34. MGH antibiotic susceptibilities
Chloramphenicol
TMP - SMX
Levofloxacin
Rifampin
Linezolid
Nitrofurantoin*
Tetracycline
Erythromycin
Clindamycin
Vancomycin
Cephalothin c
Oxacillin
Penicillin
No of Strains
Gram positive susceptibilities (Jan-Dec 2002) (% susceptible)




95





85
92
54
97
100
76






55
46
99
100
98
95
99
98
92
98
56
98
96

100






30
100
100
100
100






99
100
100
100
100






94
Staphylococcus aureus
2299 10
56
56 100 66 43 90
Coagulase-negative staphylococci
2855 12
35
35 100 61 35 85
Organism
Staphylococcus saprophyticus
135


 100 95 44 85
Staphylococcus lugdunensis
38
82 100 d  100 87 76 87
Streptococcus pneumoniae
245
75

 100 92 78 82
63
100
100 100 94 87 86
-hemolytic streptococci (group A)

278 100
100 100 88 73 13
-hemolytic streptococci (group B)

44
100
100 100 93 73 31
-hemolytic streptococci (group C, G)

177
72
-hemolytic streptococcia

 100 90 59 62
Streptococcus milleri groupb
42
98

 100 83 86 81
Enterococci
2330 82
85


 12 30
* Urine isolates only
a Includes alpha-hemolytic streptococci, S. mitis, S. sanguis, S. salivarius, S. bovis, S. mutans
b Includes alpha-hemolytic and beta-hemolytic S. milleri group
c For Staph. spp. predicted from oxacillin; for streptococci predicted from penicillin
d Determined by testing for the presence of mecA gene
Piperacillin
Cefazolin
Cefpodoxime
Ceftriaxone
Ceftazidime
Cefepime
Aztreonam
Meropenem
Gentamicin
Amikacin
Levofloxacin
TMP – SMX
Chloramphenicol
Tetracycline
Nitrofurantoin*
Acinetobacter calcoaceticusbaumanni complex
Alcaligenes xylosoxidans
Burkholderia cepacia complex
Citrobacter freundii
Citrobacter koseri (diversus)
Enterobacter aerogenes
Enterobacter cloacae
Escherichia coli
Haemophilus influenzae
Klebsiella oxytoca
Klebsiella pneumoniae
Morganella morganii
Proteus mirabilis
Proteus vulgaris
Pseudomonas aeruginosa
Salmonella spp.
Serratia marcescens
Shigella spp.
Stenotrophomonas maltophilia
* Urine isolates only
Ampicillin
Organism
No of Strains
Gram negative susceptibilities (Jan-Dec 2002) (% susceptible)
283
0
0
0
0
0
21
24
9
35
34
72
29
44

24
0
50
43
152
96
177
378
5561
103
216
1199
79
476
32
1359
70
200
26
176


0
0
0
0
66
75
0
0
0
85
0

83
0
42

80
33
85
90
82
67
70

0
0
80
92
94
84
86
82
50
18


0
93
0
0
95

64
83
0
97
0


0




74
98
80
50
97

90
85
63
98
97

96
69
100



88
99
84
69
99
100
95
86
96
100
83

97
92
100

74
44
88
91
83
74
99

93
86
81
99
100
84
95
91
100
38


100
100
98
94
100
0
12
88
99
85
70
99

95
86
94
99
100
67
99
95
100
0
80
28
100
100
99
100
100

100
100
100
100
100
84
100
100
100
0
0
0
97
100
99
92
97

92
91
90
95
100
76

95

0
0
7
99
100
99
98
100

100
98
100
100
100
78

99

10
14
9
91
98
97
85
96
100
88
84
95
95
100
59
100
88
100
46
84
67
89
99
98
86
82
83
91
83
89
91
100

