aReniSnebaT poliovirusTan eqspoziciis maRali riski, rekomendebulia

ipv-s pirveladi kursi.

4.8. cofis vaqcina

gamoiyeneba cofis sawinaaRmdego ori tipis vaqcina: nervuli qsovilis

vaqcina (Semple-type) da axali ujredidan miRebuli vaqcina (modern cell-derived vaccine). cofis sawinaaRmdego vaqcinebi gamoiyeneba eqspoziciis

Semdgomi proteqciisa da eqspoziciamde imunogenurobisaTvis. cofis

sawinaaRmdego vaqcinebi ar aris ukunaCvenebi aiv inficirebulTaTvis da

saWiroebisas unda gamoviyenoT (AI).

imunokompromitirebul aiv inficirebulebSi SesaZloa ar ganviTardes

efeqturi imunologiuri pasuxi, ramdenadac imuniteti damokidebulia

CD4+ ujredebiT ganpirobebuli maneitralizebeli antisxeulebis titrze

G proteinis mimarT. amrigad, rodesac imunokompromitirebul aiv

inficirebuls utardeba eqspoziciis Semdgomi mkurnaloba,

savaldebuloa intramuskularuli vaqcinisa da cofis sawinaaRmdego

imunoglobulinis gamoyeneba sapasuxo antisxeulebis serologiuri

monitoringiT.

proteqciisaTvis saWiroa cofis sawinaaRmdego antisxeulebis titri

>0.5IU/ml. Tu cofis sawinaaRmdego vaqcinis 4-5 dozis gamoyenebis Semdeg

maneitralizebeli antisxeulebis titri<0.5IU/ml-ze, 4 kviris Semdeg

rekomendebulia damatebiTi dozebis gamoyeneba (AI).

4.9. tkipismieri encefalitis vaqcina

tkipismieri encefalitis virusiT gamowveuli infeqcia gvxvdeba evropis

did nawilSi (avstria, germania, samxreT da centaluri SvedeTi, ungreTi,

safrangeTi, Sveicaria, norvegia, dania, poloneTi, xorvatia, albaneTi,

estoneTi, latvia, litva, CexeTi, slovakeTi, ruseTi). daavadeba cnobilia

ramdenime saxeliT, rogoricaa rusuli gazafxul-zafxulis encefaliti

(RSSE), Soreuli aRmosavleTis encefaliti da centaluri evropis

encefaliti (CEE).

122

aRniSnul qveynebSi mogzaurobisas inficirebis riski dabalia.

inficireba ZiriTadad dakavSirebulia iseT aqtivobebTan, rogoricaa

soflis meurneoba da metyeveoba, seirnoba da nadiroba endemuri

regionebis Tbil da tyian arealSi. inficirebis maRali riski aqvT

metyeveebs, xis mWrelebs, fermerebs, meomrebs, laboratoriis muSakebsa

da turistebs, romelTac uwevT nadiroba, aseve savele pirobebSi muSaoba

da cxovreba.

preeqspoziciuri profilaqtika SesaZlebelia inaqtivirebuli vaqciniT.

vaqcinaciis standartuli reJimi moicavs or dozas 4-12 kviris

intervaliT da mesame dozas 9-12 Tvis Semdeg. imunokompetentur pirebSi

serokonversiis sixSire 3 dozis Semdeg 85-100%-ia. riskis qveS myofi

pirebisaTvis rekomendebulia bustireba yovel 3 weliwadSi. swrafi

reJimebi20 janmrTel pirebSi xasiaTdeba imave efeqturobiT da

praqtikulia mogzaurebisTvis (AI). swrafi reJimis vaqcinaciis

efeqturoba aiv inficirebulebSi ucnobia.

aiv inficirebulebSi vaqcinaciis imunogenurobis Sesaswavlad

Catarebulia mxolod ori kvleva. aRniSnuli kvlevebi gviCvenebs, rom

vaqcina janmrTel pirebTan SedarebiT aiv inficirebulebSi, ZiriTadad ki

im pirebSi, romelTa CD4+ ujredebis ricxvi 500/mm3-ze mcirea, naklebad

efeqturia. Tumca 4 dozis Semcvelma vaqcinaciam 0, 1, 2 da 9-12 Tveze

SeiZleba gaaumjobesos imunuri pasuxi aiv inficirebulebSi. amave dros

unda aRiniSnos, rom zemoTaRwerili strategiis Sesaxeb informacia

mcirea (CIII).

