outline before you prescribe an antibiotic…....if local resistance rate >20% or sulfa allergy: •...

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InfectiousDiseaseUpdate:AretheBugsWinning?

Amelie Hollier, DNP,FNP-BC,FAANPPresident, APEA

Speaker has no relationship to disclose.

Outline• Utilize themostcurrent evidence basedguideline to treatcommon bacterialinfections.

• Beable todiscuss current patternsofantibiotic resistance.

• Describe newly developed antibiotics andtheir advantagesforuseintreatment ofcommon infections.

Beforeyouprescribeanantibiotic….

ThereisaquestionyouMUST ask

Whatbugiscausingmypatient’sinfection?

What arethemost likelybugs?

Therearetimes….• WeHAVE togetaculture• Thepatient can’taffordtreatment failure!

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Sincewecan’tcultureeverybug……

Wehavetobeprettygoodat

EmpiricTreatment!

LungInfections• Community Acquired Pneumonia (CAP)• CAPpost influenza• Acute Bronchitis

Patient#152yearold female, ND,a retiredschool teacher,hasbeendiagnosed withCAP. Sheisanon-smoker,hasnormal BMI, takesnomeds.Shewalks 3miles,4-5timesweekly.

What’s themost likely pathogen forherCAP?1. Strept pneumoniae2. Atypical pathogen3. Staphaureus4. Viral pathogenIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

Patient#152yearoldfemale, ND,aretiredschoolteacher,hasbeen diagnosed with CAP.Sheisanon-smoker, hasnormal BMI,takesnomeds.

Mostcommon causeisanatypical pathogen:Mycoplasma pneumoniae;couldbeviral;couldbe S.pneumo butthese2aremuchlesslikelyIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

Patient#1What isanacceptable treatment forthe mostlikelypathogen?1. Azith 500mgonce, then 250mgx4days2. Azith 2gonce3. Doxycycline 100mgPOBID4. Amox-clav 875POmgBID

IDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

Patient#1

IfMycoplasma isdocumentedasthepathogen,whatthebesttreatment?

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Patient#1IfMycoplasma isdocumentedasthepathogen,what thebesttreatment?1. Azith 500mg once,then250mgx4

days2. Azith 2gonce3. Doxy100mg POBID4. Amox-clav 875POmgBIDJAC68:506,2013

Patient#1

• IncreasingmacrolideresistancewithMycoplasma• Doxyisasuperiorchoice

JAC68:506,2013

Patient#1SupposeNDdevelopedCAPpostinfluenzainfection?What’sthemostlikelypathogenforherCAP?

1. Streptpneumoniae2. Atypical pathogen3. Staph aureus4. ViralpathogenIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

Patient#1Whatisanacceptabletreatmentforthemostlikelypathogen?1. Levofloxacin750mgPOdaily2. Azithromycin2gonce3. Doxy100mgPOBID4. Amox-clav 875mgPOBIDIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

Patient#1Supposeshewasquinoloneallergicorcouldn’ttakeaquinolone(andhadpost-flupneumonia)?• Azith orClarith PlusHDamox,HDamox-clav,cefdinir (Omnicef),cefpodoxime (Vantin),cefprozil(Cefzil)

FYI:if useaceph, always givethe BIDdose!IDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

Patient#1

HowmuchamoxisconsideredHIGHDOSE?

Amox:1gramPOTIDAmox-clav:UseAmox-clav ER (1000/62.5)Prescribe2tabs BIDIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

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Patient#152yearoldfemale,ND,aretiredschoolteacher,hasbeendiagnosedwithCAP.SupposeshehasCOPDandsmokes1PPD.


Patient#1What’sthemostlikelypathogenforherCAPifshehasCOPD?

1. Strept pneumoniae2. M.catarrhalis3. H.influenzae4. ViralpathogenIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

So,knowingthemostlikelybug ishelpful inchoosingthebestantibiotic!

What’saneasywaytorememberwhichantibiotic to

giveforCAP?

CAPinanAdultGiveamacrolideordoxyfirstlineUNLESS…..


CAPinanAdultThepatienthasaco-morbid:• Alcoholism• Bronchiectasis• COPD• Post-CVA aspiration• Post-influenza• Significant chronic diseaseIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

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CAPinanAdultIfco-morbid ispresent:Respiratoryquinolone• Gemifloxacin (Factive)320mg• Levofloxacin(Levaquin)750mg• Moxifloxacin(Avelox)400mgIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

Respiratory QuinolonesCiprofloxacin nolongerconsidered arespiratoryquinolone R/Tincreased ratesofresistance:• S.pneumoniae• Pseudomonas aeruginosa• C.difficile• N.gonorrhoeae• MRSA,MSSA• S.aureus

PrescribersLetter2011;18(5):270501

WhatdoTequin,Raxar,Zagam,andTrovan allhaveincommon?

