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doi: 10.1128/CMR.00040-06 1 April 2007

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Haemophilus influenzae is a major community-acquired pathogen causing significant morbidity and mortality worldwide. Meningitis and bacteremia due to type b strains occur in areas where the protein-conjugated type b vaccine is not in use, whereas nontypeable strains are major causes of otitis media, sinusitis, acute exacerbations of chronic bronchitis, and pneumonia. Antibiotic resistance in this organism is more diverse and widespread than is commonly appreciated. Intrinsic efflux resistance mechanisms limit the activity of the macrolides, azalides, and ketolides. β-Lactamase production is highly prevalent worldwide and is associated with resistance to ampicillin and amoxicillin. Strains with alterations in penicillin binding proteins, particularly PBP3 (β-lactamase negative ampicillin resistant and β-lactamase positive amoxicillin-clavulanate resistant), are increasing in prevalence, particularly in Japan, with increasing resistance to ampicillin, amoxicillin, amoxicillin-clavulanate, and many cephalosporins, limiting the efficacy of expanded-spectrum cephalosporins against meningitis and of many oral cephalosporins against other diseases. Most strains remain susceptible to the carbapenems, which are not affected by penicillin binding protein changes, and the quinolones. The activity of many oral agents is limited by pharmacokinetics achieved with administration by this route, and the susceptibility of isolates based on pharmacokinetic and pharmacodynamic parameters is reviewed.

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Haemophilus influenzae includes six encapsulated types, a through f, as well as nonencapsulated or untypeable strains, and these are found as both respiratory tract commensals and respiratory and invasive pathogens. Carriage of H. influenzae type b (Hib) strains is influenced by use of various formulations of type b, protein-conjugated capsular polysaccharide vaccines. The major diseases caused by H. influenzae are childhood pneumonia, meningitis, and bacteremia, which are primarily caused by type b strains, and community-acquired pneumonia (CAP) in adults, acute otitis media (AOM), acute sinusitis, and acute exacerbations of chronic bronchitis (AECB), which are typically caused by untypeable strains.

Prior to introduction of Hib vaccines, Hib was estimated to be responsible worldwide for some three million serious illnesses and an estimated 386,000 deaths per year, chiefly through meningitis and pneumonia, with 95% of cases and 98% of deaths occurring in patients in developing countries ( Gold Block Heel Sandals Gold Glamorous Manchester Great Sale Sale Online Free Shipping Footlocker fDI5w
). Almost all victims are children under the age of 5 years, with those between 4 and 18 months of age especially vulnerable ( 112 ). Large, population-based disease burden studies showed annual rates of Hib meningitis at 10 to 60 cases per 100,000 children under 5 years of age in countries where Hib vaccine is not used ( 153 ). In developing countries, where the vast majority of Hib deaths occur, pneumonia accounts for a larger number of deaths than meningitis. However, Hib meningitis is also a serious problem in such countries with mortality rates several times higher than seen in developed countries, and 15 to 35% of survivors have permanent disabilities such as mental retardation or deafness. Systematic vaccination has virtually eliminated Hib disease in most industrialized nations, with 89 countries offering infant immunization against Hib by the end of 2004 compared with 38 in 1999. However, Hib vaccine is not available in Japan ( 56 , 57 ). Ninety-two percent of the populations of developed countries were vaccinated against Hib as of 2003, while vaccination coverage was 42% for developing countries and 8% for least-developed countries.

With intensified antibiotic therapy and longer survival, patients with cystic fibrosis (CF) are colonized with a more complex pattern ofbacteria and fungi. However, the clinical relevance of these emerging pathogens for lung function remains poorly defined. The aim ofthis study was to assess the association of bacterial and fungal colonization patterns with lung function in adolescent patients with CF. Microbial colonization patterns and lung function parameters were assessed in 770 adolescent European (German/Austrian) CF patients in a retrospective study (median follow-up time: 10years). Colonization with Pseudomonas aeruginosa and MRSA were most strongly associated with loss of lung function, while mainly colonization with Haemophilus influenzae was associated with preservedlung function. Aspergillus fumigatus was the only species that was associated with an increased risk for infection with P. aeruginosa.Microbial interaction analysis revealed three distinct microbial clusters within the longitudinal course of CF lung disease. Collectively, this study identified potentially protective and harmful microbial colonization patterns in adolescent CF patients. Further studies in different patient cohorts are required to evaluate these microbial patterns and to assess their clinical relevance.

Copyright © 2016 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.