imunizacia unda CautardeT aiv inficirebulebs, romlebic gegmaven

endemuri regionis qveynebis tyian arealSi mogzaurobasa an muSaobas

gvian gazafxulze an zafxulSi, rodesac tkipebi gansakuTrebiT

aqtiuria. vaqcina aseve rekomendebulia im emigrantebisaTvis, romelTac

cxovreba uwevT tkipismieri encefalitis endemur arealSi.

aiv inficirebulebSi, romelTa CD4+ ujredebis ricxvi 400/mm3-ze metia

vaqcinacia SeiZleba CautardeT standartuli an swrafi reJimiT. aiv

inficirebulebs, romelTa CD4+ ujredebis ricxvi 400/mm3-ze naklebia

vaqcinaciis meore dozidan erT TveSi sasurvelia CautardeT

serologiuri testireba. araadeqvaturi imunuri pasuxis SemTxvevaSi pirs

unda mieces vaqcinis ori damatebiTi doza, pirveli-dauyovnebeli, xolo

meore - 9-12 Tvis Semdeg. Tu serologiuri testireba araxelmisawvdomia

vaqcinacias vatarebT 4 dozis Semcveli reJimiT (0, 1, 2 da 9-12 Tveze).

imunokompromitirebul aiv inficirebulebSi vaqvinaciis Semdgomi

imunuri pasuxis daqveiTebis albaTobis gamo aucilebelia dacviTi

RonisZiebebis mniSvnelobis xazgasma. busteruli rekomendaciebi aiv

inficirebuli da imunokompetenturi pirebisaTvis erTnairia.

20 FSME: pirveladi kursis saxiT gamoiyeneba 2 doza 14 dRis intervaliT, xolo mesame

doza 9-12 Tvis Semdeg; Encepur: sami doza 0, 7 da 21 dReze pirveladi kursis saxiT,

meoTxe doza 12-18 Tvis Semdeg.

123

4.10. tifis vaqcina (Vi polisaqaridi)

dabali efeqturobisa da gverdiTi reaqciebis sixSiris gamo Zveli

inaqtivirebuli vaqcina rekomendebuli ar aris, Tumca ekonomikur

mizezTa gamo zogierT qveyanaSi is mainc iwarmoeba.

parenteruli daxocili vaqcina, romelic Seicavs Vi polisaqarids

kanqveS an kunTSi erTjeradi dozirebisas zomierad efeqturia (50-80%).

vaqcina ineqciidan 7 dReSi uzrunvelyofs proteqcias, romelic

narCundeba sul mcire ori weli. riskis qveS myofi pirebisTvis

rekomendebulia bustireba yovel sam weliwadSi.

aiv inficirebul pirebs salmonelas StamiT inficirebis maRali riski

aqvT. garda amisa imunodeficiti ganapirobebs baqteriemias

antibiotikebis mimarT rezistentobas, daavadebis relafss da persistul

infeqcias. miuxedavad imisa, rom zogadad saerTaSoriso mogzaurobisas

saWiro ar aris, Vi polisaqaridis Semcveli vaqcina rekomendebulia

yvela aiv inficirebulisaTvis, romelic gegmavs mogzaurobas

eqspoziciis maRali riskis arealSi. mosalodnel eqspoziciamde sul

mcire ori kviriT adre unda Catardes erTjeradi vaqcinacia. tifis

vaqcina ar uzrunvelyofs proteqcias 100%-Si da pasuxi SiZleba kidev

ufro Semcirdes aiv infeqcia/SidsiT daavadebulebSi. zogadad bustireba

rekomendebulia yovel sam weliwadSi. maTTvis ki, romelTa CD4+

ujredebis ricxvi 200/mm3-ze naklebia. es intervali SeiZleba Semcirdes

or wlamde. mogzaurebs unda mieceT rekomendaciebi sakvebTan da

sasmelTan dakavSirebuli akrZalvebis Sesaxeb.

