Transcript 2013 Antimicrobial Update Oklahoma ACP Chapter October 18, 2013

2013 ANTIMICROBIAL
UPDATE
OKLAHOMA ACP CHAPTER
OCTOBER 18, 2013
MICHELLE R. SALVAGGIO MD FACP
ASSOCIATE PROFESSOR, MEDICINE
SECTION OF INFECTIOUS DISEASES
OUHSC
OUTLINE
Clostridium difficile
Methicillin resistant Staphylococcus aureus
Hepatitis C
HIV
I will be discussing off-label use of some medications.
QUESTION 1
A 66 yo WM was recently admitted to the hospital for
pneumonia. While admitted he was also diagnosed with C
difficile diarrhea and has now completed a course of
metronidazole. He is calling your office complaining of
continued diarrhea. What do you do?
A. Tell him take a probiotic and Immodium.
B. Have him come to the office and submit stool for testing.
C. Retreat with an extended course of metronidazole.
D. Ask him if he has money saved, if he says yes, prescribe
oral vancomycin.
E. Call your GI colleague and arrange for fecal
transplantation.
C. DIFFICILE BACKGROUND
Gram-positive, anaerobic, sporeforming bacillus (“Difficile” because it
is difficult to culture)
Accounts for 20-30% cases of
antibiotic-Major cause of hospital
infection, morbidity and mortality.
Present epidemic strain
(BI/NAP1/027)first reported in the US in
2005
Now reported from 40 US states and all
Canadian providences
Comprises 36% of all C difficile
infection (CDI) associated
Rates continue to increase in North
America
Gerding D Infect Control Hosp Epidemiol 2010; 31(S1):S32-S34
CDI CLINICAL
MANIFESTATIONS
• Range from symptomless carriage to fatal
pseudomembranous colitis
• 96% have received antibiotics within the previous 14
days
• Fever, abdominal cramps, peripheral leukocytosis, and
hypoalbuminemia
• WBC can exceed 30,000-50,000 cells/mL and be
indicative of severity
Kelly CP and JT LaMont. NEJM 2008; 359: 1932-1940.
CDI TREATMENT
Clinical definition
Supportive Clinical Data
Recommended Treatment
Initial episode, mild/moderate
WBC ≤ 15K, Cr ≤ 1.5 x
premorbid
Metronidazole 500mg po tid,
10 – 14 days
Initial episode, severe
WBC ≥15K, Cr ≥1.5 x
premorbid
Vancomycin 125 mg po qid,
10 – 14 days
Initial episode, severe,
complicated
Hypotension/shock,
ileus, megacolon
Vancomycin 500mg po/ngt
qid + metronidazole 500mg iv
q 8 hrs, consider pr
vancomycin w ileus
1st recurrence
Symptom driven
Same as initial episode
2nd recurrence
Symptom driven
Taper or pulse vancomycin
Adapted from Cohen et al. ICHE 2010; 31: 431-455 and Kelly CP. NEJM 2008; 359: 1932-1940.
FIDAXOMICIN (DIFICID)
• FDA approved in 2011: treatment of Clostridium difficile
associated diarrhea
• Granted New Technology Add On-Payment by CMS
(August 2012)
• Mechanism of action
• Bacteriocidal against C. dificile in vitro, inhibiting RNA
synthesis by RNA polymerases
• Macrolide but does not confer cross-resistance
• Low rate of spontaneous resistance (although specific
mutation Val-II43-Gly has been identified)
Dificid Package Insert: http://www.dificid.com/sites/default/files/prescribing.pdf
FIDAXOMICIN FACTS
• Dose is 200mg po twice daily x 10 days
• Retail cost: $4000/course (cash)
• Very little systemic absorption, essentially no dose
adjustment with various other medications, no adjustment
with renal or hepatic impairment
• Warnings: hypersensitivity reaction (dyspnea, rash,
pruritis, angioedema of mouth, throat, face), may report
previous allergy to macrolides
• Adverse events/side effects: same rate of blood
dyscrasias, GI symptoms (N/V/abd pain/GI bleed) as
vancomycin
Dificid Package Insert: http://www.dificid.com/sites/default/files/prescribing.pdf
FIDAXOMICIN DATA
•
Two randomized, double-blinded controlled studies
•
Non-inferiority design
•
Fidaxomicin 200mg po BID vs vancomycin 125 mg po qid x 10
days in patients with CDAD
Dificid Package Insert: http://www.dificid.com/sites/default/files/prescribing.pdf