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1 GUIDE TO ANTIMICROBIALS San Francisco VA Medical Center 2017

2 Guide to Antimicrobials 2017 Daniel Maddix, Pharm.D. Harry Lampiris, M.D. Mai Vu, Pharm.D. Drug Category may be changed from time to time. Please consult the hospital computer for current classification. Category I agents are available without prior approval although some restrictions may apply. Category II agents are restricted and require approval prior to use. To obtain approval for a Category II agent, page digital beeper (415) prior to ordering. Current antimicrobial sensitivity patterns and UCSF/SFGH/VASF Guidelines for Antimicrobial Use in Adults are available on the Antibiotic Stewardship Program page on Sharepoint (http://vaww.visn21.portal.va.gov/sanfrancisco/ic/sitepages/antibioticste wardship.aspx ). Acknowledgments: Thanks to past and current staff of the Pharmacy Service and Infectious Diseases Section for preparing, compiling, and reviewing the materials contained in this pamphlet. This material has been endorsed by the San Francisco VA Medical Center Infectious Diseases Section, and represents recommended Medical Center policy.

3 Table of Contents I. Sensitivity Patterns of Unique Isolates 2 II. Guidelines for the Use of Antimicrobial Agents in Febrile 4 Neutropenic Cancer Patients III. Guidelines for the Use of Antimicrobial Agents in the 5 Prevention of Bacterial Infection in Cirrhotic Patients IV. Guidelines for the Empiric Therapy of Community-Acquired 7 Pneumonia and Urinary Tract Infections V. Guidelines for the Treatment of Diarrhea Associated with 8 Clostridium difficile Infection 8a Va. SSTI Empiric Therapy Guidelines VI. Administration of ß-lactam antibiotics to penicillin-allergic patients 9 VII. Antimicrobial Agents Acyclovir Amikacin Amoxicillin/Clavulanic Acid Amphotericin B Atovaquone. Aztreonam. Cefazolin. Cefepime.... Ceftazidime. Ceftriaxone. Cidofovir.... Ciprofloxacin..... Clindamycin... Dapsone Daptomycin Ertapenem Ethambutol.. 26 Fluconazole Foscarnet 29 Ganciclovir.. 31 Gentamicin/Tobramycin Imipenem/Cilastatin Isoniazid.. 34 Itraconazole Levofloxacin Linezolid.. 38 Meropenem.. 39 Metronidazole 40 Micafungin. 41 Nafcillin 42 Nitrofurantoin Pentamidine.. 44 Piperacillin/Tazobactam.. 45 Posaconazole 46 Primaquine Pyrazinamide 49 Pyrimethamine.. 50 Rifabutin Rifampin.. 53 Sulfadiazine 55 Trimethoprim-Sulfamethoxazole 56 Vancomycin. 58 Voriconazole 59 Adverse Effects of ß-Lactam Antibiotics VIII. Drugs for HIV Infection Antiretroviral Agent Dosing Guidelines.. 62

4 Sensitivity Patterns of NON-URINE Isolates (First isolate per patient per organism) San Francisco VA Medical Center January-December 2016 Confidential: For official use by San Francisco VA Medical Center Employees and Students only. Percent Sensitive TOTAL ORGANISM #ISO* AMP ZOS ERTA CIP T/S CTRI CPIM GEN Enterobacter cloacae 23 NA NA NA 100 Escherichia coli Klebsiella pneumoniae Proteus mirabilis Pseudomonas aeruginosa 51 NA 82 NA 90 NA NA VANC OXAC T/S ERYT CLIN TCN Staphylococcus aureus MRSA NA MSSA NA Staphylococcus coag neg NA = not available AMP - ampicillin, ZOS - Zosyn, ERTA - ertapenem, CIP - ciprofloxacin, T/S - trimethoprim/sulfamethoxazole, CZOL - cefazolin, CTRI - ceftriaxone, CPIM - cefepime ERTA - ertapenem, GEN - gentamicin, TOB - tobramycin, VANC - vancomycin, OXAC - oxacillin, ERYT - erythromycin, CLIN - clindamycin, TCN - tetracycline *Statistical validity of % susceptible is decreased if fewer than 30 isolates are tested. 7.8% (33/424) of all enterococcal isolates were vancomycin-resistant Extended-Spectrum Beta-Lactamase (ESBL) Positive - E. coli - 13%; K. pneumoniae - 6% 2 Prepared by D. Maddix, Pharm.D. 1/08/2017

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