The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th
SANFORD GUIDE ,, The Sanford Guide To Antimicrobial Therapy 2016 th 46 Edition David N Gilbert, M.D Henry Chambers, M.D F George M Eliopoulos, M.D Michael S Saag, M.D Andrew! Pavia, M.D Douglas Black, Pharm.D David Freedman, M.D Kami Kim, M.D Brian S Schwartz, M.D Note Editorial To our readers, We have made significant improvements Therapy First, we thank you in this 46 th edition of The Sanford Guide to Antimicrobial your comments, questions and reviews of our content You are an for integral part of the collaborative process that results in each updated edition of The Sanford Guide We strive to provide you with the current range of evidence-based options for treatment, management and prevention of infectious diseases The Sanford Guide reaches a global which means you should consider our recommendations in light of local resistance and susceptibility patterns, availability of and variations in audience, formulation of antimicrobial agents and other local conditions that guide care for your patients New • Table major updates include genital 1: & bladder kidney • and areas of significant change material in this 46 th edition include: tract infections based on new CDC STD Guidelines, infections, enterococcal endocarditis (also Table 5A), empiric therapy for pneumonia, as well as updated regimens and references Tables 4A, 4B and 4C: Activity spectra (antibacterial, antifungal and antiviral) These tables have been completely reworked, updated and are now color-coded The color coding and associated symbols are intended to provide more descriptive categorization of the table data Drug • Table • Table 8: Pregnancy Risk 7: methods for additional drugs are added and of Antimicrobial During Lactation This new table adds data Desensitization Desensitization on safety of antimicrobials • Table 10A (and elsewhere): in lactating mothers New antibacterials added: ceftazidime-avibactam and cefto oza ne-tazobactam I New antifungal drug: Isavuconazole added New direct-acting agents and combination • Table • Table 14 (HCV): 1: agents and updated HCV treatment regimens • Table 16: Pediatric Dosing Reinstated of antimicrobials in children • Table including edition is a new table summarizing dosing older 7A: Dosing in Renal Impairment This table has also been thoroughly reworked and reviewed As always, in this age 28 days and all for improved clarity in our recommendations content has been updated with new practice new references from the published literature, and treatment guidelines, updated prescribing information and drug safety information Some recommendations in suggest the use of agents for indications or in doses other than found product labeling Such recommendations are based on published reports literature; with due consideration of the concerns of the regarding in peer-reviewed they are not based on input from any pharmaceutical manufacturer They are ''off-label" uses We U.S provide reference(s) for and, in some cases, annotate such recommendations with the notation "NAI" meaning not an FDA-approved indication The Editors January 2016 made Food and Drug Administration (FDA) or dose SANFORD GUIDE® The Sanford Guide To Antimicrobial Therapy 2016 46 th Edition GET MORE BOOKS AND FREE SANFORD GUIDE WEB EDITION TRIAL RESOURCES Visit store.sanfordguide.com, click the Redeem Coupon button and enter WEB16 to receive a complimentary Website: 60-day subscription to the Sanford Guide Web Edition www.pharmacybr.blogspot.com *Limit one per customer 30,2017 trial • Offer expires April Facebook page: www.fb.com/pharmacybr Telegram channel: https://t.me/pbr123 The Sanford Guide to Antimicrobial Therapy 2016 46th Edition Editors Henry David N Gilbert, M.D Providence Portland Medical Center, Oregon Sciences University Beth Israel Deaconess San Francisco Michael S Saag, M.D UAB Center for AIDS Research, Director, Firm, L Tullis Research Services Translational Sciences Institute University of California at George M Eliopoulos, M.D James Chambers, M.D Director, Clinical UCSF Clinical and Professor of Medicine, Oregon Health Chief, F Professor of Medicine Chief of Infectious Diseases Professor of Medicine and Director, Hospital, Division of Infectious Diseases, Professor of Medicine, Harvard Medical School, Boston, Massachusetts University of Alabama, Birmingham Andrew T Pavia, M.D George & Esther Gross Presidential