ࡱ> M  Fbjbj== WW:Pld |c|c|c,dDpd 'tffRfff'z'z'z$ ̹'zsu'z'z'z̹IffIII'zr ffI'zIjIŸftf [ņ: lZ|cڞŸ0'oSoŸI  Gram positive susceptibilities (Jan-Dec 2002) (% susceptible) Organism No of StrainsPenicillinOxacillinCephalothin cVancomycinClindamycinErythromycinTetracyclineChloramphenicolTMP - SMXLevofloxacinRifampinLinezolidNitrofurantoin*Staphylococcus aureus 2299105656100664390(925598100100Coagulase-negative staphylococci 2855123535100613585(544696100100Staphylococcus saprophyticus 135(((100954485(9799(100100Staphylococcus lugdunensis3882100 d(100877687(100100100100100Streptococcus pneumoniae 24575((100927882957698((((-hemolytic streptococci (group A) 63100(100100948786((95((((-hemolytic streptococci (group B) 278100(100100887313((99((((-hemolytic streptococci (group C, G)44100(100100937331((98((((-hemolytic streptococcia 17772((100905962((92(((Streptococcus milleri groupb 4298((100838681((98(((Enterococci 233082((85(123085(56309994* Urine isolates only a Includes alpha-hemolytic streptococci, S. mitis, S. sanguis, S. salivarius, S. bovis, S. mutans b Includes alpha-hemolytic and beta-hemolytic S. milleri group c For Staph. spp. predicted from oxacillin; for streptococci predicted from penicillin d Determined by testing for the presence of mecA gene Gram negative susceptibilities (Jan-Dec 2002) (% susceptible) OrganismNo of StrainsAmpicillinPiperacillinCefazolinCefpodoximeCeftriaxoneCeftazidimeCefepimeAztreonamMeropenemGentamicinAmikacinLevofloxacinTMP SMXChloramphenicolTetracyclineNitrofurantoin*Acinetobacter calcoaceticus-baumanni complex28300000212493534722944(240Alcaligenes xylosoxidans 50(80(((74(08000148442((Burkholderia cepacia complex 43(33(((44(12280796730((Citrobacter freundii 15208507488881008810097999189(7797Citrobacter koseri (diversus)9609093989991100991001001009899(9499Enterobacter aerogenes 177082080848398859999999798(8842Enterobacter cloacae 3780670506974947010092988586(7864Escherichia coli 556166709597999910099100971009682(7799Haemophilus influenzae 10375(((100(((((1008395((Klebsiella oxytoca 21600649095939695100921008891(8991Klebsiella pneumoniae 11990083858686868610091988483(7956Morganella morganii 79080063968110094100901009589(6717Proteus mirabilis 47685929798100998999100951009591(00Proteus vulgaris 3209409783100100100100100100100100(347Pseudomonas aeruginosa 1359(84(((84846784767859((((Salmonella spp. 708386(96979510099100((10099(87(Serratia marcescens 20008206992911009510095998897(23(Shigella spp. 264250(100100100100100100((10023(4100Stenotrophomonas maltophilia 176(18(((38(00010469559((* Urine isolates only Recommendations for initiation of antiretrovirals for HIV Asymptomatic infection: evaluate with history, physical exam, CBC, chemistry, LFTs, lipids, CD4+ count, Plasma HIV RNA (viral load), evaluation for opportunistic infections (OIs); CMV, syphilis, toxo, hepatitis serologies, PPD, CXR, Pap smear. Symptomatic disease (wasting, thrush, unexplained fever > 2 weeks) including AIDS: all patients should be offered treatment. Clinical CategoryCD4+ T cell countPlasma HIV RNARecommendationSymptomatic (AIDS, severe symptoms)Any valueAny valueTreatAsymptomatic AIDS< 200/mm3Any valueTreatAsymptomatic200-350/mm3Any valueTreatment offered; controversialAsymptomatic> 350/mm3 > 55,000 (bDNA or RT-PCR)Some would initiate therapy as 3-yr risk of AIDS >30%; others would monitor CD4+ count and RT-RNA frequentlyAsymptomatic> 350/mm3<55,000 (bDNA or RT-PCR)Many would defer therapy and observe as 3-yr risk of AIDS is <15%Acute HIV infection, within 6 months Any valueAny valueTreatment offered; ongoing clinical trials assess the benefitGoals of treatment Decrease in viral load (0.5-0.75 log10) within 4 weeks or VL (1 log) within 8 weeks Undetectable VL (<50 or <20 viral copies) at 4-6 months Restoration and/or preservation of immunological function Reduction of HIV-related morbidity and mortality Hospital