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February '25 Infectious Diseases Update

Posted by Doug Black, PharmD., Ann Lloyd, PharmD. on Feb 11th 2025

Sanford Guide ID Update features current developments in infectious diseases, curated by the Sanford Guide Editorial Board and our AMS Program Manager. Links marked with a * are available to Sanford Guide All Access & Sanford Guide for Web clients. All other links are available without a Sanford Guide subscription. To receive monthly updates via email, sign up now.

Article of the Month (Editors' Choice)

  • Drug Reaction with Eosinophilia and Systemic Symptoms (N Engl J Med 2024;391:2242-54).
  • Overview. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a T-cell-mediated severe cutaneous adverse reaction most commonly associated with antiepileptics, antibiotics, allopurinol, and nonsteroidal anti-inflammatory drugs (NSAIDs). In the US, these five drugs (listed in order of decreasing prevalence) account for most cases: allopurinol, vancomycin, lamotrigine, carbamazepine, and TMP-SMX.
  • Clinical presentation. DRESS typically manifests with:
    •    Rash and fever
    •    Facial edema
    •    Lymphadenopathy
    •    Hematologic abnormalities
    •    Organ involvement (e.g., hepatitis, acute kidney injury)
  • Pathophysiology. DRESS is classified as a delayed type IV hypersensitivity reaction. However, its prolonged course after drug discontinuation, association with viral reactivation, and potential long-term autoimmune sequelae suggest the involvement of complex immune mechanisms.
  • Differential diagnosis. It is crucial to distinguish DRESS from other severe cutaneous reactions and life-threatening conditions such as:
    •    Stevens-Johnson syndrome, toxic epidermal necrolysis
    •    Acute generalized exanthematous pustulosis (AGEP)
    •    Hemophagocytic lymphohistiocytosis
    •    Angioimmunoblastic T-cell lymphoma
    •    Acute graft-versus-host disease
  • Management. Consensus guidelines for management of DRESS are not available, and there is a need for comparative studies to inform treatment. The following recommendations are based on observational data and expert opinion:
    •    Immediate discontinuation of the suspected drug
    •    Supportive care to manage symptoms and organ involvement
    •    Immunosuppressive therapy, with systemic glucocorticoids as the first-line treatment. Emerging evidence suggests alternative immunosuppressive and targeted therapies, including biologic medications.
  • Diagnosis & long-term care. There are no validated diagnostic tests for DRESS. Consultation with a dermatologist or allergist-immunologist is valuable for drug causality assessment and identifying safe alternative medications. Due to its relapsing and remitting nature and potential long-term complications, ongoing multidisciplinary follow-up care and patient support are essential. About 5% of cases result in death.
  • Author: Doug Black, PharmD

Early Initiation of Oseltamivir

  • The 2018 IDSA guidelines recommend initiating oseltamivir* treatment as soon as possible for patients hospitalized with suspected or confirmed influenza, regardless of symptom duration. However, variations in clinical practice, timing of antiviral use, and circulating influenza strains may impact treatment effectiveness. Many observational studies have shown that oseltamivir is often not prescribed, or prescribed late to hospitalized patients with influenza.
  • A multicenter US observational sentinel surveillance network prospectively enrolled adults hospitalized with laboratory-confirmed influenza across 24 hospitals from October 1, 2022, to July 21, 2023. Researchers used a multivariable proportional odds model to compare peak pulmonary disease severity (categorized as no oxygen support, standard supplemental oxygen, high-flow oxygen/non-invasive ventilation, invasive mechanical ventilation, or death) among patients who received oseltamivir on the day of admission (early treatment) versus those who received it later or not at all. The analysis adjusted for baseline severity, age, sex, hospital site, and vaccination status. Additionally, multivariable logistic regression models evaluated the odds of ICU admission, acute kidney replacement therapy or vasopressor use, and in-hospital death. The design largely controlled for immortal time bias.
  • Among 840 influenza-positive patients, 415 (49%) received oseltamivir on the day of admission, while 425 (51%) did not. Compared to those treated later or not at all, early treatment was associated with:
    • Lower peak pulmonary disease severity (adjusted odds ratio [aOR]: 0.60, 95% CI: 0.49–0.72).
    • 75% reduced odds of ICU admission (aOR: 0.24, 95% CI: 0.13–0.47).
    • 60% lower likelihood of requiring acute kidney replacement therapy or vasopressors (aOR: 0.40, 95% CI: 0.22–0.67).
    • 64% lower odds of death (aOR: 0.36, 95% CI: 0.18–0.72).
  • Conclusion: In this 24-hospital study during the 2022–2023 influenza season, early oseltamivir treatment on the day of hospital admission was associated with a lower risk of disease progression, including respiratory failure, organ dysfunction, and death.
  • Reference: Clin Infect Dis 2024 Nov 28:ciae584 [online ahead of print].
  • Authors: Andy Pavia, MD, Doug Black, PharmD

New or Updated Guidelines

AMS Pearl: Primary Care Electronic Medical Records for AMS

  • A newly published systematic review analyzes the evidence for electronic medical record (EMR) data to support antimicrobial stewardship (AMS) efforts.
  • The study included 34 articles from 10 countries. The important strengths identified were established processes for data access and collection and embedding data collection into standard practice. The most common barrier was EMR design differences across vendors.
  • AMS programs could use this study to support the implementation of EMR processes that facilitate interventions. Antimicrob Steward Healthc Epidemiol. 2025 Jan 24;5(1):e16. doi: 10.1017/ash.2024.499.