Professor - Infectious Chief, Division of Pediatric Diseases University of Utah, Salt Lake City Contributing Editors Douglas Black, Pharm Associate Professor of Pharmacy, University of Washington, Seattle D Brian S Schwartz, M.D David O Freedman, M.D Associate Professor of Medicine Director, Travelers Health Clinic, University of California University of Alabama, at Professor of Medicine, San Francisco Birmingham Kami Kim, M.D Professor of Medicine, Microbiology & Immunology, Pathology Albert Einstein College of Medicine New York, NY Managing Editor Jeb C Sanford Memoriam Jay R Sanford, M.D 1928-1996 Merle A Sande, M.D 1935 2007 Robert C Moellering, Jr., M.D 1936 2014 Publisher Antimicrobial Therapy, Inc The Sanford Guides are updated annually and published by: ANTIMICROBIAL THERAPY, INC RO Box 276, 11771 Lee Highway Sperryville, VA 22740-0276 USA Tel 540-987-9480 Fax 540-987-9486 www.sanfordguide.com Email: info@sanfordguide.com Copyright All rights reserved No © 1969-2016 by Antimicrobial Therapy, Inc may be may be reproduced, stored in a retrieval any form or by any means-digital, electronic, mechanical, optical, part of this publication system or transmitted in photocopying, recording or otherwise-without prior written permission from Inc., 1771 Lee Hwy, P.O Box 276, Sperryville, VA 22740-0276 Antimicrobial Therapy, “Sanford Guide” and “Hot Disease” logo are USA ® registered trademarks of Antimicrobial Therapy, Inc Acknowledgements Thanks Ushuaia Solutions SA Argentina: Alcorn Printing, Harleysville, PA and Fox Bindery, Quakertown PA for design and production of this edition of the Sanford Guide to Note to Readers Since 1969, the Sanford Guide has been independently prepared and published Decisions regarding the content of the Sanford Guide are solely those of the editors and the publisher We welcome questions, comments and feedback concerning and taken Every effort is made to into account in the Sanford Guide ensure accuracy of the content of package All of your feedback is reviewed updating the content of the Sanford Guide this guide However, current full prescribing each drug should be consulted before prescribing any product The editors and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the currency, accuracy, or completeness of the contents of this publication Application of this information in a particular situation remains the professional responsibility of the practitioner information available in the insert for For the most current information, subscribe to webedition.sanfordguide.com or Sanford Guide mobile device applications Printed in the United States of America ISBN 978-1-930808-93-5 Library Edition (English) QUICK PAGE GUIDE TO THE SANFORD GUIDE RECOMMENDED TREATMENT— DIFFERENT SITES/MICROBES: 4-68 BY ORGAN SYSTEM: CAPD 231 Peritonitis BY ORGANISM: 69-71 Bacteria Highly Resistant Bacteria 81 CA-MRSA 82 121-133 137-147 151-161 166-176 Fungi Mycobacteria Parasites Non-HIV Viruses HIV/AIDS 181 Influenza 173 72 DURATION OF TREATMENT: ANTIMICROBIAL PROPHYLAXIS: - 191 199 199 Pregnancy/Delivery Post-Splenectomy Sexual Exposure Sickle Cell Disease Surgical Endocarditis Exposure to HIV/HBV/HCV Transplants: Opportunistic Infections 200 200 200 204 205 209 IMMUNIZATIONS: 232 233 Anti-tetanus Rabies Post Exposure ANTIMICROBIALS: Spectra Adverse Dosage/SE Effects 73-80 Antibiotics AG-Once Daily 115-116 119 83 120 Continuous/Prolonged Infusion Desensitization (Pen, TMP-SMX, ceftriaxone) Inhalation Antibiotics 85 Pregnancy Risk Categories 134-136 148-150 162-165 177-180 192-195 79 Antifungals Antimycobacterials Antiparasitics Antivirals (Non-HIV) Antiretrovirals Pediatric 211 Dosinq DOSE ADJUSTMENTS: Renal 214-228 Hepatic 230 229 Obesity DRUG INFORMATION: Pharmacologic Features Pharmacodynamics Drug-Drug Interactions Generic/Trade Names 88 99 235 244 MISCELLANEOUS: Abbreviations Parasites Causing Eosinophilia Parasitic Drugs: 102 118 Dosing Sources Directory of Resources 165 165 234 - 242 (243 ARV Drugs) —TABLE OF CONTENTS— ABBREVIATIONS TABLE TABLE TABLE TABLE 4A Clinical Approach Recommended Choice to Initial of Antimicrobial Therapy 69 Antimicrobial Agents Against Selected Bacteria Suggested Duration Therapy of Antibiotic in Immunocompetent 72 Patients 73 79 79 Antibacterial Activity Spectra 4B 4C Antifungal Activity Spectra Antiviral Activity TABLE 5A 5B Spectra Treatment Options For Systemic Infection Due To Multi-Drug Resistant