Hint:Theyall“were” quinolones.

RememberThese?• Tequin (gatifloxacin):bloodsugarirregularities• Zagam(sparfloxacin):phototoxicityandQTprolongation• Trovan (trovafloxacin):hepatotoxicity

QuinolonesasaClass• Bloodsugarlevelissues!• QTprolongation• CNSadverseeffects(dizziness,etc.)• Tendonrupture(rare)


FDABulletin May,2016• SafetyLabeling Changes• “serious side effectsassociated with FQsgenerallyoutweigh thebenefits forpatientswith acute sinusitis, acute bronchitis, anduncomplicated UTIwho haveother treatmentoptions”

• FQsshould bereservedforpeople who havenoalternative treatment options

5-12-16FDABulletin;Updated6/7/16

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FDABulletin May,2016WhatSideeffects?• Serious sideeffects involving the tendons,muscles, joints,nerves,andCNS

• “…stop systemic FQtreatment immediately ifapatient reportsserious sideeffects…”

5-12-16FDABulletin;Updated6/7/16

ThingstoRemember!• Noneapprovedinchildren*• Donotuseinpregnantpatients• SeparatefromMg,Al,sucralfate,Fe,Zn(Ca probablyOKbutnotwithcipro):drugspecific• NosigCYP450interactionsexceptwithcipro


Ciprofloxacin• Ciprofloxacinisa1A2med• Combinedwiththeophylline,xanthines (CAFFEINE),resultsinincreasedplasmaconcentrationsoftheco-administereddrug• Sowhathappens???


Respiratory QuinolonesWhatwouldmakeyou

chooseoneovertheother?• Gemifloxacin (Factive) 320mg• Levofloxacin (Levaquin) 750mg• Moxifloxacin (Avelox) 400mg


Levofloxacin• Diminished activity againstStreptpneumo andanaerobic pathogens

• Levofloxacin originally dosed at500mgdailybut increased to750mgdaily toimprovecoverageagainst resistant organisms


RespiratoryFluoroquinolones3rdGeneration

Staph:MSSAListeria

Strept:all; M.cat,H.flu,E.coli,Legionella,Chlamydophila, Mycoplasma,Klebsiella, + Pseudomonas,

Levofloxacin (Levaquin)GramPositives, GramNegatives,Atypical Pathogens, DRSP,many

aerobes,someanaerobes

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RespiratoryFluoroquinolones4thGeneration

Staph:MSSAListeriaNoturinarypathogens

Strept:all;M.cat,H.flu,E. coli,Legionella,Chlamydophila,Mycoplasma,Klebsiella

Moxifloxacin*(Avelox)Gemifloxaxin (Factive),

Gatifloxacin (Zymar ophth)GramPositives, Atypical Pathogens, superior

pneumococcus and anaerobic coverage

*GIpathogencoverage

TakeHomePoint• A4th generationquinolonewouldbeabetterchoice thana3rd genquinoloneforDRSP


Patient#238yearoldmale, otherwisehealthy hasbeendiagnosed withacutebronchitis. Heisanon-smoker, hasBMI 29,haswell controlledHTN,lipids.What’s themost likely pathogen forhisacutebronchitis?1. Strept pneumoniae2. Atypical pathogen3. Staphaureus4. Viral pathogenIDSA/ATSGuidelinesforCAPinadults:CID44(Suppl2):S27-S72,2007;NEJM370:543,2014;NEJM371:1619;2014.

Patient#2AcuteBronchitis90%viral5%M.pneumoniae5%C.pneumoniae

AntibioticsareNOTindicatedusually!JAMA312:2678,2014

Whenmightantibioticsbeindicated?

• Associated sinusitis• Heavygrowthon throat culture forS.pneumo, Group AStrept,H.flu

• Noimprovement in 1week• Otherwise, treatment isSYMPTOMATIC!

JAMA312:2678,2014

AcuteBronchitis• Expectcough to last2weeks (

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QuizWhydomostpatientswithacutebronchitis havepurulentlookingsputum?

PurulentSputumIFpatienthasfever,rigors,systemicsymptoms,getchestx-ray

JAMA312:2678,2014

UrinaryTractInfectionIfLocal resistance rate<20%• TMP-SMXBIDx3daysAddphenazopyridine (Pyridium)

Local resistance ratecorrelates with clinicalfailure

JAMA312:1677,2014

TMP/SMXDrug Interactions

• You’ll seethis asaNewDrugInteraction inyourSmartPhone Apps!

