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July '26 Infectious Diseases Update

Posted by Doug Black, PharmD., Ann Lloyd, PharmD. on Jul 20th 2026

Article of the Month (Editors' Choice) 

Oral Nirmatrelvir-Ritonavir (Paxlovid) for COVID-19 in Higher-Risk Outpatients

By Michael S. Saag, M.D. and Andrew T. Pavia, M.D.

ARTICLE SUMMARY:

  • Two randomized open-label trials (PANORAMIC in the UK and CanTreatCOVID in Canada) were reported in the same NEJM article (N Engl J Med 2026;394:1583-94) that evaluated the effectiveness of nirmatrelvir-ritonavir (300mg-100mg; "N/r") twice-daily oral therapy for 5 days compared to standard of care (SOC) among "at risk" individuals with a new diagnosis of COVID-19 infection. "At risk" was defined as age ≥50 years or ≥18 years with comorbid conditions.
  • Of note, only 1% of the population in each trial had never received a COVID-19 vaccine and ~98% had received 2 or more vaccinations. Approximately 50% had coexistent conditions. Median age was 55 years.
  • In the PANORAMIC trial, 14 of 1698 (0.8%) patients randomized to N/r were hospitalized or died compared to 11 of 1673 (0.7%) in the SOC group (adjusted odds ratio [AOR] 1.18; 95% Bayesian credible interval [BCI] 0.55-2.62). In the CanTreatCOVID trial, 2 of 343 (0.6%) patients in the N/r group versus 4 of 324 (1.2%) in the SOC group were hospitalized or died (AOR 0.48; 95% BCI 0.08-2.23).
  • Serious adverse events were uncommon in the N/r recipients: 9/1698 in the PANORAMIC trial and 4/343 in the CanTreatCOVID trial.
  • The authors concluded that N/r did not reduce the incidence of hospitalization or death in either trial.
  • The authors used a complicated definition of sustained recovery and looked at intervals, where time to recovery is a continuous outcome. With all those caveats, 33.0% of N/r recipients in the PANORAMIC trial had "early" sustained recovery compared to 22.1% in the SOC (estimated treatment effect [TE] 1.74; 95% BCI 1.48-2.04). Time to recovery was faster in the N/r group, with an estimated TE of 2.123 (95% BCI 1.792-2.511) for recovery between days 3 and 7 of onset of illness.
  • By day 5, geometric mean SARS-CoV-2 viral load was reduced 10-fold among N/r recipients in the PANORAMIC trial vs SOC, estimated TE 0.13 (95% BCI 0.08-0.21).

PERSPECTIVE/COMMENTARY:

  • The populations in each trial were highly immune to SARS-CoV-2, either through vaccination or prior infection. The circulating Omicron variant at the time of the trials was generally more infectious but less virulent compared to the original alpha-variant of SARS-CoV-2. 
  • As such, among the SOC population, only 11 of 1673 participants reached the trial endpoint criteria of hospitalization or death. With such low endpoints in the control group, no intervention can show benefit. 
  • While the populations were technically at "high risk," few patients were extremely frail or immune compromised (<1% were transplant recipients and only 9% and 3.3%, respectively, had a weakened immune system in the PANORAMIC and CanTreatCOVID trials).
  • For those with significant immunocompromise (e.g., stem cell bone marrow transplant, other transplant/chemotherapy recipients), most experts recommend outpatient remdesivir for 3-5 days as soon as possible after the onset of symptoms.
  • For others at significantly higher risk of disease progression, including those who are older (>70 years), have multiple comorbid conditions (especially pulmonary disease, advanced CV disease, advanced liver disease, or diabetes), or those never vaccinated, N/r remains an appropriate intervention, especially when used early in the course of symptomatic COVID-19 disease.
  • Conversely, for those without the above conditions who are younger and otherwise healthy, shared decision making should be employed to determine if the benefits of shorter duration of symptoms outweigh the potential exposure to side effects and costs of N/r.

Pneumococcal Vaccine - PCV21 Expanded Age Range

  • On June 17, the FDA expanded the indicated age range for PCV21 (Capvaxive, Merck) to include children and adolescents 2 through 17 years of age who have completed a primary pediatric PCV series (with PCV15 or PCV20) and have one or more chronic medical conditions that put them at increased risk for invasive pneumococcal disease. This is the same population of children for whom a dose of pneumococcal polysaccharide vaccine (PPSV23) is currently recommended (i.e., PCV21 should replace the PPSV23 dose).

New Drug Approvals

  • Tebipenem pivoxil (Utebzi), approved by the FDA for the oral treatment of complicated UTI, including pyelonephritis, caused by susceptible strains of E. coli, K. pneumoniae, E. cloacae species complex, K, oxytoca, and E. faecalis in adult patients who have limited or no alternative oral treatment options. Tebipenem pivoxil is hydrolyzed by esterases as it is absorbed to form tebipenem, a carbapenem, and pivalate (trimethylacetic acid). Pivoxil ester prodrugs have been associated with a reversible decrease in serum carnitine concentrations. The drug may also lower serum valproic acid concentrations in patients treated with valproic acid or divalproex. The recommended dose of tebipenem pivoxil is 600 mg po q6h x7-10 days, with or without food.