Gram-Positive Bacteria Treatment Options for Systemic Infection Due to Selected Multi-Drug Resistant 81 Gram-Negative 81 Bacilli Suspected or Culture-Positive Community-Associated TABLE Suggested Management TABLE TABLE Antibiotic Hypersensitivity Reactions Pregnancy Risk and of 82 Methicillin-Resistant S aureus Infections TABLE 9A in 85 of Antimicrobial 0B 0C Antibiotic Dosage 88 99 99 Agents Pharmacodynamics of Antibacterials Enzyme -and Transporter- Mediated Interactions TABLE 0A 83 Desensitization methods Lactation Selected Pharmacologic Features 9B 9C TABLE Safety & Drug of Antimicrobials 02 115 and Side-Effects Selected Antibacterial Agents— Adverse Reactions— Overview Antimicrobial Agents Associated with Photosensitivity 117 118 10D 0E Aminoglycoside Once-Daily and Multiple Daily Dosing Regimens Prolonged or Continuous Infusion Dosing of Selected Beta Lactams 10F Inhalation Antibiotics 120 Treatment of Fungal Infections—Antimicrobial Agents of Choice Antifungal Drugs: Dosage, Adverse Effects, Comments 121 Treatment o' Mycobacterial Infections Dosage and Adverse Effects of Antimycobacterial Drugs 137 148 Treatment o' Parasitic Infections Dosage and Selected Adverse Effects of Antiparasitic Drugs Parasites that Cause Eosinophilia (Eosinophilia In Travelers) 151 1 A 1 B TABLE 12A 12B TABLE 13A 3B 13C 3D Sources for 162 165 165 Hard-to-Find Antiparasitic Drugs Antimicrobial Prophylaxis for Selected Bacterial Infections Antibiotic Prophylaxis to Prevent Surgical Infections in Adults Antimicrobial Prophylaxis for the Prevention of Bacterial Endocarditis 199 200 Antiviral 181 192 196 97 in Patients with 204 205 Underlying Cardiac Conditions 15D 15E Management of Exposure to HIV-1 and Hepatitis B and Prevention of Selected Opportunistic Infections in C Human Hematopoietic Transplantation (HCT) or Solid Organ Transplantation (SOT) in Cell Adults With Normal 209 Renal Function TABLE TABLE 17A 17B 17C TABLE TABLE 19 TABLE 20A 20B TABLE 21 TABLE 22A 22B 34 166 177 Antiviral 14B 14C 14D 14E 4F 15B 15C Therapy Drugs (Non-HIV) Antiretroviral Therapy (ART) in Treatment-Naive Adults (HIV/AIDS) Antiretroviral Drugs and Adverse Effects Hepatitis A & HBV Treatment a HCV Treatment Regimens and Response TABLE 14A TABLE 15A 1 Pediatric dosing (AGE Dosages > 28 DAYS) of Antimicrobial Drugs No Dosage Adjustment with Antimicrobial Dosing in 21 Adult Patients with in Renal Impairment Renal Insufficiency by Category Obesity Antimicrobials and Hepatic Disease: Dosage Adjustment Treatment of CAPD Peritonitis in Adults Anti-Tetanus Prophylaxis, Wound Classification, Immunization Rabies Postexposure Prophylaxis Selected Directory of Anti-Infective Drug-Drug Interactions Drug-Drug Interactions Between Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) and Protease Inhibitors Trade 230 231 232 233 234 Resources List of Generic and Common TABLE 23 INDEX OF MAJOR ENTITIES 214 229 229 Names 235 243 244 246 ABBREVIATIONS 3TC = lamivudine AB,% = percent absorbed ABC = abacavir CSF = CXR = ABCD = amphotericin B colloidal dispersion ABLC = ampho B lipid complex AD = after dialysis ADF = adefovir AG = aminoglycoside AIDS = Acquired Immune Deficiency Syndrome AM-CL = amoxicillin-clavulanate AM-CL-ER = amoxicillin-clavulanate extended release AMK = amikacin Amox = amoxicillin AMP = ampicillin Ampho B = amphotericin B AM-SB = ampicillin-sulbactam AP = atovaquone proguanil APAG = antipseudomonal aminoglycoside ARDS = acute respiratory distress syndrome ARF = acute rheumatic fever ASA = aspirin ATS = American Thoracic Society ATV = atazanavir AUC = area under the curve Azithro = azithromycin bid = 2x per day BL/BLI = beta-lactam/beta-lactamase BSA = body surface area BW = body weight C&S = culture & sensitivity CARB = carbapenems inhibitor CAPD = continuous ambulatory peritoneal CDC = Centers for Disease Control Cefpodox = cefpodoxime Ceftaz = ceftazidime dialysis proxetil Ceph= cephalosporin CFB = ceftobiprole CFP = cefepime d4T = cerebrospinal chest x-ray stavudine ddC = zalcitabine IT = intrathecal = itraconazole intravenous IVDU = intravenous drug user IVIG = intravenous immune globulin Itra DLV = delavirdine DORI = doripenem DOT = directly observed therapy Doxy = doxycycline DR = delayed release Keto = ketoconazole kg = kilogram DRSP = drug-resistant DS = double strength S pneumoniae EBV = Epstein-Barr virus EES = erythromycin ethyl succinate EFZ = efavirenz ELV = elvitegravir EMB = ethambutol ENT = entecavir ER = extended release ERTA = ertapenem Erythro = erythromycin ESBLs = extended spectrum (Wactamases ESR = erythrocyte sedimentation rate ESRD = endstage renal disease Flu = fluconazole Flucyt - flucytosine FOS-APV = fosamprenavir FQ = fluoroquinolone FTC = emtricitabine G = generic GAS = Group A Strep Gati - gatifloxacin - gonorrhea Clarithro = clarithromycin; ER Clav = clavulanate Clinda = clindamycin CLO = clofazimine Clot = clotrimazole = cytomegalovirus CQ = chloroquine phosphate gm gram GNB gram-negative Cobi = cobicistat CrCI = creatinine clearance CrCIn = CrCI normalized for BSA CRRT = continuous renal replacement therapy C/S = culture & sensitivity CSD = cat-scratch disease isoniazid Inv = investigational IP = intraperitoneal IV Gemi - CMV INH = trial ddl = didanosine DIC = disseminated intravascular coagulation div = divided GC extended release intramuscular imipenem-cilastatin IMP = Dapto = daptomycin DBPCT = double-blind placebo-controlled dc = discontinue Chloro = chloramphenicol CIP = ciprofloxacin; CIP-ER = CIP extended release = IM= fluid Gent griseofulvin HEMO hemodialysis HHV HLR MSSA/MRSA = methicillin-sensitive/resistant S MTB = Mycobacterium tuberculosis NB = name brand aureus NF = nitrofurantoin NAI = not FDA-approved (indication or dose) NFR = nelfinavir NNRTI = non-nucleoside reverse transcriptase inhibitor NRTI = nucleoside reverse transcriptase inhibitor NSAIDs = non-steroidal NUS = not available in the U.S NVP = nevirapine O Ceph 2, = oral cephalosporins Ceph 1, 2, 3, = parenteral cephalosporins parenteral cephalosporins with antipseudomonal activity polymerase chain reaction bacilli PCR = virus hematopoietic stem herpes simplex virus PEP = post-exposure prophylaxis PI = protease inhibitor PIP-TZ = piperacillin-tazobactam o = high-level resistance HSCT HSV - MQ = mefloquine MSM = men who have sex with men P Ceph AP = history of cell transplant injectable agent/anti-inflammatory drugs indinavir interferon IDV = IFN = = milliliter Moxi = moxifloxacin P H/O IA mL , human herpesvirus human immunodeficiency HIV LAB = liposomal ampho B LCM = lymphocytic choriomeningitis virus LCR = ligase chain reaction Levo = levofloxacin LP/R = lopinavir/ ritonavir meg (or pg) = microgram MDR = multi-drug resistant MER = meropenem Metro = metronidazole Mino = minocycline Oflox = ofloxacin gomifloxacin gentamicin Griseo = oral dosing Q = primaquine PRCT = Prospective randomized controlled trials post-transplant lymphoproliferative disease Pts = patients Pyri = pyrimethamine PTLD = PZA = pyrazinamide ABBREVIATIONS SM = streptomycin SQV = saquinavir qid = 4x per day QS = quinine sulfate Quinu-dalfo = Q-D = = every [x] hours, e.g., q8h = wk = dose weekly = resistant RFB = rifabutin RFP = rifapentine Rick = Rickettsia RIF = rifampin RSV = respiratory syncytial virus RTI = respiratory tract infection RTV = ritonavir = every hrs tumor necrosis factor Tobra = tobramycin TPV = TST = tipranavir tuberculin skin test UTI = urinary tract infection Vanco = vancomycin VISA = vancomycin intermediately VL = resistant S aureus load voriconazole viral = VZV = varicella-zoster virus ZDV = zidovudine Vori Tetra = tetracycline tid = 3x per day TMP-SMX = trimethoprim-sulfamethoxa/olu treatment SA = Staph, aureus sc = subcutaneous SD = serum drug level after single dose Sens = TNF = SS = steady state serum level STD = sexually transmitted disease subcut = subcutaneous Sulb = sulbactam Sx = symptoms Tazo = tazobactam TBc = tuberculosis TDF = tenofovir TEE = transesophageal echocardiography Teico = teicoplanin Telithro = telithromycin quinupristin-dalfopristin q[x]h rx (2) sensitive (susceptible) ABBREVIATIONS OF JOURNAL TITLES Med Res Am Opin: Current Medical Research and Opinion Ther: Dermatologic Therapy Dermatol Clin: Dermatologic Clinics Dig Dis Sci: Digestive Diseases and Sciences DMID: Diagnostic Microbiology and Infectious Disease EID: Emerging Infectious Diseases EJCMID: European Journal of Clin Micro & Infectious Diseases Eur J Neurol: European Journal of Neurology Exp Mol Path: Experimental & Molecular Pathology Exp Rev Anti Infect Ther: Expert Review of Anti-Infective Therapy AnEM: Gastro: Gastroenterology Hpt: Hepatology Curr AAC: Antimicrobial Agents & Chemotherapy Adv PID: Advances in Pediatric Infectious Diseases AHJ: American Heart Journal AIDS Res Hum Retrovir: AIDS Research & Human AJG: American Journal of Gastroenterology