May 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.

MAY 2020

Free Trials for Hospitals and Health Systems

  • Sanford Guide is currently offering free 60-day trials of Sanford Guide All Access (web & mobile) to hospitals and health systems. Click here for more information.


Updated Pediatric HIV Guidelines

  • Updated Guidelines for the Use of Antiretroviral Agents in Pediatric HIV infection from the DHHS Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV are available on the AIDSinfo website.

Other New or Updated Treatment Guidelines

  • British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease (Thorax 2020;75:370). The guidelines are available on the BTS website.
  • Diagnosis and treatment of acute appendicitis: 2020 update of the World Society of Emergency Surgery (WSES) Jerusalem guidelines (World J Emerg Surg 2020;15:27). The guidelines are available on the WJES website.
  • 2020 update of the World Society of Emergency Surgery (WSES) guidelines for the management of acute colonic diverticulitis in the emergency setting (World J Emerg Surg 2020;15:32). The guidelines are available on the WJES website.
  • Clinical practice guidelines for the treatment of left-sided colonic diverticulitis, from the American Society of Colon and Rectal Surgeons (Dis Colon Rectum 2020;63:728). The guidelines are available on the journal website.
  • Position paper on antimicrobial therapeutic drug monitoring in critically ill patients from these endorsing organizations: European Society of Intensive Care Medicine (ESICM), Pharmacokinetic/Pharmacodynamic and Critically Ill Patient Study Groups of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT), and International Society of Antimicrobial Chemotherapy (ISAC) (Intensive Care Med 2020 May 7 [Epub ahead of print]).

Dosing Pearls

  • IV infusion over 30 minutes is the recommended method of ceftriaxone* administration in adults. IV push administration over 1-2 minutes allows for a decrease in time to administration, which might positively affect outcome in a time-sensitive situation such as sepsis. In a retrospective study of 753 administrations in an emergency department, the total adverse event rate with IV push ceftriaxone was 0.13%, similar to or lower than previously reported. A cost savings for the hospital was also realized (Am J Emerg Med 2020 Mar 30 [Epub ahead of print]).
  • The effect of extracorporeal membrane oxygenation (ECMO) on TMP-SMX* pharmacokinetics has not been described. A 33-yo male with recently diagnosed HIV infection and Pneumocystis jirovecii pneumonia requiring venovenous ECMO for refractory respiratory failure was treated with high-dose TMP-SMX. No significant effect on trimethoprim or sulfamethoxazole pharmacokinetics was found, suggesting that no dose adjustment in ECMO may be necessary (Pharmacotherapy 2020 May 7 [Epub ahead of print]).
  • For CMV prophylaxis in solid-organ transplant (SOT) patients, valganciclovir* (a ganciclovir prodrug) is typically given in a dose of 900 mg po q24h. A ganciclovir trough concentration of ≥0.6 µg/mL in this setting is a reasonable target. Until recently, specific valganciclovir dose adjustment data in CRRT have been scant. In a prospective PK study in ten SOT patients receiving CVVHD, eight (80%) achieved the target ganciclovir concentration at steady state using valganciclovir 450 po q24h. The mean ganciclovir concentration was 2.27 µg/mL. Most patients had minimal enteral nutrition during the study period. Neutropenia was not observed; thrombocytopenia was common but likely multifactorial (Clin Infect Dis 2020 May 7 [Epub ahead of print]).

Drug Shortages (US)

  • Antimicrobial drugs or vaccines in reduced supply or unavailable (as of May 10, 2020) due to increased demand, manufacturing delays, product discontinuation by a specific manufacturer, or unspecified reasons:
    • New on the list since April 8Erythromycin 0.5% ophthalmic ointment
    • Shortage recently resolvedBenzylpenicilloyl polylysine (Pre-Pen), Ceftazidime/avibactam injection
    • Antibacterial drugs in continued reduced supply:
      • Aminoglycosides: Amikacin injection, Gentamicin injection, Gentamicin ophthalmic ointment (unavailable), Tobramycin injection, Tobramycin lyophilized powder for injection
      • Carbapenems: Meropenem injection
      • Cephalosporins: Cefazolin injection, Cefepime injection, Cefotaxime injection (FDA is allowing temporary importation of product from SteriMax in Canada, in conjunction with Apollo Pharmaceuticals and its distributor FFF Enterprises. Click here for details), Cefoxitin injection, Ceftazidime injection, Cefuroxime injection
      • Clindamycin injection
      • Fluoroquinolones: Ciprofloxacin 0.3% ophthalmic solution, Gemifloxacin tablets
      • Glycopeptides, glycolipopeptides, lipopeptides: Vancomycin injection
      • Macrolides/azalides: Azithromycin injection, Azithromycin ophthalmic solution 1% (unavailable)
      • Methanamine hippurate tablets
      • Nitrofurantoin oral suspension
      • Nitroimidazoles: None
      • Penicillins: Ampicillin/sulbactam injection, Piperacillin/tazobactam injection
      • Tetracyclines: Doxycycline injection
      • Topical (miscellaneous) antibacterials: Bacitracin ophthalmic ointment, Mupirocin calcium 2% cream, Mupirocin calcium 2% nasal ointment (unavailable), Neomycin and Polymyxin B sulfates GU irrigant, Neomycin and Polymyxin B sulfates and Dexamethasone ophthalmic ointment, Sulfacetamide 10%/Prednisolone 0.2% ophthalmic ointment (unavailable), Sulfanilamide 15% vaginal cream (unavailable)
    • Antifungal, antiparasitic, and antiviral drugs in continued reduced supply:
      • Antifungal drugs: Clotrimazole 10 mg oral troches, Fluconazole injection, Griseofulvin oral tablets and suspension
      • Antiparasitic drugs: Chloroquine tablets, Hydroxychloroquine tablets, Pentamidine isethionate
      • Antiviral drugs: Cidofovir injection
    • Vaccines in coninued reduced supply:
      • 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: 
    • Recent discontinuations: Bacitracin inection (in February 2020), Interferon alfa-2b (Intron A, in October 2019), Quinidine gluconate IV (in December 2017), 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).