99
97
23
95
42
30





95









59


77
94
88
78
77

89
79
67
0
34

87
23
4



97
99
42
64
99

91
56
17
0
7



100

MGH Medical Housestaff Manual
96
86
100
89
100
84
100
100
100

86
35. HIV antiretroviral therapy
Recommendations for initiation of antiretrovirals for HIV
 Asymptomatic infection: evaluate with history, physical exam, CBC, chemistry, LFTs, lipids, CD4+
count, Plasma HIV RNA (viral load), evaluation for opportunistic infections (OIs); CMV, syphilis,
toxo, hepatitis serologies, PPD, CXR, Pap smear.
 Symptomatic disease (wasting, thrush, unexplained fever > 2 weeks) including AIDS: all patients
should be offered treatment.
Clinical Category
Symptomatic (AIDS,
severe symptoms)
Asymptomatic AIDS
Asymptomatic
Asymptomatic
CD4+ T cell count
Any value
Plasma HIV RNA
Any value
Recommendation
Treat
< 200/mm3
200-350/mm3
> 350/mm3
Any value
Any value
Treat
Treatment offered; controversial
Some would initiate therapy as
3-yr risk of AIDS >30%; others
would monitor CD4+ count and
RT-RNA frequently
Many would defer therapy and
observe as 3-yr risk of AIDS is
<15%
Treatment offered; ongoing
clinical trials assess the benefit
> 55,000 (bDNA or
RT-PCR)
Asymptomatic
> 350/mm3
<55,000 (bDNA or
RT-PCR)
Acute HIV infection,
within 6 months
Any value
Any value
Goals of treatment