AJM: American Journal of Medicine AJRCCM: Derm Retroviruses of Respiratory Critical Care Medicine Journal of Tropical Medicine & Hygiene Aliment Pharmacol Ther: Alimentary Pharmacology & Therapeutics J Hlth Pharm: American Journal of Health-System Pharmacy Amer J Transpl: American Journal of Transplantation American Journal AJTMH: American Annals of Emergency Medicine AnIM: Annals of Internal Medicine Ann Pharmacother: Annals of Pharmacotherapy AnSurg: Annals of Surgery Antivir Ther: Antiviral Therapy ArDerm: Archives of Dermatology ArIM: Archives of Internal Medicine ARRD: American Review of Respiratory Disease BMJ: British Medical Journal BMT: Bone Marrow Transplantation Brit J Derm: British Journal of Dermatology Can JID: Canadian Journal of Infectious Diseases Canad Med J: Canadian Medical Journal CCM: Critical Care Medicine CCTID: Current Clinical Topics CDBSR: Cochrane Database CID: Clinical Infectious in Infectious Disease of Systematic Reviews Diseases Microbiology and Infection Microbiology Newsletter Clin Micro Rev: Clinical Microbiology Reviews CMAJ: Canadian Medical Association Journal COID: Current Opinion in Infectious Disease Clin Micro CMN: Inf: Clinical Clinical ICHE: Infection Control and Hospital Epidemiology DC No Amer: Infectious Disease Clinics of Norlh America IDCP: Infectious Diseases in Clinical Practice JAA: International Journal of Antimicrobial Agents I I Inf Med: Infections in Medicine of AIDS and Human Retrovirology Journal of Allergy and Clinical Immunology Ger Soc: Journal of the American Geriatrics Society Chemother: Journal of Chemotherapy Clin Micro: Journal of Clinical Microbiology Clin Virol: Journal of Clinical Virology Derm Treat: Journal of Dermatological Treatment Hpt: Journal of Hepatology Inf: Journal of Infection Med Micro: Journal of Medical Microbiology Micro Immunol Inf: Journal of Microbiology, J AIDS & HR: Journal J J J J J J J J J J All Clin Immun: Am Immunology, & Infection J Ped: Journal of Pediatrics J Viral Hep: Journal of Viral Hepatitis JAIDS: JAIDS Journal of Acquired Immune Deficiency Syndromes JAMA: Journal of the American Medical Association JAVMA: Journal of the Veterinary Medicine Association JCI: Journal of Clinical Investigation JCM: Journal of Clinical Microbiology JIC: Journal of Infection and Chemotherapy JID: Journal of Infectious Diseases JNS: Journal of Neurosurgery JTMH: Journal of Tropical Medicine and Hygiene Ln: Lancet LnID: Lancet Infectious Disease Mayo Clin Proc: Mayo Clinic Proceedings Med Lett: Medical Letter Med Mycol: Medical Mycology MMWR: Morbidity & Mortality Weekly Report NEJM: New England Journal of Medicine Neph Dial Transpl: Nephrology Dialysis Transplantation OFID: Open Forum Infectious Diseases Ped Ann: Pediatric Annals Peds: Pediatrics Pharmacother: Pharmacotherapy PIDJ: Pediatric Infectious Disease Journal QJM: Quarterly Journal of Medicine Scand J Inf Dis: Scandinavian Journal of Infectious Diseases Seminars in Respiratory Infections SGO: Surgery Gynecology and Obstetrics SMJ: Southern Medical Journal Surg Neurol: Surgical Neurology Transpl Inf Dis: Transplant Infectious Diseases Transpl: Transplantation TRSM: Transactions of the Royal Society of Medicine Sem Resp Inf: of Antimicrobial Chemotherapy Journal of American College of Cardiology JAC: Journal JACC: TABLE - CLINICAL APPROACH TO INITIAL CHOICE OF ANTIMICROBIAL THERAPY* Treatment based on presumed site or type of infection In selected instances, treatment and prophylaxis based on identification of pathogens Regimens should be reevaluated based on pathogen isolated, antimicrobial susceptibility determination, and individual host characteristics (Abbreviations on page ANATOMIC SITE/DIAGNOSIS/ MODIFYING CIRCUMSTANCES ABDOMEN: BONE: See Peritoneum, page (usual) 46; Gallbladder, Osteomyelitis Microbiologic diagnosis of bone SUGGESTED REGIMENS* ETIOLOGIES PRIMARY page is 17; ALTERNATIVE 2) ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES AND COMMENTS and Pelvic Inflammatory Disease, page 26 essential If blood culture negative, need culture of bone (EurJ Clin Microbiol Infect Dis 33:371, 2014) Culture of sinus tract drainaqe not predictive culture For comprehensive review of antimicrobial penetration into bone, see Clinical Pharmacokinetics 48:89, 2009 Hematogenous Osteomyelitis (see IDSA guidelines for vertebral osteo: CID July 29, 2015) Empiric therapy Collect bone and blood cultures before