October ID Update

Sanford Guide ID Update features current developments in infectious diseases, curated by the Sanford Guide Editorial Board. Links marked with an asterisk (*) provide details to Web Edition subscribers, while all other links are universal. If you would like to automatically receive our monthly ID Updates by e-mail, subscribe now.
 

OCTOBER 2017

New Drug Approvals

  • Secnidazole* (Solosec) for the single-dose treatment of bacterial vaginosis in adult women. The recommended dosage is a 2 gram packet of granules sprinkled onto applesauce, yogurt, or pudding and consumed within 30 minutes without chewing or crunching the granules.

Newly Available Generics (US)

  • Oseltamivir phosphate oral suspension 6 mg/mL (Nesher Pharmaceuticals), approved September 14.

New Treatment Guidelines

Updated Treatment Guidelines

  • The AASLD-IDSA guidelines for treatement of hepatitis C* have been updated. This update (September 21, 2017) reflects several important developments including the recent approvals of Mavyret* (glecaprevir/pibrentasvir) and Vosevi* (sofosbuvir/velpatasvir/voxilaprevir). While most sections have been updated, the most significant changes have been made in the Initial Treatment of HCV Infection and Retreatment of Persons in Whom Prior Treatment Has Failed sections as well as the Unique Populations sections, which include patients living with HIV, kidney disease, and severe liver disease including those with severe liver dysfunction and those who have had a liver transplant. The updated guidelines are available at HCVguidelines.org, a website developed by the AASLD and the IDSA to provide up-to-date guidance on the treatment of hepatitis C.

Antimicrobial Stewardship

  • In patients with acute respiratory infection, does greater certainly about etiology improve physician prescribing? In a pragmatic, open-label, randomized trial, patients seen in the ED or acute medical unit of a large hospital in the UK were assigned to receive point-of-care testing (POCT) or routine clinical care. POCT consisted of a rapid molecular test for 15 respiratory viruses that provided results within a few hours. No difference was observed in the proportion of patients receiving antibiotics in each group (83%), although more than half the patients in the POCT group received antibiotics before test results were available, and mean duration of antibiotics was also the same in the two groups (about seven days). However, significantly more patients in the POCT group received only one dose of antibiotics than patients in the routine care group (10% vs. 3%), and duration of treatment <48 hours was significantly more common in the POCT group (17% vs. 9%). In addition, mean length of stay was significantly shorter in the POCT group (5.7 vs. 6.8 days), and appropriate antiviral treatment of influenza-positive patients was significantly more common in the POCT group (91% vs. 65%). These beneficial effects might be further enhanced by combining rapid virus detection with other tests, such as procalcitonin (Lancet Respir Med 5:401, 2017).

New Sanford Guide Integration

  • On September 26, Sanford Guide and digital intelligence provider VigiLanz announced a collaboration to integrate Sanford Guide recommendations into VigiLanz’s market-leading clinical intelligence platform. Read the press release.

Practice Pearls

  • Supratherapeutic vancomycin serum concentrations from oral administration. Although we generally think of oral vancomycin as a minimally absorbed drug, it is important to remember that impressive serum concentrations can be achieved in patients with severe intestinal mucosa injury and impaired renal function. In this report, a patient with rectal cancer admitted for sepsis, renal insufficiency (managed with CRRT), and pseudomembranous colitis was treated with oral vancomycin 500 mg every six hours. After four days the serum vancomycin concentration was found to be 30.6 µg/mL. Colonoscopy demonstrated severe damage throughout the large intestine (J Infect Chemother 2017 Sept 8 [Epub ahead of print]).
  • Weakening of tendons due to divalent cation chelation and/or upregulation of collagen-degrading enzymes are possible mechanisms of fluoroquinolone-associated tendinopathy. Although the Achilles tendon is most frequently involved, it is important to appreciate that non-Achilles tendinopathy also occurs. Here are four recently reported cases of musculoskeletal toxicity associated with fluoroquinolone use involving sites of injury not previously reported. The extent to which fluoroquinolone exposure contributed to these injuries cannot be determined from the data provided.

