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 received this message from a colleague, subscribe now.


New or Updated Treatment Guidelines

Improved Access to IV Artesunate

  • IV artesunate* is the first-line, WHO-recommended treatment for severe malaria but is neither FDA-approved nor commercially available in the United States. Obtaining the drug from CDC has been problematic due to limited supply and other issues, but recent efforts have improved drug accessibility for those who need it. As of April 2019, CDC will release artesunate for all cases of severe malaria, any case of malaria where the patient is not tolerating oral medications, or any highly suspected case of severe malaria. The drug is pre-positioned at 18 locations nationally, and the hospital will need to send someone to the receiving airport or quarantine station to retrieve it. Call the CDC Malaria Hotline, (770) 488-7788, Mon-Fri, 9 am to 5 pm US EST. After hours, or on weekends or holidays, call the CDC Emergency Operations Center at (770) 488-7100 and ask to page the person on call for the Malaria Branch.

Practice Pearl

  • DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) is a T-cell-mediated hypersensitivity reaction characterized by fever, facial edema, maculopapular rash, lymphadenopathy, eosinophilia, mononucleosis-like atypical lymphocytosis, and multiorgan involvement (hepatitis, nephritis, arthritis, pneumonitis, carditis). The latency period is 2-8 weeks, and mortality approaches 10%. Recognized drug triggers include anticonvulsants, allopurinol, and antibiotics, including vancomycin. There are well-known HLA associations with drug hypersensitivity reactions, such as HLA-B*57:01 and hypersensitivity to abacavir; could variation within HLA predispose to vancomycin-associated DRESS? In 23 patients with vancomycin-associated DRESS, 82.6% carried the HLA-A*32:01 allele compared to 0% of 46 matched vancomycin-tolerant control patients (p=1 x 10-8). The patients with vancomycin-associated DRESS were primarily of European ancestry. In a larger cohort of 54,249 patients, the HLA-A*32:01 allele carriage rate was 6.3%, matching the carriage rate in other cohorts of mainly European ancestry. The authors estimate that approximately 75 patients started on vancomycin would need to undergo HLA-A*32:01 testing to prevent one case of vancomycin-associated DRESS. If validated, the association of HLA-A*32:01 carriage with vancomycin-associated DRESS could be useful not only for the prediction and prevention of the hypersensitivity reaction, but also for monitoring and risk stratification (J Allergy Clin Immunol 2019;144:183).

Drug Shortages (US)

  • Antimicrobial drugs or vaccines in reduced supply or unavailable (as of October 7, 2019) due to increased demand, manufacturing delays, product discontinuation by a specific manufacturer, or unspecified reasons:
    • [New on the list since August 30]: Acyclovir injection, Rabies Immune Globulin, Rabies vaccine
    • [Shortage recently resolved]: Erythromycin lactobionate injection
    • [Continue to be in reduced supply]:
      • Aminoglycosides: Amikacin injection, Gentamicin ophthalmic ointment (unavailable), Tobramycin injection
      • Carbapenems: Meropenem injection
      • Cephalosporins: Cefazolin injection, Cefepime injection, Cefotaxime injection (unavailable), Cefoxitin injection, Ceftazidime injection, Ceftriaxone injection, Cefuroxime injection
      • Clindamycin injection
      • Fluoroquinolones: Ciprofloxacin 0.3% ophthalmic solution, Ciprofloxacin oral suspension, Gemifloxacin tablets
      • Glyco-, glycolipo-, lipopeptides: Daptomycin injection, Vancomycin injection
      • Macrolides/azalides: Azithromycin injection, Azithromycin ophthalmic solution 1% (unavailable), Erythromycin 0.5% ophthalmic ointment
      • Nitrofurantoin oral suspension
      • Nitroimidazoles: Metronidazole injection
      • Penicillins: Ampicillin/sulbactam injection, Piperacillin/tazobactam injection
      • Tetracyclines: Doxycycline hyclate injection
      • Topical (miscellaneous) antibacterials: Bacitracin ophthalmic ointment (unavailable), Mupirocin calcium 2% cream, Mupirocin calcium 2% nasal ointment (unavailable), Sulfanilamide 15% vaginal cream (unavailable)
      • Antifungal drugs: Clotrimazole 10 mg oral troches, Fluconazole injection, Griseofulvin oral tablets, Nystatin oral suspension
      • Antiparasitic drugs: Pentamidine isethionate
      • Antiretroviral drugs: None
      • Antiviral drugs: Cidofovir injection, Letermovir injection (unavailable)
      • Vaccines: Hepatitis B vaccine recombinant, Zoster vaccine recombinant (Shingrix), Yellow Fever vaccine (YF-VAX is unavailable, but Stamaril can be obtained through a limited number of clinics in the US. Click here).
  • Antimicrobial drugs newly discontinued: Quinidine gluconate IV (in December 2017). Product distribution will continue until expiration of current stock (March 2019).
    • 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)