Decrease in viral load (0.5-0.75 log10) within 4 weeks or VL (1 log) within 8 weeks
Undetectable VL (<50 or <20 viral copies) at 4-6 months
Restoration and/or preservation of immunological function
Reduction of HIV-related morbidity and mortality
Hospital management
 Assess patient's current regimen and adherence
 If adherent, and not admitted for adverse reactions (lactic acidosis, pancreatitis, hepatitis, rash, etc.)
resume all antiretrovirals according to dosing schedule. Encourage patient to take own medicines to
avoid delay from the pharmacy.
 When in ICU setting or if NGT is in place, Kaletra, ritonavir, and AZT can be given in liquid
formulation. Other antiretroviral preparations may also be available in liquid formulation.
 Hold all antiretrovirals if patient had not been adherent or if suffering from an adverse reaction.
 May consider checking CD4+ count, RT-RNA VL, and resistance patterns prior to resuming current
or prior to designing new regimen.
MGH Medical Housestaff Manual
87
35. HIV antiretroviral therapy
Generic drug
Brand
Typical dose
Nucleoside Analog Reverse Transcriptase Inhibitors (NRTIs)
300 mg bid (available as
Abacavir (ABC)
Ziagen (Group A)
20 mg/mL oral solution)
Zidovudine (AZT,
ZDV)
Retrovir (Group A)
200 mg tid
300 mg bid
Stavudine (d4T)
Zerit (Group A)
Lamivudine (3TC)
Epivir (Group B)
>60 kg: 40 mg bid
<60 kg: 30 mg bid
150 mg bid
Didanosine (ddI)
Videx (Group B)
Zalcitabine (ddC)
Hivid (Group B)
AZT + 3TC
Combivir (NRTI
combo)
Trizivir (NRTI
combo)
AZT + 3TC + ABC
>60 kg: 200 mg bid, 250
mg bid, or 400 mg qd
<60 kg: 125mg bid, 167 mg
bid, or 250 mg qd
0.75 mg tid
Adverse effects
Hypersensitivity reaction: fever, rash,
nausea, vomiting, malaise, fatigue,
loss appetite; lactic acidosis; SOB
Bone marrow suppression; anemia;
neutropenia; GI intolerance; HA,
insomnia; lactic acidosis
Pancreatitis, peripheral neuropathy;
lactic acidosis with hepatic steatosis
Minimal toxicity; lactic acidosis with
hepatic steatosis
Pancreatitis; peripheral neuropathy;
nausea, diarrhea; lactic acidosis with
hepatic steatosis
1 tablet bid
Peripheral neuropathy; stomatitis;
lactic acidosis
As per AZT and 3TC
1 tablet bid
As above
Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Delavirdine
Rescriptor
400 mg tid
Efavirenz
Sustiva
600 mg qhs
Nevirapine
Viramune
200 mg bid
Amprenavir
Agenerase
1200 mg bid (cap)
1400 mg bid (soln)
<50 kg: 20 mg/kg
Indinavir
Crixivan
800 mg q8h
Nelfinavir
Viracept
Ritonavir
Norvir
1250 mg bid (with meals)
750 mg tid (with meals)
600 mg q12h (with meals)
Saquinavir
Invirase
400 mg bid with ritonavir
Rash; elevated LFTs; headache;
inhibits P450
Rash; CNS effects; hepatitis; mixed
incuder/inhibitor P450
Rash; elevated LFTs; hepatitis;
induces P450
Protease inhibitors
MGH Medical Housestaff Manual
GI into, nausea, vomiting, diarrhea,
rash, oral parathesias, inc. LFTs,
diabetes, fat redistribution, lipid
abnormalities
Nephrolithiasis, GI intolerance,
nausea, headache, increased LFTs,
diabetes, fat redistribution
Diarrhea, nausea, diabetes, fat
redistribution, lipid abnormalities
GI intol, nausea, vomiting, diarrhea,
parathesias, hepatitis, pancreatitis,
increased triglycerides; fat
redistribution, diabetes
GI intol, nausea, diarrhea, headache,
88
35. HIV antiretroviral therapy
Lopinavir +
Ritonavir
Fortovase
Kaletra (PI combo)
1200 mg tid (with meals)
400 mg lopinavir + 100 mg
ritonavir bid
elevated LFTs, fat redistribution, DM
GI intol, nausea, vomiting, diarrhea,
asthenia, inc. LFTs, diabetes, fat
redistribution
Nucleotide Reverse Transcriptase Inhibitors
Tenofovir
Same
300 mg qd
No renal toxicity; limited expanded
access
Recommended regimens
 One choice from group A and one from group B
 Mono and dual therapies are not recommended. Hydroxyurea not currently recommended with
NRTIs
