@anking-maintainers if others agree I can update the table in other cards as well
I think this prompt is added because the other one is azithromycin, this is why this hint is added. don’t support at the current moment, okay for it to be easy
@Ahmed7 Azithromycin is no longer recommended for prophylaxis for patients who are on / start combined ART therapy anymore though, Amboss and UW both say no prophylaxis for patients who start cART
Correct but this might cause confusion for users, reason I am saying this is if you check suggestion history, we’ve had this issue before and nid:1514576041266
I can see your point now though, support
Ah, hadn’t seen those suggestions before, i don’t mind leaving the hint in if others like it, hadn’t covered this content until i ran into a UW question on it today 
Might be better to make a new card or change this cart to more specifically what prophylaxis is indicated for patients on cART, instead of continuing to manipulate a card based on an outdated question. especially now that there is only 1 indication for patients on cART.
Looking back this card didn’t mention patients being on cART in the past either, in which case it would be TMP-SMX and Azithromycin
Yes, just think this card needs to be read more carefully if users want it changed or they get it mixed up in the future after we push
Agreed, I added a note to extra that patients not on cART would also need prophylaxis with Azithromycin, hopefully that should help
Just want to make sure I’m getting this right: @Ahmed7 @thomas.holmes
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Patient with no active MAC infection + NOT on cART → Macrolide (azithromycin or clarithromycin)
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Patient with no active MAC infection + NOT on fully effective cART (= ineffective cART) → Macrolide (azithromycin or clarithromycin)
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Prophylaxis to be stopped with viral load becomes undetectable (i.e., fully suppressive regimen)
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Patient on fully effective cART → No prophylaxis to be given
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Patient starting cART → No prophylaxis to be given
On this card, because the patient’s CD4 count is <50 (normal CD4 value is > 500 cells/mm3), that means that the patient is on ineffective cART, so according to point #2, we need to give prophylaxis for MAC, which would be azithromycin (or clarithromycin, or alternative of rifabutin)
Source for the above: https://next.amboss.com/us/article/1o02aS#Ycd6a18c4baf02c74094511b9797b83a9
Last row in the table
Just looking over this quickly, the extra looks super bulky now. All of the comments added are direct from UW and I feel like they make the card overwhelming. Only really need the second bullet about patients not on cART, wouldn’t add the other stuff
Updated note, feel free to edit if you’d like. Added the note for PCP to clarify what the indication is and when it should be started
Couldn’t an answer for the cloze also be macrolide, because the CD4 counts are < 50, and therefore the cART is ineffective?
Ref: point #2 in my previous comment
sorry didn’t see that comment earlier, that’s a good point, it might be clearer if we change it from “on ART” to “starting ART” - a patient “on ART” but CD4+ count is <50 may suggest the ART is not properly effectively
I’d like to take another look at this tomorrow (traveling today) - feel like the edits to the table are warranted, but otherwise seems like we’ve just made this more complicated without making it more clear
Ya that’s fair, this card has caused lots of issues in the past, I removed the prompts as PJP is the only indication for prophylaxis treatment for patients on ART, toxo requires positive IgG antibodies for prophylaxis.
Beejum’s point is that if a patient is on / has been on ART and their CD4+ is at 50, then either there is resistance to the drugs or there is noncompliance (thus changed prompt to “starting” ART).
The UWorld QID (step 2 3252) tagged is about a patient newly diagnosed with HIV that has a CD4+ count <50 and asks in addition to starting ART, what prophylaxis should be added - answer is only TMP-SMX
Fine with changing to “starting ART,” I see the confusion here. However, unless I am misunderstanding the AMBOSS chart, on/off ART is only relevant to MAC, not PJP or Toxo… so the change to extra should just be:
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For patients not on ART (or not immediately starting ART), prophylaxis also includes azithromycin for Mycobacterium avium complex
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TMP-SMX is used for PJP prophylaxis at CD4 < 200 (all patients) and toxoplasma prophylaxis at CD4 < 100 (only patients with positive serology)
If we add “for patient not on ART…” we need to delete the current first bullet because that is entirely redundant.
Yeah that’s what I think Amboss means, and this the card currently is kinda misleading
Support this ^
Yup, agreed, updated extra @AnKing-Maintainers
Looks good to me! Let’s make sure we update all instances of this table