April ID Update

ID Update is The Sanford Guide’s monthly summary of significant developments in the treatment of infectious diseases. Want to receive ID Update by e-mail? Click here to subscribe. We won’t spam you or share your contact information.

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New Treatment Guidelines

  • New evidence-based American Association for Thoracic Surgery (AATS) consensus guidelines for the surgical treatment of infective endocarditis* have been developed. The guidelines focus on surgical treatment and perioperative issues: when to operate, how to prepare the patient for operation, how to operate, and other issues relevant to managing and following patients after surgery (J Thorac Cardiovasc Surg 2017 Jan 24 [Epub ahead of print]).

Updated Drug Approvals for Pediatric Patients

  • The FDA has approved sofosbuvir (Sovaldi)* and ledipasvir/sofosbuvir (Harvoni)* for treatment of hepatitis C virus in children and adolescents:
    • Sofosbuvir in combination with ribavirin is indicated for the treatment of pediatric patients 12 years of age and older or weighing at least 35 kg with genotype 2 or 3 infection without cirrhosis or with mild cirrhosis.
    • Ledipasvir/sofosbuvir is indicated for the treatment of pediatric patients 12 years of age and older or weighing at least 35 kg with genotype 1, 4, 5, or 6 infection without cirrhosis or with mild cirrhosis.

Antimicrobial Stewardship

  • Last month we summarized the recently expanded indications for procalcitonin (PCT). New data add to our understanding of the potential role of PCT in children. In a cohort of 532 prospectively enrolled children with strictly defined, radiographically confirmed community-acquired pneumonia (CAP), PCT concentrations <0.25 ng/mL were strongly associated with a decreased likelihood of detecting typical bacteria and decreased disease severity. PCT concentrations <0.1 ng/mL had a very high negative predictive value, effectively excluding typical bacterial CAP. These findings suggest that PCT may safely be incorporated into treatment algorithms for children with CAP to reduce antibiotic administration and duration (J Pediatric Infect Dis Soc 2017 Feb 3 [Epub ahead of print]).

Emerging Infection Updates

  • Human infections with an Asian lineage avian influenza A (H7N9) virus were first reported in China in March 2013. Since then, annual epidemics of sporadic human infections with Asian H7N9 viruses in China have been reported. During the first four epidemics, about 40% of people with confirmed infection died. China is currently experiencing its fifth epidemic of Asian H7N9 human infection, the largest annual epidemic to date. 460 human infections have been reported since October 1, 2016. The clinical characteristics and risk factors for human infections do not appear to have changed; most infections have been associated with poultry exposure and result in severe respiratory illness. 453 of the infections occurred in mainland China; six are associated with travel to mainland China from Hong Kong (four cases), Macao (one) and Taiwan (one), and one occurred in an asymptomatic poultry worker in Macao. Asian H7N9 viruses have not been detected in people or birds in the United States. Although some limited human-to-human spread continues to be identified, no sustained transmission has been observed. Of concern, ongoing genetic analysis of neuraminidase genes from fifth epidemic viruses indicates that approximately 7-9% of the viruses analyzed to date have known or suspected markers for reduced susceptibility to one or more neuraminidase inhibitors (which are currently recommended for treatment). CDC does not recommend delay or cancellation of trips to China, but travelers are advised to avoid contact with poultry (including poultry markets and farms), birds, and their droppings and to avoid eating undercooked poultry. Infected birds that appear healthy may still be able to transmit the virus to humans. Further information can be found at http://www.who.int/csr/don (MMWR 66:254, 2017).
  • Yellow fever is caused by an arbovirus (Flavivirus) that is transmitted to humans by the bites of infected Aedes and Haemogogus mosquitoes. Since December 2016 there has been an ongoing outbreak of yellow fever in Brazil. The first human cases were reported in the State of Minas Gerais in southeastern Brazil but many epizootic and human cases, mainly in rural areas, are under investigation in neighboring states. These are referred to as sylvatic, or jungle, cases: the virus is transmitted between non-human primates (such as monkeys) via mosquito species found in the forest canopy, and is sporadically transmitted by mosquitoes from non-human primates to human visiting or working in the jungle. As of early April, more than 1500 cases have been reported and yellow fever virus transmission continues to expand towards the Atlantic coast of Brazil in areas not previously deemed to be at risk. At present there is no evidence of human-to-human transmission through Aedes aegypti, the vector that could sustain urban transmission of yellow fever, but the outbreak is affecting areas close to major urban centers where the vaccine is not routinely administered. In response to this outbreak, the list of destinations for which yellow fever vaccination is recommended for travelers has been expanded. Because of the current shortage of yellow fever vaccine, travelers may need to contact a yellow fever vaccine provider well in advance of travel. Detailed information about the situation in Brazil including specific areas considered at risk for yellow fever transmission and vaccine recommendations can be found on at http://www.who.int/csr/don or http://www.cdc.gov/travel (N Engl J Med 2017 Mar 8 [Epub ahead of print]).

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, Cefotetan, Cefotaxime (unavailable), Cefoxitin, 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 antimicrobials: Clindamycin injection, Erythromycin lactobionate injection, Mupirocin calcium 2% cream, Mupirocin calcium 2% nasal ointment (unavailable), Vancomycin injection
      • Vaccines: Hepatitis A Virus Vaccine Inactivated, Rabies vaccine (RabAvert), Tetanus and Diphtheria Toxoids Adsorbed, Yellow Fever vaccine
    • [Shortage recently resolved]: Ampicillin injection, Meningococcal vaccines (various)
  • Antimicrobial drugs newly discontinued: MenHibrix (February 2017)
  • Other discontinuations: 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