 Class sparing regimens: NNRTI +2 NRTIs or triple NRTIs or PI + 2 NRTIs
 Consultation with HIV specialist recommended prior to initiating therapy
 Group A: efavirenz, indinavir, nelfinavir, ritonavir + indinavir, ritonavir + lopinavir (Kaletra),
ritonavir + saquinavir (soft-gel capsule or hard-gel capsule)
 Group B: didanosine + lamivudine, stavudine + didanosine, stavudine + lamivudine, zidovudine +
didanosine, zidovudine + lamivudine
Recommended alternatives
 Group A: abacavir, amprenavir, delavirdine, nelfinavir + saquinavir-SGC, nevirapine, ritonavir,
saquinavir-SGC
 Group B: zidovidine + zalcitabine
Potentially fatal adverse reactions
 Lactic acidosis and steatohepatitis. Associated with “d” drugs, NRTIs, tenofovir, and abacavir.
All antiretrovirals should be stopped and not restarted if this reaction is suspected.
 Fatal hypersensitivity reactions. Associated with abacavir. Symptoms include fever, skin rash,
fatigue, GI symptoms, dyspnea, pharyngitis, cough. Should not be rechallenged with abacavir as
death may ensue in hours.
 Propylene glycol toxicity. Found in the amprenavir oral solution. Contraindicated in children < 4
yo, pregnant women, patients with renal or hepatic failure, patients using metronidazole or
disulfiram.
 Pancreatitis. Associated with didanosine, zalcitabine.
Reference
 See also http://www.aidsinfo.nih.gov
Meg Doherty, M.D., Ph.D.
MGH Medical Housestaff Manual
89
36. Prophylaxis for opportunistic infections in HIV
Prophylaxis to prevent first episode of OIs in adults and adolescents.
Pathogen
Pneumocystis
carinii
Preventive Regimens
Indication
First Choice
Alternatives
CD4+ count <200 or
oropharyngeal
candidiasis
TMP-SMX 1 DS qd or
Dapsone 50 mg bid or
TMP-SMX 1 SS qd
dapsone 100 mg qd or
dapsone 50 mg +
pyrimethamine 50 mg +
leucovorin 25 mg qw
or aero. pentamidine 300 mg
qmonth.
Mycobacterium
tuberculosis (INH
sensitive)
PPD >5 mm or contact
with active case
INH 300 mg qd + B6 50 mg
qd x 9 mo. or
Rifampin 600 mg qd x 4 mo.
or
INH 900 mg + B6 100 mg
biweek x 9 mo.
rifabutin 300 mg qd x 4 mo.
pyrazinamide 15-20 mg/kg qd
+ rifampin
or rifabutin x 2 mos
Mycobacterium
tuberculosis (INH
resistant)
PPD > 5 mm or
contact with active
case with high prob
INH resistance
Rifampin 600 mg qd or
rifabutin 300 mg qd x 4 mo.
Pyrazinamide 15-20 mg/kg qd
+ rifampin or rifabutin x 2
mos
Mycobacterium
tuberculosis (multidrug
resistant)
PPD > 5 mm or
contact with active
case with high prob
multidrug resistance
Choice of drugs requires
consultation with public
health authorities; depends
on resistance pattern
Toxoplasma gondii
IgG Ab + Toxo and
CD4+ <100
TMP-SMX 1 DS qd
TMP-SMX 1 SS qd or
dapsone 50 mg qd +
pyrimethamine 50 mg qw +
leucovorin 25 mg qw or
dapsone 200 mg +
pyrimethamine 75 mg qw +
leucovorin 25 mg qw or
atovaquone 1500 mg qd +
pyrimethamine 25 mg qd +
leucovorin 10 mg qd
Mycobacterium avium
complex
CD4+ <50
Varicella zoster (VZV)
Exposure to VZV
VZIG 5 vials (1.25 mL) IM
within 48 hours
CD4+ > 200
Strep. pneum vaccine
Azithromycin 1200 mg qw
or clarithromycin 500 mg
bid
Rifabutin 300 mg qd or
azithromycin 1200 mg qw +
rifabutin 300 mg qd
Generally recommended
Streptococcus
MGH Medical Housestaff Manual
90
36. Prophylaxis for opportunistic infections in HIV
pneumoniae
Influenza virus
All patients
Influenza vaccine q year
Oseltamivir 75 mg qd or
rimantadine 100 mg bid or
amantadine 100 mg bid
Hepatitis B virus
All susceptible
Hepatitis B vaccine x 3
Hepatitis A virus
All susceptible at
increased risk HAV
Hepatitis A vaccine x 2
Evidence for efficacy but not routinely indicated
Bacteria
Neutropenia
G-CSF 5-10 mcg/kg sc qd
or
GM-CSF
Cryptococcus
neoformans
CD4+ <50
Fluconazole 100-200 mg qd
Histoplasma
capsulatum
CD4+ <100
Intraconazole 200 mg qd
Cytomegalovirus
(CMV)
CD4+ <50 and CMV
Ab+
Oral ganciclovir 1 g tid
Itraconazole 200 mg qd
References

