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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 ( 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

Subsequently, hematogenous seeding into distant sites, including the CNS, occurs. The specific pathophysiologic mechanisms by which the infectious agents gain access to the subarachnoid space remain unclear. Once inside the CNS, the infectious agents likely survive because host defenses (eg, immunoglobulins, neutrophils, and complement components) appear to be limited in this body compartment. The presence and replication of infectious agents remain uncontrolled and incite the cascade of meningeal inflammation described above.


Causes of meningitis include bacteria, viruses, fungi, parasites, and drugs (eg, NSAIDs, metronidazole, and IV immunoglobulin [IVIg]). Certain risk factors are associated with particular pathogens.

HIV infection increases susceptibility to meningitis from a variety of pathogens, including cryptococci, Mycobacterium tuberculosis, syphilis, and Listeria species. In addition, HIV itself may cause aseptic meningitis (see Foldaway Tote IN AWE Foldaway by VIDA VIDA Manchester For Sale chWg5dRhBS

Other viral causes of meningitis include the following:


West Nile virus

Human herpesvirus (HHV)-2

Lymphocytic choriomeningitis virus (LCM)

In patients who have had trauma or neurosurgery, the most common microorganisms are S pneumoniae (if CSF leak is present), Staphylococcus aureus, enterobacteria, and Pseudomonas aeruginosa . In patients with an infected ventriculoperitoneal (atrial) shunt, the most common microorganisms are Staphylococcus epidermidis, S aureus, enterobacteria, Propionibacterium acnes, and diphtheroids (rare). Consultation with a neurosurgeon is indicated; early shunt removal is usually necessary for cure.

As indicated by the presence of abundant pus, pachymeningitis most often results from a bacterial infection (usually staphylococcal or streptococcal) that is localized to the dura. The organisms most often gain access to the meninges via a skull defect (eg, a skull fracture) or spread from an infection of the paranasal sinuses or cranial osteomyelitis.

Haemophilus influenzae meningitis

Haemophilus influenzae meningitis

H influenzae is a small, pleomorphic, gram-negative coccobacillus that is frequently found as part of the normal flora in the upper respiratory tract. The organism can spread from one individual to another in airborne droplets or by direct contact with secretions. Meningitis is the most serious acute manifestation of systemic infection with H influenzae . (See Statement Clutch lio by VIDA VIDA Clearance 100% Original ZFVgI2VHM6

In the past, H influenzae was a major cause of meningitis, and the encapsulated type b strain of the organism (Hib) accounted for the majority of cases. Since the introduction of Hib vaccine in the United States in 1990, the overall incidence of H influenzae meningitis has decreased by 35%, with Hib accounting for fewer than 9.4% of H influenzae cases. []

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Now Reading: Nikon P1000’s 125x super-zoom lens is both ridiculous and awesome

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What do you get when you cross a telescope with a camera? Probably something a lot like the new Nikon Coolpix P1000, a bridge camera with a 125x optical zoom lens that makes the lenses on most cameras look weak. Unveiled on July 10, the Nikon Coolpix P1000 sports a lens that covers the equivalent of 24-3,000mm lens on a full-frame DSLR, including a macro mode — if a 3,000mm telephoto lens for a DSLR existed, that is. Scheduled for a September release, the P1000 costs $1,000.

The 125x zoom lens has a bright f/2.8 aperture at the widest angle and an f/8 at the end of that long zoom. That’s enough to shoot from the nosebleed section of the stadium or capture details of the moon, Nikon says. The camera’s macro mode can shoot as close as 0.4 inches from the front of the lens at the wide-angle position. A snap-back mode button temporarily pulls back the zoom to make it easier to find the subject, before returning to full telephoto.

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at 24mm Nikon

Large lenses are characteristically harder to hold steady, so Nikon has paired a Dual Detect Optical VR Technology system inside the camera, which gives the P1000 five stops of shake reduction. If there’s a downside to all that zoom, it’s probably that the large lens gives the camera a two-hands-required kind of body (it weighs 3 pounds, 2 ounces) that is probably best served with a tripod for the longest shots. Though, for what it’s worth, that’s still quite a bit smaller than what the equivalent optics on a DSLR would probably weigh.

That massive zoom lens is placed in front of an average-sized sensor, a 16 megapixel 1/2.3 inch sensor that uses a backlit design. Besides the 16-megapixel stills, the sensor is also capable of 4K at 30 fps, though with the usual 29-minute recording limit. The camera has a mic input for better audio capture, which is something you won’t find in most bridge cameras.

The P1000 also uses Nikon’s latest processor, capable of capturing stills at 7 frames per second, for up to a second. Nikon says the camera’s contrast detection autofocus system is also quick.

Despite the smaller sensor, the P1000 includes a handful of advanced features. RAW shooting is included along with manual modes, manual focus, and time-lapses. A hot shoe slot also allows the camera to use Nikon-compatible flashes. The ISO tops out at 6,400 and the shutter speed at 1/4,000. A handful of new auto modes cater to the camera’s long zoom, including a Moon Mode and Bird Watching Mode.

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