Antimicrobial Shortages (US)

  • Recent shortages:
    • None
  • Resolved shortages:
    • Ofloxacin 0.3% ophthalmic solution (3 Feb 2025) NEW
  • Antimicrobial drugs or vaccines in continued reduced supply or unavailable (as of 8 February 2025) due to increased demand, manufacturing delays, product discontinuation by a specific manufacturer, or unspecified reasons: 
    • Antibacterial drugs:
      • Aminoglycosides:
        • Gentamicin injection (22 Feb 2021)
      • Azithromycin oral suspension, 1 gm packets (20 Nov 2024)
      • Bacitracin ophthalmic ointment 500 units/gm (12 Sep 2024)
      • Cephalosporins:
        • Cefazolin injection (4 Jun 2018)
        • Cefdinir 300 mg capsules (29 Jun 2023)
        • Cefdinir 125 mg/5 mL, 250 mg/5 mL oral suspension (29 Jun 2023)
        • Cefotaxime injection (10 Jun 2015)
          • FDA is allowing temporary importation of product from SteriMax in Canada, in conjunction with Provepharm Life Solutions and its distributor Direct Success. Click here for details.
      • Chloramphenicol injection (9 Oct 2023)
      • Clindamycin phosphate injection (25 Jun 2015)
      • Fluoroquinolones:
        • Ciprofloxacin injection (13 Jan 2023)
        • Levofloxacin injection in D5W (29 May 2024)
        • Levofloxacin oral solution, 25 mg/mL (15 Sep 2023)
        • Moxifloxacin 400 mg tablets (6 Dec 2023)
      • Glycopeptides, glycolipopeptides, lipopeptides:
        • Vancomycin injection (1 Jun 2015)
      • Metronidazole injection (20 Oct 2021)
      • Neomycin and Polymyxin B Sulfates GU Irrigant (25 Jun 2023)
      • Nitrofurantoin oral suspension (5 Jun 2018)
      • Oxazolidinones:
        • Linezolid injection (16 Oct 2024)
      • Penicillins:
        • Amoxicillin, all oral formulations (18 Oct 2022)
        • Amoxicillin-clavulanate, all oral formulations (17 Nov 2022)
        • Ampicillin injection (19 Oct 2023)
        • Dicloxacillin 250 mg, 500 mg capsules (18 Aug 2021)
        • Nafcillin injection (20 Mar 2024)
        • Penicillin G benzathine injection (1 Feb 2023) Availability update here
        • Penicillin G benzathine/Penicillin G procaine (31 Mar 2023) Availability update here
        • Penicillin VK oral solution 250 mg/5 mL (17 May 2023)
        • Penicillin VK 250 mg, 500 mg tablets (17 May 2023)
      • Rifaximin 200 mg tablets (11 Apr 2024)
    • Antifungal drugs: 
      • Amphotericin B Lipid Complex (5 Aug 2022)
      • Fluconazole injection (9 Aug 2024)
      • Ibrexafungerp 150 mg tablets (3 Dec 2024)
      • Nystatin oral suspension (21 June 2024)
    • Antimycobacterial drugs: 
      • Isoniazid 100 mg, 300 mg tablets (1 Sep 2022)
    • Antiparasitic drugs:
      • Mefloquine 250 mg tablets (14 May 2024)
      • Nitazoxanide oral susp 100 mg/5 mL (15 Feb 2024)
    • Antiviral drugs: 
      • Cidofovir injection (01 Nov 2024)
      • Oseltamivir 30 mg, 45 mg, 75 mg capsules (1 Nov 2022)
      • Oseltamivir powder for oral suspension (1 Nov 2022)
      • Peginterferon alfa-2a (Pegasys) (8 Jan 2025)
      • Ribavirin for inhalation solution (23 May 2023)
  • Antimicrobial drugs recently discontinued: 
    • Bezlotoxumab injection (31 Jan 2025, by Merck) NEW
    • Posaconazole oral susp 40 mg/mL (Dec 2023, by Merck)
    • Sulfacetamide 10%/Prednisolone acetate 0.2% oph ointment (Aug 2023 by Allergan, sole supplier)
    • Penicillin G procaine 600,000 units/mL IM injection (Jun 2023)
    • Ritonavir oral solution 80 mg/mL (Jan 2023)
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