4.11. sxva daxocili antigenebi

daxocili antigenebis Semcveli sxva vaqcinebi, rogoricaa iaponuri

encefalitis, Savi Wirisa da jilexis vaqcinebi ar warmoadgens safrTxes

aiv /SidsiT daavadebulTTavis, miuxedavad maTi imunologiuri statusisa.

es vaqcinebi gamoiyeneba iseve, rogorc ara aiv inficirebul pirebSi.

4.12. imunoglobulinebis gamoyeneba

4.12.1. B hepatitis imunoglobulini (HBIg) imunokompromitirebul pirebSi, maT Soris aiv infeqcia/SidsiT

daavadebulebSi, B hepatitis imunoglobulini gamoiyeneba igive

CvenebebiTa da doziT, rogorc imunokompetentur adamianebSi (AI). B hepatitis imunoglobuliniT eqspoziciis Semdgomma profilaqtikam

SeiZleba ganapirobos droebiTi imunitetis ganviTareba. B hepatitis

imunoglobulini gamoiyeneba pasiuri imunizaciisTvis:

• HBsAg pozitiuri dedebis axalSobilebSi; • pirebSi, romelTac aReniSnaT HBsAg pozitiur sisxlTan an sxeulis

sxva siTxesTan kanismieri, lorwovanismieri an sqesobrivi eqspozicia; • pacientebSi RviZlis transplantaciiT.

rogorc wesi B hepatitis imunoglobulini gamoiyeneba B hepatitis

vaqcinasTan kombinaciaSi. nebismieri piri, romelsac esaWiroeba B hepatitis imunoglobulini miekuTvneba maRali riskis jgufs, rac imas

124

niSnavs, rom mas unda Cautardes B hepatitis vaqcinis kursi. B hepatitis imunoglobulini naCvenebia:

• axalSobilebSi, romelTaA dedebic HBsAg pozitiurni an ucnobi HBsAg statusis arian; B hepatitis imunoglobulini21, aseve, SeiZleba

gamoviyenoT B hepatitis vaqciniT imunoprofilaqtikisas

dabadebisTanave an dabadebidan mcire periodSi.

• HBsAg pozitiur dedaTa axalSobilebSi, sasurvelia pirveli 12 saaTis

ganmavlobaSi; amasTanave, B hepatitis imunoglobulinisa da vaqcinis

ineqciis wertilebi ar unda emTxveodes erTmaneTs.

• B hepatitis vaqcinaze armopasuxe HBsAg negatiur pirebSi; aRniSnuli

kategoria konsultirebul unda iqnas HBV infeqciis prevenciisa da B hepatitis imunoglobulinis saWiroebis Sesaxeb HBsAg pozitiur

sisxlTan parenteraluri eqspoziciisas.

• savaraudo sqesobrivi kontaqti mwvave B hepatitiT daavadebul

pacientTan ukanaskneli sqesobrivi kontaqtidan 14 dRis ganmavlobaSi22.

• aravaqcinirebul axalSobilebSi, romelTa dedebs an momvlel pirebs

aqvT mwvave HBV infeqcia, aseT SemTxvevaSi axalSobils unda mieces B hepatitis vaqcinaciis kursis pirveli dozac23.

• pirebSi, romelTac aqvT mWidro kontaqti mwvave HBV infeqciiT

pacientTan, an aReniSnaT eqspozicia inficirebuli adamianis sisxlTan

(mag. makratlis, saparsis an sxva gziT), aseT SemTxvevaSi unda mieces B hepatitis vaqcinaciis kursis pirveli dozac24.

4.12.2. adamianis normaluri imunoglobulini

4.12.2.1. hepatiti A

A hepatitis prevenciisTvis25 adamianis normaluri imunoglobulinis

gamoyenebis Cvenebebi da wesebi msgavsia imunokompetenturi da

imunokompromitirebuli pirebisTvis. adamianis normaluri imunoglobu-

linis da A hepatitis vaqcinis erTdrouli gamoyeneba proteqtoruli

antisxeulebis formaciaze mniSvnelovan zegavlenas ar axdens.

