Skip to main content

January '25 Infectious Diseases Update

Posted by Doug Black, PharmD., Ann Lloyd, PharmD. on Jan 14th 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)

  • An otherwise well 32-yo female developed community-acquired pneumonia (CAP) refractory to a five-day course of oral azithromycin. Her cough was non-productive. Despite a PSI of 42, she was hospitalized because of hypoxemia and failure of outpatient management. Empiric therapy with ceftriaxone and azithromycin was initiated. Blood and airway cultures failed to detect a pathogen. Urine antigen tests for Legionella pneumophila and Streptococcus pneumoniae were negative. The clinical syndrome was felt compatible with an “atypical” CAP. Concomitant diagnostic efforts focused on pathogens known to cause atypical pneumonia.

    It is helpful to divide the etiologies of atypical pneumonia into those considered as non-zoonotic versus those associated with contact with an animal(s). Common non-zoonotic pathogens include Mycoplasma pneumoniae, Legionella spp., and Chlamydophila pneumoniae. Zoonotic pathogens include Chlamydia psittaci, Coxiella burnetii, and Francisella tularensis, among others.

    After two days, the patient's oxygen requirement increased, and vancomycin plus piperacillin-tazobactam were added. The patient’s pneumonia continued to worsen over the next 24 hours, despite escalating antibiotic therapy. She repeatedly denied direct or indirect exposure to animals. However, a friend of the patient recalled that the patient recently prepared a deer carcass. She cooked the venison and served and ate it 20 days before admission. None of the other persons who consumed the cooked meat were reported to be ill.

    The etiologic differential was expanded to include zoonotic organisms associated with meat: Coxiella burnetii, Brucella melitensis, Toxoplasma gondii, Yersinia pestis, and Bacillus anthracis. Humans can contract such pathogens by inhaling contaminated aerosols or ingesting undercooked food, untreated water, or soil containing the organism.

    The diagnosis was documented several ways, including a plasma cell-free DNA assay (Karius company). Scroll down to the bottom of this month's update to learn which atypical pathogen was identified. Hint: the preferred specific therapy is the oral combination of pyrimethamine, sulfadiazine, and folinic acid. Trimethoprim-sulfamethoxazole IV or po is an alternative.

    Author: David Gilbert, MD

The BALANCE Trial

  • A shorter duration of antibiotic treatment is generally advantageous in reducing adverse effects, the risk of Clostridioides difficile infection, the development of resistance among non-target bacteria, and overall cost. However, potential downsides include clinical treatment failure, recurrent infection, and the emergence of resistance in the target pathogen.
  • The BALANCE trial (Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness), a multicenter study published in the New England Journal of Medicine (Nov 20, 2024, online ahead of print; doi: 10.1056/NEJMoa2404991), investigated the optimal duration of antibiotic therapy in hospitalized patients with bacteremia. Participants were randomly assigned to receive either 7 or 14 days of antibiotics, with drug selection and dosing determined by the treating physicians. Patients with severe immunosuppression, infections requiring prolonged treatment, single cultures with common contaminants (e.g., CoNS), or bacteremia caused by Staphylococcus aureus or S. lugdunensis were excluded from the study.
  • A total of 3,608 patients with bacteremia from various sources were enrolled, with 55% in the ICU at the time of randomization and 75.4% acquiring their infections in the community. The study found that 7 days of antibiotic therapy was noninferior to 14 days in terms of the primary outcome: all-cause mortality at 90 days. Secondary clinical outcomes, such as the duration of vasopressor use, days of mechanical ventilation, and rates of bacteremia relapse, were comparable between the two groups. The incidence of antibiotic-related adverse effects, C. difficile infections, and secondary infections with resistant organisms was also similar.

New or Updated Practice Guidelines

  • Updated national UK guidelines on the management of genital HSV in pregnancy and the neonate (Int J STD AIDS 2025;36:4-23). PDF available here.
  • Updated Spanish guidelines on the management of drug-resistant tuberculosis, from The Spanish Society of Pneumology and Thoracic Surgery (SEPAR) and the Spanish Society of Infectious Diseases and Clinical Microbiology (executive summary). These guidelines update previous recommendations on drug-resistant TB published in 2017 and 2020 by SEPAR (Arch Bronconeumol 2024;60:759-767).

Revoked EUAs

AMS Pearl: Ambulatory Stewardship Benchmarks

  • A recent review article describes potential metrics for ambulatory antimicrobial stewardship (AMS) program implementation.
  • Four of these are part of the Healthcare Effectiveness Data and Information Set (HEDIS), a tool used by many health plans to evaluate performance on patient care and services. The four HEDIS measures related to AMS are: avoidance of antibiotic treatment for acute bronchitis/bronchiolitis, appropriate treatment for upper respiratory tract infection, appropriate testing for pharyngitis, and antibiotic utilization for respiratory conditions.
  • AMS programs should consider targeting interventions toward the HEDIS measures due to their importance in value-based reimbursement, pay-for-performance, patient satisfaction, and other incentives. Antimicrobial Stewardship & Healthcare Epidemiology. 2024;4(1):e217. doi:10.1017/ash.2024.468

Antimicrobial Shortages (US)

  • New shortages:
    • Peginterferon alfa-2a (Pegasys) (8 Jan 2025)
  • Resolved shortages:
    • Acyclovir injection (27 Nov 2024)
  • Antimicrobial drugs or vaccines in continued reduced supply or unavailable (as of 13 January 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)
        • Ofloxacin 0.3% ophthalmic solution (22 Dec 2022)
      • 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)
      • Ribavirin for inhalation solution (23 May 2023)
  • Antimicrobial drugs recently discontinued:
    • 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)

***************

  • Atypical pathogen identified in the Article of the Month: Toxoplasma gondii
!