management Assess patient's current regimen and adherence If adherent, and not admitted for adverse reactions (lactic acidosis, pancreatitis, hepatitis, rash, etc.) resume all antiretrovirals according to dosing schedule. Encourage patient to take own medicines to avoid delay from the pharmacy. When in ICU setting or if NGT is in place, Kaletra, ritonavir, and AZT can be given in liquid formulation. Other antiretroviral preparations may also be available in liquid formulation. Hold all antiretrovirals if patient had not been adherent or if suffering from an adverse reaction. May consider checking CD4+ count, RT-RNA VL, and resistance patterns prior to resuming current or prior to designing new regimen. Generic drugBrandTypical doseAdverse effectsNucleoside Analog Reverse Transcriptase Inhibitors (NRTIs)Abacavir (ABC) Ziagen (Group A)300 mg bid (available as 20 mg/mL oral solution)Hypersensitivity reaction: fever, rash, nausea, vomiting, malaise, fatigue, loss appetite; lactic acidosis; SOBZidovudine (AZT, ZDV) Retrovir (Group A) 200 mg tid 300 mg bid Bone marrow suppression; anemia; neutropenia; GI intolerance; HA, insomnia; lactic acidosis Stavudine (d4T) Zerit (Group A)>60 kg: 40 mg bid <60 kg: 30 mg bidPancreatitis, peripheral neuropathy; lactic acidosis with hepatic steatosisLamivudine (3TC) Epivir (Group B)150 mg bidMinimal toxicity; lactic acidosis with hepatic steatosisDidanosine (ddI) Videx (Group B)>60 kg: 200 mg bid, 250 mg bid, or 400 mg qd <60 kg: 125mg bid, 167 mg bid, or 250 mg qdPancreatitis; peripheral neuropathy; nausea, diarrhea; lactic acidosis with hepatic steatosisZalcitabine (ddC) Hivid (Group B)0.75 mg tidPeripheral neuropathy; stomatitis; lactic acidosisAZT + 3TCCombivir (NRTI combo)1 tablet bidAs per AZT and 3TCAZT + 3TC + ABCTrizivir (NRTI combo)1 tablet bidAs aboveNon-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)Delavirdine Rescriptor 400 mg tidRash; elevated LFTs; headache; inhibits P450Efavirenz Sustiva 600 mg qhsRash; CNS effects; hepatitis; mixed incuder/inhibitor P450Nevirapine Viramune200 mg bidRash; elevated LFTs; hepatitis; induces P450Protease inhibitorsAmprenavir Agenerase1200 mg bid (cap) 1400 mg bid (soln) <50 kg: 20 mg/kgGI into, nausea, vomiting, diarrhea, rash, oral parathesias, inc. LFTs, diabetes, fat redistribution, lipid abnormalitiesIndinavir Crixivan 800 mg q8hNephrolithiasis, GI intolerance, nausea, headache, increased LFTs, diabetes, fat redistributionNelfinavirViracept1250 mg bid (with meals) 750 mg tid (with meals)Diarrhea, nausea, diabetes, fat redistribution, lipid abnormalitiesRitonavir Norvir 600 mg q12h (with meals)GI intol, nausea, vomiting, diarrhea, parathesias, hepatitis, pancreatitis, increased triglycerides; fat redistribution, diabetesSaquinavir Invirase400 mg bid with ritonavirGI intol, nausea, diarrhea, headache, elevated LFTs, fat redistribution, DMFortovase1200 mg tid (with meals)Lopinavir + Ritonavir Kaletra (PI combo)400 mg lopinavir + 100 mg ritonavir bidGI intol, nausea, vomiting, diarrhea, asthenia, inc. LFTs, diabetes, fat redistributionNucleotide Reverse Transcriptase InhibitorsTenofovir Same300 mg qdNo renal toxicity; limited expanded accessRecommended regimens One choice from group A and one from group B Mono and dual therapies are not recommended. Hydroxyurea not currently recommended with NRTIs Class sparing regimens: NNRTI +2 NRTIs or triple NRTIs or PI + 2 NRTIs Consultation with HIV specialist recommended prior to initiating therapy Group A: efavirenz, indinavir, nelfinavir, ritonavir + indinavir, ritonavir + lopinavir (Kaletra), ritonavir + saquinavir (soft-gel capsule or hard-gel capsule) Group B: didanosine + lamivudine, stavudine + didanosine, stavudine + lamivudine, zidovudine + didanosine, zidovudine + lamivudine Recommended alternatives Group A: abacavir, amprenavir, delavirdine, nelfinavir + saquinavir-SGC, nevirapine, ritonavir, saquinavir-SGC