21 perinetaluri gziT SeZenili infeqciisgan B hepatitis dauyovnebeli vaqcinaciiT (24

sT-is ganmavlobaSi) uzrunvelyofili dacva B hepatitis imunoglobulinis damatebiTi

gamoyenebisas mniSvnelovnad ar umjobesdeba. 22Tu ukanaskneli sqesobrivi kontaqtidan gasulia 14 dReze meti, miuxedavad imisa, rom

eqspoziciis Semdgomi profilaqtikis efeqturobis xarisxi cnobili ar aris, unda

Catardes B hepatitis vaqcinacia, xolo B hepatitis sawinaaRmdego imunoglobulini

rekomendebuli ar aris. 23 B hepatitis sawinaaRmdego imunoglobulini rekomendebuli ar aris CvilebisTvis,

romelTac miiRes an unda miiRon vaqcinis meore doza. 24B hepatitis vaqcinacia rutinulad unda Catardes aseve sisxlismieri eqspoziciis

gareSe mWidro arasqesobrivi kontaqtisas, gansakuTrebiT bavSvebsa da mozardebSi. 25HAV infeqciis prevenciisTvis rekomendebulia adamianis normaluri imunoglobulini

eqspoziciamde an eqspoziciidan 2 kviris manZilze. adamianis normaluri

imunoglobulinis mogvianebiTi gamoyeneba xSirad mxolod amcirebs HAV infeqciis klinikur gamovlinebebs.

125

A hepatitis prevenciis mizniT adamianis normaluri imunoglobulinis

gamoyeneba naCvenebia Semdeg jgufebSi:

• pirebi, romlebic A hepatitis vaqcinaciidan 4 kviraze nakleb

periodSi gegmaven mogzaurobas maRali riskis arealSi (vaqcinisa

da imunoglobulinis ineqciis wertilebi unda iyos daSorebuli)

• 1 wlamde asakis bavSvebi. ramdenadac maT A hepatitis vaqcinacia ar

utardebaT, maRali riskis arealSi mogzaurobisas mogzaurobis

xangrZlivobis gaTvaliswinebiT unda gamoviyenoT 0.02-0.06ml/kg

imunoglobulini.

• A hepatitis virusTan eqspozirebuli aravaqcinirebuli pirebi.

imunoglobulini unda gamoviyenoT eqspoziciidan 2 kviris

ganmavlobaSi.

• A hepatitiT daavadebulTan mWidro kontaqtSi myofi pirebi.

• bavSvebi da momuSave personali bavSvTa centrebSi A hepatitis

diagnostirebisas.

• transmisiis maRali riskis mqone pirebi (mag.,kvebiT dawesebulebebSi

inficirebul sakvebTan kontaqtisas).

Tu A hepatitis vaqcinaciidan gasulia 1 Tve an meti adamianis normaluri

imunoglobulini ar gamoiyeneba.

4.12.2.2. wiTela

imunokompromitirebul pirebSi, maT Soris aiv inficirebulebSi,

adamianis normaluri imunoglobulini naCvenebia wiTelas virusTan

eqspoziciis SemTxvevaSi prevenciis mizniT. wiTelas vaqcinaciis

ukuCvenebis SemTxvevaSi, imunokompromitirebul pirebSi, maT Soris 1

wlamde asakis bavSvebSi, naCvenebia adamianis normaluri

imunoglobulinis 0.5ml/kg (maqsimaluri doza - 15ml) intramuskularuli

gamoyeneba eqspoziciisTanave. wiTelas virusTan eqspozirebul simptomur

aiv inficirebulebSi adamianis normaluri imunoglobulini unda

gamoviyenoT vaqcinaciis statusis miuxedavad, ramdenadac am SemTxvevaSi

vaqcinacia SeiZleba iyos araefeqturi da ganviTardes daavadeba.

imunokompromitirebul pirebSi wiTelas profilaqtikis mizniT adamianis

normaluri imunoglobulinis gamoyenebisas, 6 Tvis ganmavlobaSi

vaqcinacia ar tardeba.