Refer to http://www.aidsinfo.nih.gov/ for text of 2001 USPHS/IDSA guidelines for the prevention of
opportunistic infections in persons infected with HIV, November 2001.
Meg Doherty, M.D., Ph.D.
MGH Medical Housestaff Manual
91
37. Infection control
Hand hygiene
 Essential for proper patient care. The hands
Infection Control Resources:
of health care workers are the most
 MGH Infection Control Unit: 6-2036
important vectors for nosocomial pathogens.
 For updates, see MGH ID Division website at
Hand disinfection is essential before and
http://www.mgh.harvard.edu/depts/id/index.html.
after any patient contact (or contact with a
 Partners Handbook  Clinical Topics 
patient’s immediate environment).
Infectious Disease  MGH Division of
 Proper procedure is the use of an alcoholInfectious Disease
based hand rinse (CalStat at MGH); one pull
of the dispenser lever (3mL) is generally
sufficient. The rinse should be rubbed over the entire surface of the hands and allowed to dry.
 If hands are visibly soiled or have contacted blood or body fluids, they should be washed with soap
and water and dried thoroughly prior to the application of CalStat.
Standard precautions
 Hand hygiene, as described above, before and after any contact with patient or immediate patient
environment.
 Gloves when anticipating contact with blood, body fluids, secretions, mucous membranes, non-intact
skin and any contaminated items. Remove gloves promptly after use and disinfect hands.
 Gowns when clothes are likely to be contaminated with blood, body fluids, and secretions. Remove
gown promptly after use and disinfect hands.
 Mask and goggles or a face shield during procedures that are likely to generate splashes or sprays of
blood, body fluids or secretions. Remove the face protection promptly after use and disinfect hands.
Transmission based isolation precautions
 Airborne precautions. For infections transmissible by droplet nuclei. Negative pressure isolation
room, fit-tested N95 masks for all entering the room. Hand hygiene as above.
 Droplet precautions. For infections transmissible by droplets. Private room, surgical masks within
3 feet of patient. Hand hygiene as above.
 Contact precautions. For pathogens transmitted by direct or indirect contact. Private room
(usually). Gowns and gloves to enter room. Hand hygiene as above.
Application of transmission based isolation precautions: common examples
 Comprehensive list of diseases and applicable precautions available in the Infection Control Manual
(print copies on patient care units) and on the Infection Control website
 Chickenpox or herpes zoster in an immunocompromised host: airborne and contact precautions,
though persons with a history of chickenpox may enter the room without a mask. Persons without a
history of chickenpox should not enter the room at all, if possible.
 Shingles (localized herpes zoster) in an immunocompetent host: standard precautions, though all
who enter room must have a history of chickenpox.
 Clostridium difficile diarrhea: contact precautions
 Influenza: droplet precautions
 MRSA or VRE colonization: contact precautions
 Measles: airborne precautions
MGH Medical Housestaff Manual
92
37. Infection control
 Meningitis secondary to Neisseria meningitis or Hemophilus influenzae: droplet precautions
until patient has been on effective antibiotic therapy for >24 hours.
 Tuberculosis: airborne precautions (see algorithm below)
 Severe acute respiratory syndrome (SARS) (as of May 30, 2003): Airborne and contact
precautions with eye protection (goggles or face shield). After leaving room, remove items in this
order: 1. gloves, 2. N95 mask, 3. eye protection, 4. gown. Hand hygiene as above.
TB ISOLATION
One or more of respiratory signs and symptoms: chronic cough, sputum production, dyspnea, hemoptysis
AND 1 risk factor: HIV; immigrant (except Canada, W. Europe, Australia, New Zealand); substance
abuse; homeless status; recent incarceration; TB exposure; history of non-compliance with TB treatment
No
Yes
Place surgical mask on patient until isolated in negative
pressure isolation room on airborne precautions
Regular admission
Chest X-ray
Normal
Equivocal or abnormal
HIV
No
Yes
Obtain 3 sputums, >24 hours apart, for AFB smear and culture
D/c precautions
All negative
Discontinue
precautions
unless clinical
suspicion is high
Any one positive
Maintain precautions until no longer infectious
by negative AFBs or clinical response (usually
14-21 d). Call Infection Control before
discontinuing precautions.
Kimon Zachary, M.D.
MGH Medical Housestaff Manual
93