OTHER CDAD
TREATMENT OPTIONS
•Rifaximin - 400 mg BID for 14 days
•Nitazoxanide - 500mg BID for 7 – 10 days
•Fecal transplant - successful in uncontrolled series
•Monoclonal antibodies - against toxins A&B
•Nontoxigenic C difficile
1. Kelly CP and JT LaMont. NEJM 2008; 359: 1932-1940. 2. Cohen et al. ICHE 2010; 31: 431-455.
QUESTION 2
In mid January, a 54 yo woman presents to the hospital with
increasing shortness of breath, productive cough and fever.
She was diagnosed with influenza 1 month prior and treated
with oseltamivir. Her chest Xray is consistent with lobar
pneumonia. Sputum is positive for gram positive cocci in
pairs. What is the best course of action at this time?
A. Give her another course of oseltamivir
B. Prescribe linezolid and send her home.
C. Do a chest CT with angiography to assess for PE.
D. Admit her, start vancomycin, pip/tazo and cipro.
E. You lost me at gram positive cocci…
CEFTAROLINE (TEFLARO)
• FDA approved 2010:
• treatment of acute bacterial skin and skin structure infections
• community acquired bacterial pneumonia
•Mechanism action:
• cephalosporin (β-lactam) prodrug
• bacteriocidal against S aureus due to affinity for PBP2a
• bacteriocidal against S pneumoniae due to affinity to PBP2x
Teflaro Package Insert: http://www.frx.com/pi/teflaro_pi.pdf
CEFTAROLINE DOSING
• Dosing: 600mg IV every 12 hours to be infused over one
hour
• Dosing in renal impairment:
•
•
•
•
CrCl > 50ml/min no adjustment
CrCl >30 to ≤ 50 ml/min 400mg IV every 12 hours
CrCl ≥15 to ≤ 30ml/min 300mg IV every 12 hours
ESRD including HD 200mg IV every 12 hours
• Ceftaroline is dialyzable and should be given after HD
•No dosing adjustment with hepatic disease
Teflaro Package Insert: http://www.frx.com/pi/teflaro_pi.pdf
CEFTAROLINE WARNINGS
• Hypersensitivity reactions: to ceftaroline and to other βlactams
• Cephalosporins
• Pencillins
• carbapenems
•C difficile associated diarrhea
•Direct Coombs’s test seroconversion
• Monitor for drug induced hemolytic anemia
Teflaro Package Insert: http://www.frx.com/pi/teflaro_pi.pdf
CEFTAROLINE
SPECTRUM OF ACTIVITY
• Gram positive: S aureus (MRSA, MSSA), Streptococcus
species
•Gram negative: E coli, Klebsiella species, H influenzae
(possibly Citrobacter, Enterobacter, Proteus)
DOES NOT COVER
• Enterococcus (including VRE)
•Anaerobes
•Pseudomonas species
•Any ESBL, KPC, etc
Teflaro Package Insert: http://www.frx.com/pi/teflaro_pi.pdf
CEFTAROLINE DATA – ACUTE BACTERIAL
SKIN AND SKIN STRUCTURE INFECTIONS
•
Lesion size ≥ 75 cm2
•
Major abscess with ≥ 5cm
surrounding erythema
•
Wound infection
•
Deep/extensive cellulitis
Teflaro Package Insert: http://www.frx.com/pi/teflaro_pi.pdf
CEFTAROLINE DATA- COMMUNITY ACQUIRED
BACTERIAL PNEUMONIA
•
2 studies comparing
ceftriaxone to
ceftaroline
•
1 study allowed
macrolide on first
day, the other did not
•
No MRSA allowed
Teflaro Package Insert: http://www.frx.com/pi/teflaro_pi.pdf
QUESTION 3
A 62 yo WF presents to your clinic complaining of fatigue.
She asks you test her for everything. You order
A. TSH, B12, cbc, sed rate
B. Vit D
C. HIV, Hep C
D. Nothing. She needs reassurance alone.
E. Referral to therapist.
SCREENING FOR HEPATITIS C:
RECOMMENDATIONS
•CDC Issued on May 18, 2012
•USPSTF issued on June 25, 2013
• Routine HCV screening for all adults born from 1945 through
1965 (currently aged 48 – 68).