4.12.2.3. cofis sawinaaRmdego imunoglobulini

imunokompromitirebul pacientebSi, maT Soris aiv inficirebulebSi,

cofis sawinaaRmdego imunoglobulini gamoiyeneba igive CvenebebiTa da

dozirebiT, rogorc imunokompetentur pirebSi (AI). cofis sawinaaRmdego imunoglobulini naCvenebia III kategoriis kontaqtisas (transdermaluri

nakbeni an nakawri, lorwovani membranis kontaminacia nerwyviT)

vaqcinaciis kursis pirvel dozasTan erTad. cofis sawinaaRmdego

imunoglobulini ar aris naCvenebi vaqcinirebuli pirebisaTvis

maneitralizebeli antisxeulebis titriT 0.5se/ml an meti.

126

Tu aiv inficirebul imunokompromitirebul pirs utardeba eqspoziciis

Semdgomi mkurnaloba, cofis sawinaaRmdego imunoglobulini

aucilebelia vaqcinaciis kursis pirvel dozasTan erTad. amasTan,

sasurvelia antisxeulebis serologiuri monitoringi.

4.12.2.4. tetanusis sawinaaRmdego imunoglobulini

imunokompromitirebul pacientebSi, maT Soris aiv inficirebulebSi,

tetanusis sawinaaRmdego imunoglobulini, gamoiyeneba igive CvenebebiTa

da dozirebiT, rogorc imunokompetentur pirebSi. tetanusis

imunoglobulini rekomendebulia tetanusiT avadmyofebSi, aseve

araadeqvaturi imunizaciisas pirebSi WrilobebiT an tetanusis

ganviTarebis riskTan asocirebuli sxva mdgomareobebiT. tetanusis

imunoglobulini axdens tetanusis mocirkulire toqsinis neitrali-

zacias. is ar moqmedebs nervul sistemaSi moxvedril toqsinze.

tetanusis mkurnalobisaTvis bavSvebsa da mozrdilebSi rekomendebulia

erTjeradi intramuskularuli doza 3000-5000 erTeuli. tetanusis

sawinaaRmdego imunoglobulinis gamoyenebis Cvenebebia:

• mniSvenelovani zomis dabinZurebuli Wriloba, imunizaciis

gaurkveveli statusis an mxolod 2 dozis gamoyenebisas. aseT

SemTxvevaSi damatebiT sasurvelia anatoqsinis gamoyeneba.26

• mniSvenelovani zomis dabinZurebuli Wriloba tetanusis

anatoqsinis gamoyenebis winaaRmdegCvenebiT.

• tetanusis simptomebis arseboba.

intravenuri imunoglobulini Seicavs tetanusis antitoqsins da

SesaZloa gamoyenebul iqnas, Tu tetanusis sawinaaRmdego

imunoglobulini xelmisawvdomi ar aris.

4.12.2.5. Cutyvavila-zosteris sawinaaRmdego imunoglobulini

Cutyvavila-zosteris sawinaaRmdego imunoglobulini ZiriTadad

gamoiyeneba axalSobilTa da mniSvnelovnad imunikompromitirebul

pirTa, maT Soris aiv inficirebulTa pasiuri imunizaciisaTvis

CutyvavilasTan an zosterTan eqspoziciis SemTxvevaSi (BII). CutyvavilasTan eqspozirebul imunikompromitirebul pirebSi

Cutyvavila-zosteris sawinaaRmdego imunoglobulinis gamoyenebam

SesaZloa Seamciros inficirebisa da garTulebebis riski.

aiv inficirebul bavSvebSi Cutyvavilas profilaqtikisaTvis (bavSvebi,

romelTac ar gadautaniaT Cutyvavila an zosteri an ar aReniSnebaT

Cutyvavila-zosteris sawinaaRmdego antisxeulebis deteqtabeluri done)

sasurvelia Cutyvavila-zosteris sawinaaRmdego imunoglobulinis

gamoyeneba eqspoziciidan 96 saaTis ganmavlobaSi.

