Sandbox ammu

• HIV/AIDS
• 1.Antiretroviral Regimen Options for Treatment-Naive Patients
• Integrase Strand Transfer Inhibitor-Based Regimens:

• Preferred regimen:

• Dolutegravir/Abacavir/Lamivudine IV : Only for patients who are HLA-B*5701 negative
• Dolutegravir AND Tenofovir disoproxil fumarate (Tenofovir)/Emtricitabine
• Elvitegravir/Cobicistat/Tenofovir/Emtricitabine—only for patients with pre-antiretroviral therapy CrCl >70 mL/min
• Raltegravir AND Tenofovir/Emtricitabine

• Alternative Regimen

• EFV/TDF/FTC
• RPV/TDF/FTCa—only for patients with pre-treatment HIV RNA <100,000 copies/mL and CD4 cell count >200 cells/mm3

• Protease Inhibitor-Based Regimen

• Preferred regimen:
• Darunavir/Ritonavir AND Tenofovir/Emtricitabine

• Alternative Regimen Options

• ATV/c AND TDF/FTCa —only for patients with pre-treatment estimated CrCl ≥70 mL/min
• ATV/r AND TDF/FTC
• (DRV/c OR DRV/r) AND ABC/3TCa —only for patients who are HLA-B*5701 negative
• DRV/c AND TDF/FTCa —only for patients with pre-treatment estimated CrCl ≥70 mL/min

Bronchiolitis

Treatment

Note

• Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally
• Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis.
• Clinicians should not administer epinephrine to infants and children with a diagnosis of bronchiolitis.
• Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting.
• Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one.
• Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department.
• Clinicians should not use chest physiotherapy for infants and children with a diagnosis of bronchiolitis.

Prophylaxis

• Regimen: Palivizumab (15 mg/kg/dose) during the respiratory syncytial virus season to infants who qualify for palivizumab in the first year of life.

Note

• Clinicians should administer palivizumab during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity defined as preterm infants <32 weeks 0 days’ gestation who require >21% oxygen for at least the first 28 days of life.
• Clinicians should not administer palivizumab to otherwise healthy infants with a gestational age of 29 weeks, 0 days or greater.
• All people should disinfect hands before and after direct contact with patients, after contact with inanimate objects in the direct vicinity of the patient, and after removing gloves.
• All people should use alcoholbased rubs for hand decontamination when caring for children with bronchiolitis. When alcoholbased rubs are not available, individuals should wash their hands with soap and water.
• Clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and smoking cessation when assessing a child for bronchiolitis.

Influenza

Treatment

• Preferred Regimen(1): Zanamivir 10 mg (two 5-mg inhalations) BID for 5 days.
• Preferred Regimen(2): Oseltamivir 75 mg BID for 5 days.
• Preferred Regimen(3): Peramivir 600 mg dose, IV for 15-30 minutes for 1 day.

Prophylaxis

• The chemoprophylaxis dosage of Zanamivir is 10 mg (2 inhalations) once a day.
• The chemoprophylaxis of Oseltamivir is from 3 months and older age group.

• Pediatric dose

Oseltamivir

• If younger than 1 yr old1:
• 3 mg/kg/dose twice daily2,3
• If 1 yr or older, dose varies by child’s weight:
• 15 kg or less, the dose is 30 mg twice a day
• >15 to 23 kg, the dose is 45 mg twice a day>23 to 40 kg, the dose is 60 mg twice a day>40 kg, the dose is 75 mg twice a day.

Zanamivir

• 10 mg (two 5-mg inhalations) twice daily

(FDA approved and recommended for use in children 7 yrs or older).

Dosing in Adult Patients with Renal Impairment

• Oral oseltamivir

• Creatinine clearance 61 to 90 mL/min-

• Recommended Treatment Regimen- 75 mg BID
• Recommended Chemoprophylaxis Regimen- 75 mg qd

• Creatinine clearance 31 to 60 mL/min-

• Recommended Treatment Regimen- 30 mg BID
• Recommended Chemoprophylaxis Regimen- 30 mg qd

• Creatinine clearance 10 to 30 mL/min

• Recommended Treatment Regimen- 30 mg qd
• Recommended Chemoprophylaxis Regimen- 30 mg every other day

• ESRD Patients on Hemodialysis Creatinine clearance ≤10 mL/min

• Recommended Treatment Regimen- 30 mg after every hemodialysis cycle. Treatment duration not to exceed 5 days
• Recommended Chemoprophylaxis Regimen- 30 mg after alternate hemodialysis cycles.