empiric therapy Newborn (4 mos.) Adult: Osteo of extremity (NEJM 370:352, 2014) MRSA unlikely: oxacillin) (Nafcillin or Severe allergy or toxicity: (Linezolid NA1 10 mg/kg IV/po q8h + aztreonam) (Ceftaz or CFP) + children in S aureus, Group A MRSA strep Gm-neg bacilli rare, kingae children in (Ceftaz or CFP) strep, Kingella Kingella 40 possible: Vanco mg/kg/day div q6h MRSA unlikely: (Nafcillin 150 mg/kg/day div q6h (max 12 gm) or oxacillin) Add Ceftaz or CFP Gm-ne;g bacilli on Gram stain Adult doses below MRSA possible: Vanco MRSA unlikely: Nafcillin Severe allergy or toxicity: Clinda or TMP-SMX or linezolid NAI Adults: ceftaz IV q8h, CFP IV q12h See Table 10B for adverse reactions to drugs gm gm if Adult (>21 yrs) Vertebral osteo S ± epidural aureus most common but variety other organisms abscess In (see IDSA guidelines for vertebral osteo: CID 61:859, 2015) Turkey: Brucella & M.TBc common gm IV q4h + (Ceftriaxone gm q24h OR CFP gm q8h OR 15-20 mg/kg IV q 8-1 2h for trough of 15-20 ng/mL + (Ceftriaxone gm q24h OR OR CFP Levo 750 mg q24h) gm q8h OR mg q24h) Levo 750 oxacillin Dx: MRI diagnostic test of choice, indicated to rule out epidural abscess For comprehensive review of vertebral osteomyelitis see NEJM 362:11, 2010 Whenever possible empirical therapy should be administered after cultures are obtained Blood & bone cultures essential Specific therapy -Culture and in \'itro susceptibility results knowri See CID Jul 29, 2015 MSSA for IDiSA Guidelines Nafcillin or oxacillin 2 gm gm IV IV q4h q8h or Vanco 5-30 mg/kg IV q 8-1 2h Other options if susceptible in for trough of 15-20 ng/mL OR (see NEJM 362:1 1, 2010): Dapto 6-8 mg/kg IV q24h OR 1) TMP-SMX 8-10 mg/kg/d po/IV cefazolin Linezolid 600 mg IV/po mg q12h q12h MRSA See Table 6, /»ge 82; IDSA Guidelines CID 52:e IB55, 201 1; CID 52:285-92, 201 Vanco 5-20 mg/kg 12h • for IV q 8- Linezolid 600 trough of 15-20 jig/mL IV/po RIF 300-450 mg bid ± RIF 300 mg OR Dapto allergy/toxicity issues div q8h + RIF 300-450 mg bid: limited MRSA (see AAC 53:2672, 2009); 2) Levo 750 mg po q24h) + RIF 600 mg po q24h; 3) Fusidic acid NUS 500 mg IV q8h + RIF 300 mg po bid (CID 42:394, 2006); 4) Ceftriaxone gm IV q24h data, particularly for po/IV bid (CID 54:585, 2012)(MSSA only): Duration of therapy: weeks, provided that epidural or paravertebral abscesses can be drained; consider longer IV po/IV bid course in those with extensive infection or abscess particularly if not amenable to drainage because of increased risk of treatment failure (OFID Dec 5:1, 2014) (although data are lacking that this approach improves efficacy versus a wk course) and >8 weeks in patients undergoing device implantation (CID 60:1330, 2015) mg are for adults (unless otherwise indicated) with clinically severe (often life-threatening) infections Dosages also assume normal and not severe hepatic dysfunction ALTERNATIVE THERAPY INCLUDES these and mg/kg q24h i RIF 300-450 DOSAGES SUGGESTED vitro considerations: allergy, pharmacology/pharmacokinetics, compliance, costs, local resistance profiles renal function, 241 TABLE 22A ANTI-INFECTIVE AGENT OTHER DRUG (A) (7) IMPORT EFFECT (B) Quinupristin-dalfopristin Lidocaine t levels of (Synercid) (continued) Methylprednisolone t levels of Midazolam, diazepam t levels of B ++ ++ ++ Statins T levels of B ++ t levels of | levels of levels of B -> B B A Raltegravir See Inteqrase Strand Transfer Ribavirin Didanosine Stavudine B B Inhibitors Zidovudine J, OH, ketoconazole, PZA toxicity— avoid ++ ++ + Rifamycins Al j levels of (rifampin, rifabutin) Atovaquone t levels of A, i levels of Beta adrenergic blockers i effect of B Caspofungin i levels of B— increase dose Clarithromycin | levels of A, induced | metabolism and hence lower than anticipated serum levels: ACE inhibitors, dapsone Corticosteroids T Cyclosporine effect of Delavirdine | levels of A, | levels of levels of B diazepam, digoxin, Disopyramide Fluconazole Ref.: ArIM 162:98 5, 2002 The following list is a partial of drugs with rifampin- diltiazem, doxycycline, fluconazole, fluvastatin, haloperidol, moxifloxacin, nifedipine, progestins, triazolam, tricyclics, voriconazole, zidovudine (Clin Pharmacokinetic 42:819, 2003) ++ + B + (metoprolol, propranolol) Digoxin j, levels of replacement requirement of B B l levels of —avoid B B A of A ++ ++ B ++ ++ ++ ++ ++ T levels of Amprenavir, indinavir, nelfinavir, f levels i levels of ritonavir (| dose ++ of