New or Updated Guidelines

Antimicrobial Stewardship

Stewardship in Hospital Outpatient Departments

  • A qualitative study explored the implementation of antimicrobial stewardship (AMS), congruence with outpatient Centers for Disease Control (CDC) and Prevention Core Elements, and obstacles faced by hospital outpatient departments when using hospital-based interventions in outpatient settings.
  • A total of 42 AMS program leaders from 28 hospitals were interviewed via telephone. Most represented hospitals belonging to an urban healthcare system. Over half of the respondents were pharmacists or physicians specializing in infectious diseases. The leadership and staffing of AMS activities in outpatient departments was variable. Three-quarters reported that the same staff led both inpatient and outpatient AMS activities, and only one reported additional funding for staff expansion into the outpatient setting.
  • Nine hospitals (32%) deployed outpatient facility-specific treatment guidelines using a clinical decision support system (CDSS) while 12 (43%) had guidelines without using a CDSS. A majority of hospitals (61%) tracked data on antibiotic use, and 57% of hospitals provided outpatient-specific education to providers.
  • Barriers to implementing AMS activities included clinical and operational differences between inpatient and outpatient environments, staffing limitations, uncertainty about inpatient requirements for outpatient implementation, and electronic medical record capabilities and information technology resources.
  • AMS leaders should consider advocating for additional staff to implement outpatient stewardship with a focus on developing facility-specific treatment guidelines.
  • Antimicrob Steward Healthc Epidemiol. 2026 Jun 4;6(1):e167. doi:10.1017/ash.2026.10417.

    Antimicrobial Shortages (US)

    • New shortages:
      • None
    • Resolved shortages:
      • Oxacillin injection (4 Nov 2025)
    • Antimicrobial drugs recently discontinued: 
      • None
    • Antimicrobial drugs or vaccines in continued reduced supply or unavailable due to increased demand, manufacturing delays, product discontinuation by a specific manufacturer, or unspecified reasons: 
      • Antibacterial drugs:
        • Aminoglycosides:
          • Gentamicin injection (22 Feb 2021)
        • Cephalosporins:
          • Cefazolin injection (4 Jun 2018)
          • Cefotaxime injection (10 Jun 2015)
        • Fluoroquinolones:
          • Levofloxacin injection in D5W (29 May 2024)
          • Levofloxacin oral solution, 25 mg/mL (15 Sep 2023)
          • Moxifloxacin injection (13 Jan 2026)
          • Moxifloxacin 400 mg tablets (6 Dec 2023)
        • Glycopeptides, glycolipopeptides, lipopeptides:
          • Vancomycin injection (1 Jun 2015)
        • Lincosamides:
          • Clindamycin phosphate injection (25 Jun 2015)
        • Macrolides, azalides:
          • Azithromycin injection (6 Jan 2026)
          • Azithromycin oral suspension, 1 gm packets (20 Nov 2024)
          • Erythromycin lactobionate injection (21 Apr 2025)
        • Miscellaneous
          • Bacitracin ophthalmic ointment 500 units/gm (12 Sep 2024)
          • Benzylpenicilloyl polylysine [Pre-pen] (19 Mar 2026)
          • Chloramphenicol injection (9 Oct 2023)
          • Neomycin and Polymyxin B sulfates GU irrigant (25 Jun 2023)
          • Rifaximin 200 mg tablets (11 Apr 2024)
        • Oxazolidinones:
          • Linezolid injection (16 Oct 2024)
        • Penicillins:
          • Amoxicillin, all oral formulations (18 Oct 2022)
          • Amoxicillin-clavulanate, all oral formulations (17 Nov 2022)
          • Dicloxacillin 250 mg, 500 mg capsules (18 Aug 2021)
          • Penicillin G benzathine injection (1 Feb 2023)
          • Penicillin G benzathine/Penicillin G procaine (31 Mar 2023) 
      • Antifungal drugs: 
        • Amphotericin B Lipid Complex (5 Aug 2022)
        • Ibrexafungerp 150 mg tablets (3 Dec 2024)
      • Antimycobacterial drugs: 
        • No current shortages
      • Antiparasitic drugs:
        • Nitazoxanide oral susp 100 mg/5 mL (15 Feb 2024)
      • Antiviral drugs: 
        • Acyclovir injection (16 Dec 2025)
        • Oseltamivir, all formulations (1 Nov 2022)
        • Peginterferon alfa-2a (Pegasys) (8 Jan 2025)
        • Ribavirin for inhalation solution (23 May 2023)
    • For more information including estimated resupply dates, see ASHP Drug Shortages website.
    • Data shown are current as of 10 July 2026.
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