• Numbers of diagnosed patients expected to double,
possibly triple
1.
2.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm
http://www.uspreventiveservicestaskforce.org/uspstf12/hepc/hepcfinalrs.htm
SCREENING: IDENTIFYING ESTIMATED 170
MILLION PERSONS WITH HCV INFECTION
WORLDWIDE
Europe
8.9 million
(1.03%)
Western Pacific
62.2 million
(3.9%)
Americas
13.1 million
(1.7%)
Africa
31.9 million
(5.3%)
Eastern
Mediterranean
21.3 million
(4.6%)
Southeast Asia
32.3 million
(2.15%)
World Health Organization. Wkly Epid Rec .1999;74:425-427. World Health Organization. Hepatitis C: Global
Prevalence: Update. 2003. Farci P, et al. Semin Liver Dis. 2000;20:103-126. Wasley A, et al. Semin Liver Dis.
2000;20:1-16.
HCV OVERVIEW/EPIDEMIOLOGY
“Silent Epidemic” Approximately 3.9
million in the US
• 170 million globally
• HIV—1 million US
Majority of patients in
US have Genotype 1
(75%), few G2 and G3
•
•
•
•
•
G2—10-15%; Europe
G3—4-6%; Australia
G4—Middle East, Africa
G5—South Africa
G6—Hong Kong
Ghany MG et al. 2006. Hepatology 49: 1335-1374.
Predominant cause of
chronic liver disease,
HCC, and death in US;
leading indication for
liver transplant
Transmission
• Blood
• Sexual contact
• Mother-to-child
Six genotypes
• Response to treatment
dependent on genotype
CLINICAL MANIFESTATIONS OF
HEPATITIS C
TELAPREVIR (INCIVEK)
BOCEPREVIR (VICTRELIS)
•FDA Approved 2011:
• treatment of Hepatitis C genotype 1 in adults with
compensated liver disease including cirrhosis
• May be used in treatment naïve, those who have previously
been treated with an interferon-based therapy including prior
null responders, partial responders and relapsers
• only in combination with peginterferon and ribavirin
•Mechanism of action
• NS3/4A protease inhibitor
Incivek Package Insert: http://pi.vrtx.com/files/uspi_telaprevir.pdf
Victrelis Package Insert:http://www.merck.com/product/usa/pi_circulars/v/victrelis/victrelis_pi.pdf
DOSING
TELAPREVIR
•Dose
• Standard—750mg orally
every 8 hours weeks 1-12,
with food, not low fat
• Response and prior
response dictate course of
peg-interferon and ribavirin
(12 to 36 more weeks)
•Hepatic impairment
• No dose adjustment for mild
impairment, Child-Pugh A
(score 5-6)
•Renal impairment
• No dose adjustment for CrCl
> 50 ml/min
BOCEPREVIR
•
Dose
•
• Week 1 -4 peginterferon and
ribavirin then add boceprevir
800mg orally every 8 hours
with meal or snack
• Response, prior response
and disease stage dictate
course of all 3 meds(total of
28 – 52 weeks)
Hepatic impairment
•
• No dose adjustment for
mild, moderate or severe
impairment
Renal Impairment
• No dose adjustment for
renal impairment
Peg-interferon has only been studied in adults with CrCl > 50ml/min
and is approved for use in compensated cirrhosis only
Incivek Package Insert: http://pi.vrtx.com/files/uspi_telaprevir.pdf
Victrelis Package Insert:http://www.merck.com/product/usa/pi_circulars/v/victrelis/victrelis_pi.pdf
WARNINGS
TELAPREVIR
•Adverse Effects
• Black box: rash
(Stevens Johnson,
DRESS, TEN)
• Anemia
• GI: nausea, vomiting,
diarrhea, anorectal
discomfort, dysgeusia
•Cost (30-day supply)
• Standard dose $18,350
• With peg-interferon +
ribavirin = $21,000
BOCEPREVIR
• Adverse Effects
•
•
•
Anemia
Neutropenia
Dysgeusia
• Cost (30 day supply)
• Standard dose $4,600
• With peg-interferon +
ribavirin = $7000
Incivek Package Insert: http://pi.vrtx.com/files/uspi_telaprevir.pdf
Victrelis Package Insert:http://www.merck.com/product/usa/pi_circulars/v/victrelis/victrelis_pi.pdf
TELAPREVIR AND BOCEPREVIR DRUG
INTERACTIONS
•Antiarrythmics: lidocaine, flecainide, amiodarone, digoxin
•Antibacterials: clarithromycin
•Anticoagulants: warfarin
•Anticonvulsants: carbamazepine, phenytoin