Group B: zidovidine + zalcitabine Potentially fatal adverse reactions Lactic acidosis and steatohepatitis. Associated with d drugs, NRTIs, tenofovir, and abacavir. All antiretrovirals should be stopped and not restarted if this reaction is suspected. Fatal hypersensitivity reactions. Associated with abacavir. Symptoms include fever, skin rash, fatigue, GI symptoms, dyspnea, pharyngitis, cough. Should not be rechallenged with abacavir as death may ensue in hours. Propylene glycol toxicity. Found in the amprenavir oral solution. Contraindicated in children < 4 yo, pregnant women, patients with renal or hepatic failure, patients using metronidazole or disulfiram. Pancreatitis. Associated with didanosine, zalcitabine. Reference See also http://www.aidsinfo.nih.gov  Prophylaxis to prevent first episode of OIs in adults and adolescents. PathogenPreventive RegimensIndicationFirst ChoiceAlternativesPneumocystis cariniiCD4+ count <200 or oropharyngeal candidiasisTMP-SMX 1 DS qd or TMP-SMX 1 SS qdDapsone 50 mg bid or dapsone 100 mg qd or dapsone 50 mg + pyrimethamine 50 mg + leucovorin 25 mg qw or aero. pentamidine 300 mg qmonth.Mycobacterium tuberculosis (INH sensitive)PPD >5 mm or contact with active caseINH 300 mg qd + B6 50 mg qd x 9 mo. or INH 900 mg + B6 100 mg biweek x 9 mo. Rifampin 600 mg qd x 4 mo. or rifabutin 300 mg qd x 4 mo. pyrazinamide 15-20 mg/kg qd + rifampin or rifabutin x 2 mosMycobacterium tuberculosis (INH resistant)PPD > 5 mm or contact with active case with high prob INH resistanceRifampin 600 mg qd or rifabutin 300 mg qd x 4 mo.Pyrazinamide 15-20 mg/kg qd + rifampin or rifabutin x 2 mosMycobacterium tuberculosis (multidrug resistant)PPD > 5 mm or contact with active case with high prob multidrug resistanceChoice of drugs requires consultation with public health authorities; depends on resistance patternToxoplasma gondiiIgG Ab + Toxo and CD4+ <100TMP-SMX 1 DS qdTMP-SMX 1 SS qd or dapsone 50 mg qd + pyrimethamine 50 mg qw + leucovorin 25 mg qw or dapsone 200 mg + pyrimethamine 75 mg qw + leucovorin 25 mg qw or atovaquone 1500 mg qd + pyrimethamine 25 mg qd + leucovorin 10 mg qd Mycobacterium avium complexCD4+ <50 Azithromycin 1200 mg qw or clarithromycin 500 mg bidRifabutin 300 mg qd or azithromycin 1200 mg qw + rifabutin 300 mg qdVaricella zoster (VZV)Exposure to VZVVZIG 5 vials (1.25 mL) IM within 48 hoursGenerally recommendedStreptococcus pneumoniaeCD4+ > 200Strep. pneum vaccineInfluenza virusAll patientsInfluenza vaccine q yearOseltamivir 75 mg qd or rimantadine 100 mg bid or amantadine 100 mg bidHepatitis B virusAll susceptibleHepatitis B vaccine x 3Hepatitis A virusAll susceptible at increased risk HAVHepatitis A vaccine x 2Evidence for efficacy but not routinely indicatedBacteriaNeutropeniaG-CSF 5-10 mcg/kg sc qd or GM-CSFCryptococcus neoformansCD4+ <50Fluconazole 100-200 mg qdItraconazole 200 mg qdHistoplasma capsulatumCD4+ <100Intraconazole 200 mg qdCytomegalovirus (CMV)CD4+ <50 and CMV Ab+Oral ganciclovir 1 g tid References Refer to http://www.aidsinfo.nih.gov/ for text of 2001 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with HIV, November 2001.  Hand hygiene Essential for proper patient care. The hands of health care workers are the most important vectors for nosocomial pathogens. Hand disinfection is essential before and after any patient contact (or contact with a patients immediate environment). Proper procedure is the use of an alcohol-based hand rinse (CalStat at MGH); one pull of the dispenser lever (3mL) is generally sufficient. The rinse should be rubbed over the entire surface of the hands and allowed to dry. If hands are visibly soiled or have contacted blood or body fluids, they should be washed with soap and water and dried thoroughly prior to the application of CalStat. Standard precautions Hand hygiene, as described above, before and after