     

    Case 1. A 55-yo male who presented with right lateral thumb pain following a forceful extension and adduction event was found to have disruption of the radial collateral ligament of the thumb at the proximal insertion with significant fluid collection. Six weeks prior to this injury he had been treated with ciprofloxacin 500 twice daily x7 days for gastroenteritis following international travel. He was conservatively managed and the ligament healed in about four months.

     

    Case 2. A 62-yo female presented with a 6-7 month history of right hip pain that she could not relate to any specific event. She was found to have near complete avulsion of the right hamstring tendons from the ischial tuberosity with a large amount of adjacent free fluid. Of note, she had been treated with frequent courses of ciprofloxacin for chronic recurrent diverticulitis and she was also taking corticosteroids that were prescribed after a previous evaluation of her pain. She was conservatively managed with regular follow-up.

     

    Reference for cases 1 and 2: Am J Phys Med Rehabil 2017 Aug 25 [Epub ahead of print]

     

    Case 3. A 60-yo male sustained injury to his left elbow after abruptly stopping on a bicycle. MRI showed complete triceps avulsion with retraction. Three months prior to the injury he had been given a course of levofloxacin around the time of a prostate biopsy. The details of his levofloxacin regimen are not provided.

     

    Case 4. A 47-yo male suffered a left elbow injury competing in judo and was diagnosed with complete triceps avulsion off the olecranon by MRI. He had been treated for epididymitis with ciprofloxacin three months prior to the injury. Again, the details of the fluoroquinolone regimen are not provided.

     

    Reference for cases 3 and 4: Sports Health 9:474, 2017

Drug Shortages (US)

  • Antimicrobial drugs or vaccines in reduced supply or unavailable due to increased demand, manufacturing delays, product discontinuation by a specific manufacturer, or unspecified reasons:
    • [New on the list]: None
    • [Continue to be in reduced supply]:
      • Aminoglycosides: Amikacin injection, Gentamicin injection, Tobramycin injection
      • Cephalosporins: Cefepime, Cefotaxime injection (unavailable), Cefoxitin, Cefpodoxime oral suspension, Ceftazidime, Ceftriaxone, Cefuroxime injection
      • Fluoroquinolones: Ciprofloxacin oral suspension, Ofloxacin 0.3% ophthalmic solution
      • Penicillins: Amoxicillin/clavulanate 1000 mg/62.5 mg ER tablets, Ampicillin/sulbactam, Oxacillin injection, Penicillin G benzathine, Penicillin G benzathine 900,000 units/Penicillin G procaine 300,000 units (Bicillin C-R 900/300), Penicillin G benzathine/Penicillin G procaine 1.2 million units (Bicillin C-R), Penicillin G procaine injection (unavailable), Piperacillin/tazobactam
      • Other antibacterials: Clindamycin injection, Erythromycin lactobionate injection (unavailable), Metronidazole injection, Mupirocin calcium 2% cream, Mupirocin calcium 2% nasal ointment (unavailable), Vancomycin injection
      • Antifungal drugs: Fluconazole injection
      • Antiparasitic drugs: None
      • Vaccines: Hepatitis A Virus Vaccine Inactivated (Vaqta), Hepatitis B vaccine recombinant, Yellow Fever vaccine (unavailable)
    • [Shortage recently resolved]: Albendazole tablets, Tetanus and Diphtheria Toxoids Adsorbed
  • Antimicrobial drugs newly discontinued:
    • Recent discontinuations: Terbinafine granules (in May 2017), MenHibrix (in February 2017), Elvitegravir (Vitekta, in December 2016), Peginterferon alfa-2b (in February 2016; 50 mcg vials still available in limited quantities), Boceprevir (in December 2015), Permethrin 1% topical lotion (in September 2015)
  • For detailed information including estimated resupply dates, see http://www.ashp.org/menu/DrugShortages