•Antidepressants: escitalopram, trazodone
•Antifungals: itraconazole, posaconazole, voriconazole
•Antigout: colchicine
•Antimycobacterial: rifabutin
•Benzodiazepines: alprazolam, IV midazolam, zolpidem
•Calcium channel blockers: amlodipine, all others
•Corticosteroids: prednisone, nasal fluticasone/butesanide
•HMG co-reductase inhibitors: atorvastatin, all others
•Hormonal contraceptives: ethinyl estradiol
Incivek Package Insert: http://pi.vrtx.com/files/uspi_telaprevir.pdf
Victrelis Package Insert:http://www.merck.com/product/usa/pi_circulars/v/victrelis/victrelis_pi.pdf
SVR RATES WITH BOC OR TVR IN
GENOTYPE 1 TREATMENT-NAIVE PATIENTS
100
SVR (%)
80
63-75
60
38-44
40
20
0
PegIFN/RBV
Poordad F, et al. N Engl J Med. 2011;364:1195-1206.
Jacobson IM, et al. N Engl J Med. 2011;364:2405-2416.
BOC or TVR +
PegIFN/RBV
SVR RATES WITH BOC OR TVR IN
GT1 TREATMENT-EXPERIENCED PATIENTS
100
PegIFN + RBV
69-83
BOC or TVR + PegIFN + RBV
SVR (%)
80
40-59
60
40
29-38
24-29
20
7-15
5
0
Relapsers
Partial Responders
Null
Responders
Bacon BR, et al. N Engl J Med. 2011;364:1207-1217. Zeuzem S, et al. N Engl J Med. 2011;364:2417-2428.
Vierling JM, et al. AASLD 2011. Abstract 931.
HEPATITIS C TREATMENT OPTIONS
First-line therapy
• Genotype 1
• Telaprevir or Boceprevir + Pegylated interferon/Ribavirin
• Genotypes 2/3
• Pegylated interferon/Ribavirin
Treatment Duration
• Response-guided therapy
• Not to be used in cirrhotic and/or null responders
• Determined by early virologic decline
• RVR—undetectable HCV RNA at week 4
• eRVR—undetectable HCV RNA at weeks 4 and 12
QUESTION 4
A 28 yo man presents to your office. He states he has heard
about a medicine that will keep him from getting HIV. He
would like for you to prescribe that to him. You
A. Refer him to Infectious Diseases.
B. Ask him why he thinks he is going to be infected with
HIV.
C. Ask him if he is infected with HIV.
D. Give him a package of condoms.
US NATIONAL HIV STRATEGY RELEASED JULY
2010
http://www.whitehouse.gov/files/documents/nhas-implementation.pdf
JULY 16, 2012
• FDA approves first drug for reducing the risk of sexually acquired HIV
infection
• Truvada™ is indicated in combination with safer sex practices for preexposure prophylaxis to reduce the risk of sexually acquired HIV-1 in
adults at high risk. Originally approved 2004 for use in combination
with other antiretrovirals for the treatment of HIV-1 in adults and
children > 12 years.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm312210.htm
EMTRICITABINE/TENOFOVIR DISOPROXIL
FUMARATE (TRUVADA) FACTS
• Combination product of two different nucleoside analogs
emtricitabine (200mg) and tenofovir (300mg)
• Given orally once daily (regardless of indication)
• Retail cost: $1500/month
• Dosing in renal impairment:
• CrCl ≥ 50ml/min no adjustment
• CrCl 30 – 49 one tablet every 48 hours
• CrCl < 30 should not be used (includes HD pts)
Truvada Package Insert: https://www.gilead.com/~/media/Files/pdfs/medicines/hiv/truvada/truvada_pi.pdf
FTC/TDF BLACK BOX WARNINGS
• Lactic acidosis and severe hepatomegaly (including fatal
cases)
• Severe exacerbations of hepatitis B have been reported in
pts coinfected with hep B and HIV who discontinued
FTC/TDF
• TRUVADA used for a PrEP indication must only be
prescribed to individuals confirmed to be HIV-negative
immediately prior to initiating and periodically (at least
every 3 months) during use. Drug-resistant HIV-1 variants
have been identified with use of TRUVADA for a PrEP
indication following undetected acute HIV-1 infection. Do
not initiate TRUVADA for a PrEP indication if signs or
symptoms of acute HIV-1 infection are present unless
negative infection status is confirmed.