• Possible HYPERKALEMIA when TMP-SMXcombined with medsthat increase potassium

• ACEs,ARBs,potassium sparing diuretics,NSAIDs

PrescribersLetter;January2015;Vol31


• Trimethoprim decreasesexcretion ofpotassium (acts onthedistal nephron,blocking theepithelium Nachannel whichleads toreduction inrenalexcretion ofK)

• Hyperkalemia develops 4-5daysaftertakingTMP/SMX,so3daydoselikely OK



• 81.5%hadsignificant increase inserumKfrombaseline

• 18%hadhyperkalemia >5meq/L• 6%hadhyperkalemia >5.5meq/L• Reversibleonce TMP/SMXisd/c’d

Alappan R,Buller GK,Perazella MA.Trimethoprim-sulfamethoxazole therapyinoutpatients:ishyperkalemiaasignificantproblem? AmJNephrol1999;19:389-94.

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DrugInteractions• 6%ofpatients onTMP/SMXdevelophyperkalemia

• Hospitalizations increase7-fold when elderstakeTMP-SMXwith ACE,ARB,etc

• Evenhigher when combined in patients whotakeACEs,ARBs,orspironolactone


CareinThesePatients!• Elderly• Renalinsufficiency• DM• Heartfailure

***Ifnoalternative to TMP/SMX,checkKlevelafterday3


So…UTIIfLocal resistance rate<20%• TMP-SMXBIDx3daysAddphenazopyridine (Pyridium)

Local resistance ratecorrelates with clinicalfailure

JAMA312:1677,2014

Whyareweaddingphenazopyridine?

JAMA312:1677,2014

UrinaryTractInfectionIFLocal resistance rate> 20%orsulfaallergy:• Nitrofurantoin 100mgPOBIDx5days• Fosfomycin single 3gdose• *Ciprofloxacin 250mgBIDor500mgERq24h• *Levofloxacin 250mgq24Addphenazopyridine (Pyridium)

JAMA312:1677,2014

UrinaryTractInfectionIFLocal resistance rate> 20%orsulfaallergy:• Ciprofloxacin 250mgBIDor500mgERq24h• Levofloxacin 250mgq24

Whyaren’tthe4th generationquinolonesusedtotreatUTIs?

Drugpackageinserts:Moxifloxacin,Gemifloxacin

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Lets talkaboutNitrofurantoin

IFLocal resistance rate> 20%orsulfaallergy:• Ciprofloxacin 250mgBIDor500mgERq24h• Levofloxacin 250mgq24• Nitrofurantoin 100mgPOBIDx5days• Fosfomycin single 3gdoseAddphenazopyridine (Pyridium)

JAMA312:1677,2014

Mrs. Jones is75yearsold. Sheisdiagnosed withaUTI. HerCrCl is 50mL/min.What drugmight beagood choice forher?

2012BeersCriteriaUpdateExpertPanelJAMGeriatr Soc.2012;60(4):616-631

Mrs. Jones is75yearsold. Sheisdiagnosed withaUTI. HerCrCl is50mL/min.Which anti-infective should beavoided in herbecause ofinadequate drugconcentration in theurine?1. Sulfadrug(none aslongasCrCl>30mL/min)2. Ciprofloxacin (none aslong asCrCl >30

mL/min)3. Nitrofurantoin (AVOID!)

Mrs. Jones is75yearsold. Sheisdiagnosed withaUTI. HerCrCl is 50mL/min.BeersCriteriarecommends nitrofurantoinavoidance:• CrCl<60mL/min• Forlong-term suppression

2012BeersCriteriaUpdateExpertPanelJAMGeriatr Soc.2012;60(4):616-631

NitrofurantoinIFusedfordailyprophylaxis, maycausepulmonary toxicity, neuropathy, orhepatotoxicity.

HootonTM,BradleySF,CardenasDD,etal. Diagnosis,prevention,andtreatmentofcatheter-associatedurinarytractinfectioninadults:2009InternationalClinicalPracticeGuidelinesfromtheInfectiousDiseasesSocietyofAmerica. ClinInfectDis2010;50:625-63.

Dailymed.nlm.gov;Nitrofurantoinproductinsert

EtiologyofAcuteSinusitis

Mostcommon???