26 anatoqsinis sawyisi dozebi ar axdens imunitetis inducirebas. tetanusis

sawinaaRndego imunoglobulini uzrunvelyofs antitoqsinis proteqtorul dones

imunuri pasuxis ganviTarebamde.

127

Cutyvavila-zosteris sawinaaRmdego imunoglobulini aseve

rekomendebulia aiv inficirebul orsulTaTvis Cutyvavila-zosteris

virusTan eqspoziciidan 96 saaTis ganmavlobaSi. Tu gamoiyeneba

acikloviri, sasurvelia Cutyvavila-zosteris sawinaaRmdego

antisxeulebis kontroli. seropozitiur SemTxvevaSi medikamenti

SesaZlebelia Sewydes.

danarTi 1. rekomendaciebi aiv infeqcia/SidsiT imunokompro-mitirebulTa imunizaciis Sesaxeb

rekomendaciebi aiv infeqcia/SidsiT imunokompromiti-

rebulTa imunizaciis Sesaxeb vaqcina Cvilebi da bavSvebi zrdasrulebi ararutinuli

imunizacia

jilexi _ _ gamoiyeneT Cvenebisas

BCG ukunaCvenebia/gansaxilvelia _ ukunaCvenebia

qolera(CVD103HgR) _ _ ukunaCvenebia

qolera (WC/rBs) _ _ gamoiyeneT Cvenebisas

DTP/DTaP/DT rekomendebulia _ _

hepatiti A _ _ gamoiyeneT Cvenebisas

hepatiti B rekomendebulia gamoiyeneT

Cvenebisas

_

HiBB rekomendebulia gansaxilvelia _

gripi _ _ gamoiyeneT Cvenebisas

ipv rekomendebulia _ gamoiyeneT Cvenebisas

iaponuri enc. _ _ gamoiyeneT Cvenebisas

meningokoki _ _ gamoiyeneT Cvenebisas

MMR/MR/M/R rekomendebulia/gansaxilvelia gansaxilvelia _

opv ukunaCvenebia _ ukunaCvenebia

Savi Wiri _ _ gamoiyeneT Cvenebisas

pnevmokoki _ _ gamoiyeneT Cvenebisas

cofi _ _ gamoiyeneT Cvenebisas

rotavirusi _ _ ukunaCvenebia

tkipismieri enc. _ _ gamoiyeneT Cvenebisas

TT/Td rekomendebulia rekomendebulia _

tifi(Ty21a) _ _ ukunaCvenebia

tifi, inaqt. _ _ gamoiyeneT Cvenebisas

Cutyvavila _ _ ukunaCvenebia/gansaxilvelia

yviTeli cxeleba _ _ ukunaCvenebia

rekomendebulia: vaqcina rekomendebulia rutinuli reJimis mixedviT an naCvenebia aiv

imunosupresirebulTaTvis.

gamoiyeneT Cvenebisas: imunosupresia ukuCvenebis mizezi ar aris; SeiZleba arsebobdes

ukuCvenebis sxva mizezi

ukunaCvenebia: aiv imunosupresia absoluturi an SedarebiTi ukuCvenebaa vaqcinis

gamoyenebisTvis

gansaxilvelia: gadawyvetileba vaqcinaciis Sesaxeb damokidebulia konkretul

pacientTan daavadebis risksa da vaqcinis efeqturobaze,

128

danarTi 2. aiv asocirebuli imunodeficitis klasifikacia bavSvebSi

aiv asocirebuli imunodeficitis klasifikacia

klasifikacia CD4 ujredebis maCvenebeli asakis mixedviT

<11 Tve

(%)

12-35 Tve

(%)

36-59 Tve

(%)

5w. da meti

(ujredi/mm3)

umniSvnelo >35 >30 >25 >500

saSualo 30-35 25-30 20-25 350-499

Sors wasuli 25-30 20-25 15-20 200-349

mZime <25 <20 <15 <200

an <15%

aRniSnuli exeba mozardebsa da mozrdilebsac

wyaro: jandacvis msoflio organizacia, 2006w.