any contact with patient or immediate patient environment. Gloves when anticipating contact with blood, body fluids, secretions, mucous membranes, non-intact skin and any contaminated items. Remove gloves promptly after use and disinfect hands. Gowns when clothes are likely to be contaminated with blood, body fluids, and secretions. Remove gown promptly after use and disinfect hands. Mask and goggles or a face shield during procedures that are likely to generate splashes or sprays of blood, body fluids or secretions. Remove the face protection promptly after use and disinfect hands. Transmission based isolation precautions Airborne precautions. For infections transmissible by droplet nuclei. Negative pressure isolation room, fit-tested N95 masks for all entering the room. Hand hygiene as above. Droplet precautions. For infections transmissible by droplets. Private room, surgical masks within 3 feet of patient. Hand hygiene as above. Contact precautions. For pathogens transmitted by direct or indirect contact. Private room (usually). Gowns and gloves to enter room. Hand hygiene as above. Application of transmission based isolation precautions: common examples Comprehensive list of diseases and applicable precautions available in the Infection Control Manual (print copies on patient care units) and on the Infection Control website Chickenpox or herpes zoster in an immunocompromised host: airborne and contact precautions, though persons with a history of chickenpox may enter the room without a mask. Persons without a history of chickenpox should not enter the room at all, if possible. Shingles (localized herpes zoster) in an immunocompetent host: standard precautions, though all who enter room must have a history of chickenpox. Clostridium difficile diarrhea: contact precautions Influenza: droplet precautions MRSA or VRE colonization: contact precautions Measles: airborne precautions Meningitis secondary to Neisseria meningitis or Hemophilus influenzae: droplet precautions until patient has been on effective antibiotic therapy for >24 hours. Tuberculosis: airborne precautions (see algorithm below) Severe acute respiratory syndrome (SARS) (as of May 30, 2003): Airborne and contact precautions with eye protection (goggles or face shield). After leaving room, remove items in this order: 1. gloves, 2. N95 mask, 3. eye protection, 4. gown. Hand hygiene as above.        34. MGH antibiotic susceptibilities MGH Medical Housestaff Manual  PAGE 89 35. HIV antiretroviral therapy 36. Prophylaxis for opportunistic infections in HIV PAGE  PAGE 91 MGH Medical Housestaff Manual 58. Infection control PAGE  PAGE 93 MGH Medical Housestaff Manual 37. Infection control Kimon Zachary, M.D. Discontinue precautions unless clinical suspicion is high All negative NO Maintain precautions until no longer infectious by negative AFBs or clinical response (usually 14-21 d). Call Infection Control before d/c precautions. Obtain 3 sputums, =>24 hours apart, for AFB smear and culture Discontinue precautions unless clinical suspicion is high ANY ONE POSITIVE D/C precautions Place surgical mask on patient until isolated in negative pressure isolation room on airborne precautions TB ISOLATION One or more of respiratory signs and symptoms: chronic cough, sputum production, dyspnea, hemoptysis AND (1 risk factor: HIV; immigrant (except Canada, W. Europe, Australia, New Zealand); substance abuse; homeless status; recent incarceration; TB exposure; history of non-compliance with TB treatment Yes No Regular admission HIV Yes Chest X-ray Obtain 3 sputums, >24 hours apart, for AFB smear and culture D/c precautions No Equivocal or abnormal Normal Maintain precautions until no longer infectious by negative AFBs or clinical response (usually 14-21 d). Call Infection Control before discontinuing precautions. 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