A), B INH Converts INH to toxic hydrazine Itraconazole, ketoconazole Linezolid levels of B, T levels of | levels of B Methadone \l serum Nevirapine i levels of Warfarin Oral contraceptives Suboptimai anticoagulation i effectiveness; spotting, pregnancy Phenytoin i levels of Protease inhibitors | A levels (withdrawal) B— avoid ++ ++ ++ + ++ ++ + + B levels of A, f levels of B ++ CAUTION Rimantadine Ritonavir Saquinavir effect of Raltegravir i levels of Sulfonylureas l hypoglycemic Tacrolimus i levels of Theophylline T levels of B B TMP/SMX | levels of A Tocainide i effect of B + ++ effect + + + See Amantadine See protease inhibitors and Table 22B See protease inhibitors and Table 22B Stavudine i levels of See Integrase Strand Transfer ++ A AVOID Mutual interference Zidovudine Strand Transfer Integrase + ++ B B Quinidine —do not combine ++ Inhibitors Inhibitors (INSTI) Sulfonamides Telithromycin (Ketek) Beta blockers t levels of B ++ Cyclosporine cyclosporine levels Methotrexate Warfarin T antifolate activity T prothrombin time; bleeding Phenobarbital, rifampin j, + + + + Phenytoin t Sulfonylureas | nystagmus, ataxia hypoglycemic effect Carbamazine | levels of A Digoxin t levels of B— digoxin levels Ergot alkaloids f levels of Itraconazole; ketoconazole t levels of A; Metoprolol t levels of levels of A levels of B; B —avoid no dose change Midazolam t levels of Warfarin | prothrombin time Phenobarbital, phenytoin | levels of Pimozide | levels of B; Rifampin Simvastatin l & other "statins’ + ++ A levels of QT prolongation A— avoid t levels of B T levels of B + ++ ++ B B AVOID + + ++ ++ ++ (| risk of ++ ++ myopathy) ++ hotaioi Theophylline ++ 242 TABLE 22A ANTI-INFECTIVE AGENT Tenofovlr OTHER DRUG (A) (8) EFFECT (B) Atazanavir Didanosine Terbinafine (ddl) T Cimetidine Kee B (reduce dose) A levels of A | levels of B t toxicity of Methoxyflurane T toxicity; polyuria, renal failure B (may persist months— up to 10% pts) absorption of A (separate by >2 hrs) T serum i levels of Theophyllines Tigecycline Oral contraceptives Tinidazole (Tindamax) See Metronidazole similar entity, expect similar interactions See Aminoglycosides — Amantadine, dapsone, digoxin, methotrexate, procainamide, zidovudine Potassium-sparing diuretics T T Repaglinide serum theophylline, nausea levels of serum K B + + + ++ + ++ | B (hypoglycemia serum Na‘ T serum ' Ace inhibitors Amantadine T levels of Azathioprine Reports of leukopenia Cyclosporine l levels of B | Loperamide T levels of Methotrexate Enhanced marrow suppression | effect of B Oral contraceptives, pimozide, ++ ++ B T levels of Thiazide diuretics several i Thiabendazole oxazole + + + Digoxin Sucralfate T rimethoprim-Sulfameth- IMPORT ++ ++ Doxycycline, plus: Atovaquone Tobramycin Trimethoprim ritonavir levels of t levels of Phenobarbital, rifampin Tetracyclines —add B i levels of + K+ B ++ (toxicity) serum _ creatinine B 4- + ++ + and 6-mercaptopurine Phenytoin T levels of Rifampin T levels of Spironolactone, sulfonylureas t levels Warfarin T activity of Valganciclovir (Valcyte) See Ganciclovir Vancomycin Aminoglycosides Zalcitabine (ddC) (HMD) T Valproic acid, pentamidine (IV), alcohol, B B + + ++ K+ B + frequency of nephrotoxicity f pancreatitis risk ++ + lamivudine Cisplatin, INH metronidazole, nitrofurantoin, d4T, Zidovudine (ZDV) (Retrovir) vincristine, t risk of peripheral A A of ZDV toxic of A of A Atovaquone, fluconazole, methadone T levels of Clarithromycin i levels of Indomethacin T levels Nelfinavir Probenecid, neuropathy + oapsone j TMP/SMX levels t levels ± metabolite A Rifampin/rifabutin l levels of Stavudine Interference—DO Valproic Acid * levels of + A NOT COMBINE! -f ++ + ++ ++ ++ TABLE 22B - DRUG-DRUG INTERACTIONS BETWEEN NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIS) AND PROTEASE INHIBITORS (Adapted from Guidelines NAME (Abbreviation, Delavirdine DARUNAVIR Atazanavir (ATV, Reyataz) Trade Name) (DRV, Prezista) No No data data (DLV, Rescriptor) Efavirenz (EFZ, Sustiva) ATV AUC 74% Dose: EFZ standard; ATA/RTV Standard doses of both drugs 300/100 mg q24h with food Etravirlne (ETR, Intelence) T ATV & t ETR levels Standard doses of both drugs for the Use of Antiretroviral Agents in IIV I Inlnrlnd A< Fosamprenavir (FOS-APV, Lexiva) Indinavir (IDV, Crlxivan) Co-administration not recommended IDV levels T 40% Dose: IDV 600 mg q8h, DLV standard 31% Levels: IDV FOS-APV levels [ Dose: EFZ standard; Dose: IDV 