danarTi 3. cofis vaqcina

eqspoziciamdeli vaqcinacia SesaZlebelia Catardes nebismier ujredul

vaqcinasTan kombinaciaSi da rekomendebulia cofis virusTan eqspoziciis

riskis mqone yvela pirisTvis. ZiriTadad es rekomendaciebi exeba:

• laboratoriis muSakebs;

• veterinarebs;

• cxovelTa mwvrTnelebs;

• potenciurad inficirebul cxovelebTan xSiri eqspoziciis mqone

pirebs;

• maRalendemuri arealis27 vizitorebs, romelTac SesaZloa aReniSnoT

eqspozicia cofis virusis maspinZelTan.28

eqspoziciamdeli reJimi iTvaliswinebs vaqcinis 1 ml an 0.5ml-is

gamoyenebas 0, 7 da 28 dReze.29 aRniSnuli vaqcinebiT eqspoziciis

Semdgomi vaqcinaciis (cofis sawinaaRmdego imunoglobulinis

gamoyenebiT an mis gareSe) saWiroeba damokidebulia cofiT daavadebul

cxovelTan kontaqtis tipze. vaqcinis tipis gaTvaliswinebiT eqspoziciis

Semdgomi profilaqtikisTvis gamoiyeneba 1 ml an 0.5 ml 4-5 doza 4 kviris

ganmavlobaSi. cofis virusTan eqspozirebul pacientebSi, romelTac

Catarebuli aqvT eqspoziciamdeli vaqcinaciis sruli kursi an

eqspoziciis Semdgomi mkurnaloba cofis ujreduli vaqciniT, sakmarisia

cofis ujreduli vaqcinis ori intramuskularuli doza 3 dRis

intervaliT. aseT SemTxvevaSi cofis sawinaaRmdego imunoglobulinis

gamoyeneba saWiro ar aris. igive wesebi vrceldeba vaqcinirebul pirebze,

romelTa maneitralizebeli antisxeulebis titri 0.5 se/ml-Si an metia.

27 2.5 mlrd adamianze meti cxovrobs cofis endemur arealSi(afrika, azia, samxreT

amerika).yovelwliurad saSualod 50 000 adamiani iRupeba cofiT da 10 mln-ze met

adamians utardeba eqspoziciis Semdgomi profilaqtika. 5-15 wlis asakis bavsvebi

imyofebian maRali riskis qveS.

28 calkeul asakobriv jgufebSi Catarebuli kvlevebis mixedviT daavadebis maRali

riski aqvT ganviTarebadi qveynebis cofis endemur areebSi mcxovreb bavSvebs.

29 ZiriTadad rekomendebulia 1 wlis Semdeg damatebiti doza bustirebisTvis;

vaqcinacia yovel 5 weliwadSi maRali riskis pirebisTvis; cofis virusis sawinaaRmdego

antisxeulebis perioduli gamokvleva (proteqciisaTvis aucilebeli titria >0.5se/ml)

129

adamianis diploidur-ujreduli vaqcina miCneulia oqros standartad.

jandacvis msoflio organizaciis mixedviT aucilebelia ujreduli

vaqcinis minimum 2.5se-s gamoyeneba TiToeuli dozirebisas. miuxedavad

maRali efeqturobisa ujreduli vaqciniT eqspoziciis Semdgom

Catarebuli milioni mkurnalobidan erTi SeiZleba aRmoCndes uSedego.

analizi gviCvenebs, rom uSedego mkurnaloba, rogorc wesi,

dakavSirebulia mniSvnelovan dazianebasTan Tavis an mezobel midamoSi,

an arasworad Catarebul mkurnalobasTan.

eqspoziciis Semdgomi mkurnalobis sruli kursi nervuli qsovilis

vaqcinis gamoyenebiT gulisxmobs 23 ineqciisgan Semdgari imunizaciis

gaxangrZlivebul da mtkivneul kurss. amasTan nervuli qsovilis

vaqcinebi ujredul vaqcinebTan SedarebiT neklebad efeqturia. amrigad,

aRniSnuli vaqcina eqspoziciis Semdgomi imunizaciisaTvis rekomendebuli

ar aris.