Truvada Package Insert: https://www.gilead.com/~/media/Files/pdfs/medicines/hiv/truvada/truvada_pi.pdf
ACUTE ANTIRETROVIRAL SYNDROME
Vanhems P, et al. 2002. JAIDS 31: 318- 321.
FTC/TDF ADVERSE EVENTS/WARNINGS
• New onset or worsening renal impairment
• Fanconi syndrome
• Avoid concurrent nephrotoxic agents
• Decreased in bone mineral density
• Redistribution/accumulation of body fat
• Side effects in HIV positive patients (in combination with
other agents): diarrhea, nausea, rash
• Side effects in HIV-negative patients: no significant
difference from placebo
Truvada Package Insert: https://www.gilead.com/~/media/Files/pdfs/medicines/hiv/truvada/truvada_pi.pdf
FTC/TDF NPREP DATA
iPrEx
TDF2
FEM-PrEP
Partner’s
VOICE
2499 MSM
International
1216 HTXL
men/women
in Botswana
2056 HTXL
women in
Kenya,
Tanzania, S
Africa
1458 HTXL
couples in
Kenya,
Uganda
2029 HTXL
women in S
Africa,
Uganda,
Zimbabwe
FTD/TDF v
placebo
FTC/TDF v
placebo
FTC/TDF v
placebo
FTC/TDF v
TDF v
placebo
FTC/TDF v
TDF v
placebo
TDF gel v
placebo gel
Reduction in
incidence of
HIV infection
44% (CL 15 –
63, p= 0.005)
Decreased rate
of infection by
62.2% (study
stopped early
due to poor
retention)
Max 2.8 years
Max 3.7 years
No reduction in
infection
Reduction in
infection 75%
FTCTDF (CI
55-87, p
<0.001), 67%
TDF (CI 44-81,
p <0.001)
TDF oral and
gel stopped
early due 6%
infection rate for
both
No reduction of
infection with
FTC/TDF
BEFORE
MSM
Heterosexual
Document negative HIV antibody test immediately before stating PrEP
Test for acute HIV infection if patient
has symptoms consistent with acute
HIV infection
+ – if the person reports unprotected
sex with an HIV-positive person in the
preceding month
Determine if women are planning to
become pregnant or are currently
pregnant or breastfeeding
Confirm that patient is at ongoing, very high risk for acquiring HIV infection
Confirm that calculated Cockcroft-Gault is >60 mL/min
Truvada REMS: http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatients
andProviders/UCM312304.pdf
BEFORE
MSM
Heterosexual
If any sexual partner is known to be
HIV-infected, determine whether
receiving ART; assist with linkage to
care if not in care or not receiving ART
Screen for Hep B, vaccinate if susceptible, treat if active regardless of PrEP
Screen and treat as needed for STIs
Disclose to women that safety for
infants exposed during pregnancy is
not fully assessed, but no harm has
been reported
Do not prescribe to women who are
breastfeeding
Truvada REMS: http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatients
andProviders/UCM312304.pdf
BEGINNING
MSM
Heterosexual
1 tablet TDF/FTC daily
90 day supply renewable
after HIV repeat testing
For women confirm
pregnancy test is negative
or if pregnant informed
about use of medication
during pregnancy
For active Hep B consider using TDF/FTC for treatment
Provide risk-reduction and PrEP medication adherence
counseling and condoms
Truvada REMS: http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatients
andProviders/UCM312304.pdf
FOLLOW-UP
MSM
Heterosexual
Every 2-3 months perform HIV antibody test (or antibody/antigen test);
document negative results
At each f/u for women conduct
pregnancy test, document, if pregnant
discuss the continued use of PrEP
and prenatal-care
Evaluate and support PrEP medication adherence at each follow-up visit,
more often if inconsistent adherence is identifies
Every 2-3 months assess risk behaviors and provide risk-reduction counseling
and condoms. assess STI symptoms and if present treat
Every 6 months test for bacterial STI even if patient is asymptomatic and treat
as needed
3 months after initiation, then yearly
3 months after initiation, then every 6