• ESRD Patients on Continuous Ambulatory Peritoneal Dialysis Creatinine clearance ≤10 mL/min.

• Recommended Treatment Regimen- A single 30 mg dose administered immediately after a dialysis exchange
• Recommended Chemoprophylaxis Regimen- 30 mg once weekly immediately after dialysis exchange
• Recommended Chemoprophylaxis Regimen- 30 mg after alternate hemodialysis cycles.

Note:

• Early treatment of hospitalized patients can reduce death.
• An emphasis on close monitoring and early initiation of antiviral treatment if fever and/or respiratory symptoms develop is an alternative to chemoprophylaxis after a suspected exposure for some persons.
• To be effective as chemoprophylaxis, an antiviral medication must be taken each day for the duration of potential exposure to a person with influenza and continued for 7 days after the last known exposure. For persons taking antiviral chemoprophylaxis after inactivated influenza vaccination, the recommended duration is until immunity after vaccination develops (antibody development after vaccination takes about two weeks in adults and can take longer in children depending on age and vaccination history).
• Antiviral chemoprophylaxis generally is not recommended if more than 48 hours have elapsed since the first exposure to an infectious person.
• Patients receiving antiviral chemoprophylaxis should be encouraged to seek medical evaluation as soon as they develop a febrile respiratory illness that might indicate influenza.
• Zanamivir is contraindicated in patients with history of allergy to milk protein.
• Oral oseltamivir is preferred for treatment of pregnant women.
• For control of outbreaks in institutional settings (e.g. long-term care facilities for elderly persons and children) and hospitals, CDC recommends antiviral chemoprophylaxis for a minimum of 2 weeks, and continuing up to 1 week after the last known case was identified. Antiviral chemoprophylaxis is recommended for all residents, including those who have received influenza vaccination, and for unvaccinated institutional employees.

Empyema

Culture negative pleural infection

• Preferred regimen: Cefuroxime 1.5 g IV q8h AND Metronidazole 500 mg IV q8h OR Template:Benzyl penicillin 1.2 g IV q6h PLUS Ciprofloxacin 400 mg IV q12h OR meropenem 1 g IV q8h PLUS metronidazole 500 mg q8h.

• Preferred regimen(2): Amoxycillin 1 g oral q8h PLUS clavulanic acid 125 mg oral q8h PLUS metronidazole 400mg oral q8h OR clindamycin 300 mg oral q8h.LastName, FirstName (2007). Sanford guide to antimicrobial therapy. Place of publication not identified: Antimicrobial Therapy. ISBN 9781930808386.

For culture negative hospital acquired infection

• Preferred regimen: Piperacillin 3 gm IV q4h PLUS tozobactam 4.5g IV q6h OR ceftazidime 2g IV q8h OR meropenem 1g IV q8h PLUS metronidazole 500mg q8h.

Pathogen based empyema

Strep. pneumoniae, Group A strep

• Preferred regimen(1):Ceftriaxone ≤30 days old, 75 mg/kg IV/IM q24h (use with caution in infants with jaundice) or >30 days old 100 mg/kg IV/IM q24h

Staph. aureus

• Preferred regimen(1): Nafcillin 2 gm IV q4h OR oxacillin 2 gm IV q4h if MSSA
• Alternate regimen(1): Vancomycin 1 gm IV q12h OR Linezolid 600 mg po bid if MRSA

H. influenzae

• Preferred regimen: Ceftriaxone 75 mg/kg IV/IM q24h
• Alternate regimen: TMP-SMX 1 tab po 5 days/wk or AM-SB

Subacute/chronic empyema

Anaerobic strep, Strep. milleri, Bacteroides sp., Enterobacteriaceae, M. tuberculosis

• Preferred regimen: Clindamycin 450–900 mg IV q8h + Ceftriaxone
• Alternate regimen: Cefoxitin or IMP or TC-CL or PIP-TZ or AM-SB