130

gamoyenebuli litratura:

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35. Welch K, Morse A. Improving screening and vaccination for hepatitis B in patients coinfected with HIV and hepatitis C. American Journal of Gastroenterology, 2002, 97:2928–2929.

36. Hodges GR et al. Response to influenza A vaccine among high-risk patients. Southern Medical Journal, 1979, 72(1):29–32.

37. Safrin S, Rush JD, Mill J. Influenza in patients with human immunodeficiency virus infection. Chest, 1990, 98:33–37.

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41. Centers for Disease Control. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR: Recommended Reports, 1997, 46(RR-08):1–24 (http://www.cdc.gov/mmwr/PDF/rr/rr4608.pdf accessed 14 November 2006).

42. Requirements for tick-borne encephalitis vaccine (inactivated) 2. In: WHO Expert Committee on Biological Standardization. WHO Expert Committee on Biological Standardization: forty-eighth report. Geneva, WHO, 1999:4463 (WHO Technical Report Series 889; http://www.who.int/biologicals/publications/ trs/areas/vaccines/tick_encephalitis/WHO_TRS_889_A2.pdf, accessed 16 November 2006).

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44. WHO position on the use of hepatitis B vaccines. Weekly Epidemiological Record, 2004, 28(79):255–263 (http://www.who.int/wer/2004/en/wer7928.pdf accessed 25 June 2006).

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gaidlainis gadasinjvis da ganaxlebis vada _ 2 weli

gaidlainis miRebis xerxi/wyaro

aRniSnuli gaidlaini eyrdnoba jandacvis msoflio organizaciis 2006

wlis gaidlains: “aiv/SidsiT daavadebuli mozrdili da mozardi pirebis

gamokvleva da antiretrovirusuli mkurnaloba”, aseve Sejerebulia

DHHS da EACS 2005 wlis antirtrovirusuli mkurnalobis gaidlainebTan.

avtorebi:

s.s. infeqciuri paTologiis, Sidsisa da klinikuri imunologiis samecniero-praqtikuli centri

⇒ Tengiz cercvaZe _ mmk, ss infeqciuri paTologiis Sidsisa da

klinikuri imunologiis s/p centris sameTvalyureo sabWos

Tavmjdomare; Sidsis nacionaluri programis koordinatori, iv.

javaxiSvilis saxelobis Tsu-s infeqciur daavadebaTa da klinikuri

imunologiis departamentis sruli profesori

⇒ fati gabunia _ mmk, ss infeqciuri paTologiis Sidsisa da klinikuri

imunologiis s/p centri, #2 boqsirebul ganyofilebis gamgis m/S;

⇒ nino goCitaSvili _ ss infeqciuri paTologiis Sidsisa da klinikuri

imunologiis s/p centri, Sidsisa da imunodeficitebis dispanseruli

ganyofilebis eqimi-infeqcionisti.

⇒ lali SarvaZe _ infeqciuri patologiis, Sidsis da klinikuri

imunologiis s/p centri, Sidsis da imunodeficitebis ganyofilebis

gamgis m/S, iv. javaxiSvilis saxelobis Tsu infeqciur daavadebaTa da

klinikuri imunologiis departamentis asistent-profesori

eqspertTa jgufi:

⇒ al.nanuaSvili _ mmk, antimikrobuli qimioTerapiis samsaxuris

xelmZRvaneli,:

133

⇒ l.vaSakiZe _ Tssu onkologiuri departamentis sruli profesori,

ftiziatrTa da pulmonologTa asociaciis prezidenti;:

⇒ m.zodelava _ Tssu onkologiuri departamentis onkohematologiuri

mimarTulebis sruli profesori;

⇒ m.maxvilaZe _ Tssu infeqciur sneulebaTa kaTedris asocirebuli

profesori, sihpem-Ta asociaciis wevri;

⇒ saqarTvelos onkologTa asociacia (vl.kuWava);

⇒ saqarTvelos respiraciuli asociacia (iv. CxaiZe)

⇒ T. TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri

dacvis saministros jandacvis departamenti;

⇒ l. woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri

dacvis saministros jandacvis departamenti.