August 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.

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.



  • Sanford Guide recently released a new AUC Dosing Calculator* which uses two serum concentration measurements to determine AUC24, the preferred method for vancomycin dosing for Staph bacteremia, endocarditis and invasive infection pursuant to new guidelines.
  • Sanford Guide is hosting a Virtual Open House from September 22-24, beginning with a COVID-19 Panel Discussion with members of our editorial board. Pre-registration is required.


  • Sanford Guide SARS-CoV-2 / COVID-19 material is freely available to all for the course of the pandemic.
  • Guidelines on COVID-19 diagnosis, treatment and management, and infection prevention: IDSA and NIH.
  • Guidelines (available at PMC) for the pharmacological treatment of COVID-19 from the Brazilian Association of Intensive Care Medicine, the Brazilian Society of Infectious Diseases, and the Brazilian Society of Pulmonology and Tisiology (Rev Bras Ter Intensiva 2020;32:166).
  • Remdesivir for severe COVID-19: a clinical practice guideline (BMJ 2020;370:m2924). Available on the BMJ website.
  • Comprehensive review of pathophysiology, transmission, diagnosis and treatment of COVID-19 in JAMA online 10 July 2020 doi:10.1001/jama.2020.12839.
  • Vaccine development pipeline: see COVID-19, Prevention for summary of vaccine development and clinical trials.

New or Updated Treatment Guidelines

  • Full clinical practice guidelines for the treatment of nontuberculous mycobacterial pulmonary disease, from the ATS, ERS, ESCMID, and IDSA (Eur Resp J 2020;56:2000535). The guidelines are available on the journal website.

Practice Pearls

  • Posaconazole has recently been associated with pseudohyperaldosteronism (secondary hypertension, hypokalemia, and sometimes metabolic acidosis). The drug inhibits adrenal 11β-hydroxylase and 11β-hydroxysteroid dehydrogenase type 2, resulting in accumulation of metabolites with mineralocorticoid effects (11-deoxycorticosterone, 11-deoxycortisol) and reduced inactivation of cortisol. This study found a positive correlation between serum posaconazole concentrations and systolic blood pressure and serum 11-deoxycortisol concentrations, and a negative correlation between posaconazole concentrations and serum potassium concentrations. Posaconazole-induced pseudohyperaldosteronism occurred at posaconazole concentrations (median 3.0 μg/mL) lower than previously reported, suggesting that the issue is underrecognized (Clin Infect Dis 2020;70:2593).
  • When considering cephalosporin cross-reactivity with other β-lactams, we often focus only on the R1 side chain. A recent report describes a 17-year-old female who twice experienced anaphylaxis to cefuroxime. Skin prick test results were negative for all antibiotics; intradermal test results, along with R1 and R2 side chain similarity to cefuroxime, are seen below. Provocation tests with oral amoxicillin, oral cefadroxil (different R1 and R2 side chains), and IM ceftriaxone were negative. These data suggest hypersensitivity to cefuroxime and cefotaxime due to similar R2 side chains (Ann Allergy Asthma Immunol 2020;125:101).
    Drug Intradermal test R1 R2
    Ampicillin Negative Different N/A
    Amoxicillin/clavulanate Negative Different N/A
    Benzylpenicillin Negative Different N/A
    Cefazolin Negative Different Different
    Cefotaxime Positive Similar Similar
    Ceftriaxone Negative Similar Different
    Cefuroxime Positive
  • 2,478 TB patients treated with standard firstline drugs (INH, rifampin, PZA, ethambutol) were reviewed for the occurrence of serious adverse effects (SAEs). 407 patients (16.4%) experienced a SAE (most commonly hepatotoxicity, followed by cutaneous reaction, GI intolerance, and arthropathy) that led to drug discontinuation. The most common causative drug was PZA (55.8%), followed by ethambutol (23.3%), rifampin (13.8%), and INH (6.4%). The incidence of SAEs increased with age, and this held true for all individual drugs except rifampin (PLoS ONE 2020;15:e0236109).

Drug Shortages (US)

  • Antimicrobial drugs or vaccines in reduced supply or unavailable (as of August 9, 2020) due to increased demand, manufacturing delays, product discontinuation by a specific manufacturer, or unspecified reasons:
    • New on the list since July 7Cefotetan injection
    • Shortage recently resolvedBacitracin ophthalmic ointment, Daptomycin injection, Griseofulvin oral tablets and suspension, Mupirocin calcium 2% cream (Glenmark)
    • Antibacterial drugs in continued reduced supply:
      • Aminoglycosides: Amikacin injection, 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, Ceftazidime/avibactam 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: Metronidazole injection
      • Penicillins: Ampicillin/sulbactam injection, Piperacillin/tazobactam injection
      • Tetracyclines: Doxycycline injection
      • Topical (miscellaneous) antibacterials: 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)
    • Antimycobacterial drugs
      • Ethambutol tablets
    • Antifungal, antiparasitic, and antiviral drugs in continued reduced supply:
      • Antifungal drugs: Clotrimazole 10 mg oral troches, Fluconazole injection
      • Antiparasitic drugs: Chloroquine tablets, Hydroxychloroquine tablets, Pentamidine isethionate
      • Antiviral drugs: Acyclovir injection, Cidofovir injection
    • Vaccines in coninued reduced supply:
      • Hepatitis B vaccine recombinant, 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: Mupirocin calcium 2% cream (Bactroban [GSK], in June 2020), Bacitracin injection (in February 2020), Interferon alfa-2b (Intron A, in October 2019), Mupirocin calcium 2% nasal ointment (Bactroban Nasal [GSK], in August 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).