1000 mg FOS-APV 1400 mg q8h LI Z standard + RTV 300 mg q24h or 700 mg FOS-APV + 100 mq RTV q12h | t levels of FOS-APV j level of IDV lull:; K Adolescents; see Nelfinavir Lopinavir/Ritonavir (LP/R, Kaletra) xpecl LP levels to t No dose data 1 ! ovulol 1* 40% lose P/H >33/133 mi| 25%; NVP decreases ATZ AUC by 42% Standard doses of both drugs levels of NFV levels of LP/R Use with caution NVP AUC increased 14% (700/100 Fos/rit; NVP AUC inc (Fos 1400 mq IDV levels i 28% Dose: IDV 1000 mg q8h or RTV; combine with NVP LP levels J 53% Dose: Standard doses LP/R 533/133 mg q12h; NVP standard data DLV standard Level: i ETR levels 33%; SQV/R no change Standard dose both drugs Nevirapine (NVP, Viramune) No No dose change necessary i levels of q8h, Dose: Tipranavir (TPV) Saquinavir (SQV, Invirase) of Dose: SQV + RTV 400/400 mg, both i levels of levels of ETR, t TPV & RTV Avoid combination Standard doses q12h standard 29% bid) 243 TABLE 23 GENERIC NAME: TRADE NAMES Abacavir: Ziagen Elvitegravir: Vitekta + Lamivudine: Epzicom + Lamivudine + Abacavir Abacavir Triumeq Abacavir + Lamivudine + Zidovudine: Dolutegravir: + Elvitegravir + Paritaprevir, ritonavir, ombitasvir: Cobicistat + rilpivirine: Fuzeon Entecavir: Baraclude Amantadine: Symmetrel Amikacin: Amikin Amoxicillin: Amoxil, Polymox Amoxicillin extended release: Moxatag Amox./clav.: Augmentin, Augmentin ES-600; Augmentin XR Amphotericin B: Fungizone Ertapenem: Invanz Ampho Ampho Ethambutol: Myambutol Ethionamide: Trecator Famciclovir: Famvir Fidaxomicin: Dificid Fluconazole: Diflucan B-liposomal: AmBisome complex: Abelcet Omnipen, Polycillin Ampicillin/sulbactam: Unasyn Artemether-Lumefantrine: Coartem Atazanavir: Reyataz Atovaquone: Mepron Piperacillin/tazobactam: Zosyn, Tazocin Piperazine: Antepar Podophyllotoxin: Condylox Etravirine: Intelence Erythromycin(s): llotycin Pediamycin Glucoheptonate: Erythrocin Ethyl succinate: Estolate: llosone Erythro/sulfisoxazole: Pediazole Flucytosine: Pak Paromomycin: Humatin Pentamidine: NebuPent, Pentam 300 Peramivir: Rapivab dasabuvir: Viekira Truvada + tenofovir Enfuvirtide (T-20): Technivie Paritaprevir, ritonavir, ombitasvir, Complera Hepsera Ampicillin: Emtricitabine Tenofovir: Stribild Albendazole: Albenza B-lipid + Emtricitabine: Emtriva Emtricitabine + tenofovir: Emtricitabine Trizivir Acyclovir: Zovirax Adefovir: OF GENERIC AND COMMON TRADE NAMES GENERIC NAME: TRADE NAMES GENERIC NAME: TRADE NAMES - LIST Polymyxin B: Poly-Rx Posaconazole: Noxafil Praziquantel: Biltricide Primaquine: Primachine Proguanil: Paludrine Pyrantel pamoate Artiminth Pyrimethamine: Darac'm Pyrimethamine/sulfacox re: Fansidar Quinupristin/dalfop' s: ~ Synercid Raltegravir: Isentress Ancobon Retapamulin: Altabax Ribavirin: Virazole Azithromycin: Zithromax Azithromycin ER: Zmax Fosamprenavir: Lexiva Foscarnet: Foscavir Fosfomycin: Monurol Fusidic acid: Taksta Aztreonam: Azactam, Cayston Ganciclovir: Cytovene Gatifloxacin: Tequin Rifaximin: Xifaxan Atovaquone + proguanil: Malarone Bedaquiline: Sirturo Boceprevir: Victrelis Caspofungin: Cancidas Cefaclor: Ceclor, Ceclor Cefdinir: CD pivoxil: Rifapentine: Edurant Rimantadine Florae ~e Ritonavir: Non/' Griseofulvin: Fulvicin Idoxuridine: Dendrid, Stoxil Spectracef INH INH + + RIF: Rifamate + PZA: RIF Priftin Rilpivirine: Halofantrine: Halfan Omnicef Cefditoren Rifampin: Rifadin c ~s::a"e Gemifloxacin: Factive Gentamicin: Garamycin Cefadroxil: Duricef Cefazolin: Ancef, Kefzol Mycobutn Rifabutin: Rifater Saquinavir: Inv'ase Spectinorryc r 'cb c Stavudine- Ze" Stibogluccra:e Pentcstan Silver sulfac az -e acene Simeprevir: Ciys z Sofosbuv So =c Sulfametncxazc e Ganta.-o Sulfasaiaz Az u z ne Sulfisoxazo e 3a"/ s ~ A Cefepime: Maxipime NUS Cefixime Suprax Cefoperazone-sulbactam: NUS Sulperazon Cefotaxime: Claforan Cefotetan: Cefotan Cefoxitin: Mefoxin Imiquimod: Aldara Telaprevr: Cefpodoxime Indinavir: Crixivan Telavancr ca: Teibivuc/e ~,ze*a Interferon alfa: Intron Interferon, pegylated: PEG-Intron, : Pegasys Interferon + Imipenem + Tienam proxetil: Vantin ribavirin: Rebetron cilastatin: Primaxin, Cresemba Isavuconazole: Itraconazole: Sporanox lodoquinol: Yodoxin Cedax Ceftizoxime: Cefizox Ceftobiprole: Zeftera Epivir, Epivir-HBV Ceftolozane-tazobactam: Zerbaxa + abacavir: Levofloxacin: Levaquin Ceftriaxone: Rocephin Linezolid: Lamivudine Cefuroxime: Zinacef, Ceftin Cephalexin: Keflex Cephradine: Anspor, Velosef Chloroquine: Aralen Telithromyc ^