while on PrEP medication, check BUN months while on PrEP medication,
and SCr
check SCR and calculate CrCl
Truvada REMS: http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatients
andProviders/UCM312304.pdf
DISCONTINUING
MSM
Heterosexual
Perform HIV test to confirm whether HIV infection has occurred
If HIV positive, order and document results of resistance testing and establish
linkage to HIV care
If HIV negative, establish linkage to risk-reduction support services as
indicated
If active hepatitis B is diagnosed at initiation of PrEP consider appropriate
medication for continued treatment of hepatitis B
If pregnant, inform prenatal-care
provider of TDF/FTC use in early
pregnancy and coordinate care to
maintain HIV prevention during
pregnancy and breastfeeding
Truvada REMS: http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatients
andProviders/UCM312304.pdf
QUESTION 1
A 66 yo WM was recently admitted to the hospital for
pneumonia. While admitted he was also diagnosed with C
difficile diarrhea and has now completed a course of
metronidazole. He is calling your office complaining of
continued diarrhea. What do you do?
A. Tell him take a probiotic and Immodium.
B. Have him come to the office and submit stool for testing.
C. Retreat with an extended course of metronidazole.
D. Ask him if he has money saved, if he says yes, prescribe
fidaxomicin.
E. Call your GI colleague and arrange for fecal
transplantation.
QUESTION 2
In mid January, a 54 yo woman presents to hospital with
increasing shortness of breath, productive cough and fever.
She was diagnosed with influenza 1 month prior and treated
with oseltamivir. Her chest Xray is consistent with lobar
pneumonia. Sputum is positive for gram positive cocci in
pairs. She takes paroxetine daily. What is the best course of
action at this time?
A. Give her a another course of oseltamivir
B. Prescribe linezolid and send her home.
C. Do a chest CT to assess for empyema.
D. Admit her, start vancomycin, pip/tazo and cipro.
E. Admit her, start ceftaroline.
QUESTION 3
A 62 yo WF presents to your clinic complaining of fatigue.
She asks you test her for everything. You order
A. TSH, B12, cbc, sed rate
B. Vit D
C. HIV, Hep C
D. Nothing. She needs reassurance alone.
E. Referral to therapist.
QUESTION 3B
You test the patient from the previous question for Hepatitis
C. Her Hep C IgG is positive, viral load is 600,000 and her
genotype is 1a. Her US shows mild cirrhosis and her LFTs
are 1.5 ULN. What is the next step in her management?
A. Test for HIV, Hepatitis A and B and syphilis.
B. Have her come back in 6 months and repeat testing.
C. Schedule her for a liver biopsy.
D. Refer her to ANYONE treating Hepatitis C.
E. Start her on telaprevir with peg-interferon and ribivirin.
QUESTION 4
A 28 yo man presents to your office. He states he has heard
about a medicine that will keep him from getting HIV. He
would like for you to prescribe that to him. You
A. Refer him to Infectious Diseases.
B. Ask him why he thinks he is going to be infected with
HIV.
C. Ask him if he is infected with HIV.
D. Give him a package of condoms.
E. Prescribe FTC/TDF.
SUMMARY
• C difficile remains a serious health issue. Vancomycin
and metronidazole remain the mainstays of therapy.
Fidaxomicin (Dificid) is another treatment option.
• MRSA skin and lung infections remain a serious health
issues. Ceftaroline (Teflaro) has been approved for SSTI
and may be used in pneumonia.
•
•
Screen everyone for Hepatitis C.
•
•
Ceftaroline = cefazolin + MRSA coverage
If ab positive, get viral load and genotype then send to specialist.
Screen everyone for HIV. Encourage safe sex practices to all of
your patients.
•
If pre-exposure prophylaxis questions come up, send the patient to us.