ICU infections, stewardship and the immunocompromised

Tuberculosis and HIV in the ICU

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

Start NTEP weight-band ATT for critically ill TB, steroids for TB meningitis, and manage PJP, cryptococcal meningitis and ART timing in advanced HIV.

Definition
TB presents to the ICU as miliary TB with ARDS, TB meningitis, massive haemoptysis, TB-IRIS or drug-induced liver injury. In advanced HIV (CD4 < 200), PJP, cryptococcal meningitis, TB and bacterial sepsis dominate.

At the bedside

  1. 1

    Diagnose TB quickly

    Sputum/tracheal aspirate/BAL GeneXpert (CBNAAT/TrueNat) with rifampicin resistance, CSF Xpert Ultra and ADA, urine LAM in HIV, imaging; start empirical ATT if high suspicion and critically ill.

  2. 2

    ATT

    2HRZE/4HRE by NTEP weight band (extend continuation to 10 months for CNS TB). Give by NG if needed; IV options limited.

  3. 3

    TB meningitis steroids

    Dexamethasone 0.4 mg/kg/day IV in divided doses during admission, tapered over 6-8 weeks (HIV-negative).

  4. 4

    Drug-induced liver injury

    Stop hepatotoxic drugs if ALT > 3× with symptoms or > 5× without, or bilirubin rise; give non-hepatotoxic bridge (e.g. ethambutol + levofloxacin + streptomycin/linezolid per specialist); reintroduce sequentially.

  5. 5

    PJP

    CD4 < 200, hypoxaemia, bilateral ground-glass: cotrimoxazole 15-20 mg/kg/day (TMP) in 3-4 doses × 21 days + prednisolone if PaO2 < 70 mmHg.

  6. 6

    Cryptococcal meningitis

    Single L-AmB 10 mg/kg + 14 days flucytosine 100 mg/kg/day + fluconazole 1,200 mg/day (WHO 2022); therapeutic LPs for raised opening pressure (> 25 cm H2O).

  7. 7

    ART timing

    Continue ART if already on it. New diagnosis: start within 2 weeks for most OIs (including PJP, and TB if CD4 < 50); delay 4-6 weeks in cryptococcal meningitis and TB meningitis (IRIS risk).

Drug-sensitive TB

HRZE fixed-dose combination (NTEP)

Oral/NG
Dose
Weight-band FDC daily (e.g. 50-64 kg: 4 tablets)
Worked example
70 kg: 5 tablets of HRZE (75/150/400/275) daily for 8 weeks

TB meningitis

Dexamethasone

IV
Dose
0.4 mg/kg/day in 3-4 divided doses, taper
Worked example
70 kg: 28 mg/day (e.g. 8 mg q8h ≈ 24 mg or 7 mg q6h)

PJP

Trimethoprim-sulfamethoxazole

IV/oral
Dose
TMP 15-20 mg/kg/day in 3-4 doses × 21 days
Worked example
70 kg: TMP 1,050-1,400 mg/day, e.g. 2 double-strength (160/800 mg) tablets q6h = TMP 1,280 mg/day

Moderate-severe PJP

Prednisolone

Oral
Dose
40 mg BD × 5 days, 40 mg OD × 5 days, 20 mg OD × 11 days

Cryptococcal meningitis

Liposomal amphotericin B

IV
Dose
Single 10 mg/kg dose (with flucytosine + fluconazole)
Red flag · call your senior now
TB meningitis with falling GCS: hydrocephalus - urgent CT and neurosurgical review (VP shunt/EVD).
Pitfall
Empirical fluoroquinolone or linezolid for 'pneumonia' masking TB.
Pitfall
Starting ART immediately in cryptococcal meningitis: increased mortality from IRIS.
Pearl
Rifampicin markedly lowers levels of azoles, many ART drugs, steroids and warfarin - review all drug interactions on starting ATT.

References

  1. 1

    Department of Health Research, MoHFW / ICMR. Standard Treatment Workflow: Drug-sensitive TB treatment as per NTEP. New Delhi; March 2022.

  2. 2

    Thwaites GE, Nguyen DB, Nguyen HD, et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med 2004;351:1741-51.

  3. 3

    World Health Organization. Guidelines for diagnosing, preventing and managing cryptococcal disease among adults, adolescents and children living with HIV. Geneva: WHO; 2022.

  4. 4

    Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Pneumocystis Pneumonia. NIH/CDC/HIVMA-IDSA; continuously updated.

  5. 5

    National Centre for Disease Control (DGHS, MoHFW) and Indian Council of Medical Research. National Treatment Guidelines for Antimicrobial Use in Infectious Disease Syndromes, Version 2.0. New Delhi: MoHFW; November 2025.

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