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EtiologyofAcuteSinusitis

Obstructionofthesinusostia byinflammation from

virusorallergy

Treatment:Salineirrigation

IFPathogenpresent:• S.pneumoniae33%• H.influenzae 32%• M.catarrhalis9%• Anaerobes6%• Grp AStrep 2%• Viruses15-18%• S.aureus10%

S/SBacterialInfection• Fever• Pain• Purulentnasaldischarge• Stillsymptomaticafter10dayswithnoantibiotic• Clinical failuredespiteantibiotictreatment

IFPathogenpresent:• S.pneumoniae33%• H.influenzae 32%• M.catarrhalis9%• Anaerobes6%• Grp AStrep 2%• Viruses15-18%• S.aureus10%

WhatAntibiotic forABRS?• Amoxicillinnotagoodfirstchoice

(toomuchresistance,lessStreptpneumo,moreincidenceofH.flu)

• Empiric:Amoxicillin-clavulanate (500TIDor875BID)

• Amoxicillin-clavulanate (2gBID)inareaswhereDRSPlikely

CID54:e72,2012

Penicillins

Whatbugdosmokersharbor?

H.influenza (40%)M.catarrhalis (90%)

Extended Spectrum PENICILLINSAmoxicillin/Clavulanic acid (Augmentin)

GramPositives,GramNegativesΒ- lactamase,NOTMRSA

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WhatifPCNallergic?• Doxycycline(alternative first linetx

PCNallergy)• *Resp FQforPCN allergicpatients• NoMacrolides: 30%resistance rate!• TMPS, 2ndor3rd gencephs NOT

recommended

WhatAntibiotic forPeds?

• Firstline:Amoxicillinwithorwithoutclavulanate

• Alternatives:cefdinir,cefuroxime,cefpodoxime

• Avoidsulfadrugs,azithromycinWald ER, Applegate KE,Bordley C,et al. Clinical practiceguideline forthediagnosisandmanagement of acutebacterial sinusitisinchildren1to18years.Pediatrics2013;132:e262–e280.

Duration• Eradication ifonappropriate antibiotic

in72hours buttreat…..• 5-7days (no longer treat10-14days)• Withshortercourses: equalefficacy,

fewercomplications, noincreasedriskofrelapse

• Bettercompliance!

Can PCNallergic patientssafelyreceive

cephalosporins?

2IssuesThereMUSTbeaPCNallergic reaction!!!

TrueAllergicReaction

• IgEmediated(type1hypersensitivityreaction)

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Morbilliform Rash• Rashis macularormaculopapular, lesionsarefixed,areaexpandsoverseveraldays

• Mayitch• Moreprevalent inchildren

• Morecommon withaminopenicillins (amoxandampicillin)

MorbilliformRashUsually T-cellmediated• Concurrent viralinfectionspredispose patients tomorbilliform rash

• Unknownmechanism bywhich this occurs

The rash isNot IgE-mediatedifneitherurticarialnorpruritic!!!

AndthereisNOincreasedriskofthesamerashrecurringwithrepeatedcoursesofthesameantibiotic.

JournalofFamilyPractice,Feb.2006

SecondIssueHowsignificant isthecross-sensitivityreaction?

Likely AllergytoCephalosporinsafterallergytoPCNVerylikely tohaveSAME allergic reactionwith these drugsbecause theyshareasimilarRside chain

PenG

Amoxicillin

Ampicillin

Cefaclor

Cephalexin

Cefprozil

Cefadroxil

Ceftriaxone

CefpodoximeJournalofFamily Practice, Feb.2006

Likely AllergytoCephalosporins

afterallergy toPCN

• Cephalexin (1st gen)• Cefadroxil (1st gen)• Cefaclor (2nd gen)• Cefprozil (2nd gen)• Ceftriaxone (3rd genIM)• Cefpodoxime (3rd gen)

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UNLIKELY AllergytoCephalosporins

after allergy toPCNNOTlikelyto haveSAME allergic reactionwith these drugsbecause theyaredissimilarinstructure

Cefazolin Cefuroxime

Cefdinir

Cefixime

Ceftibuten

JournalofFamily Practice, Feb.2006

UNLIKELYAllergytoCephalosporins afterallergy toPCN

• Cefazolin (1st genIM)• Cefuroxime(2nd gen)• Cefdinir(3rd gen)• Cefixime(3rd gen)• Ceftibuten(3rd gen)

RECOMMENDATION

Theriskofanallergicreactionisverylowornon-existentifthesidechainsofthedrugsarenotsimilar.

Journal ofFamilyPractice, Feb.2006

Medications• TMP-SMX• Doxycycline/Minocycline• Clindamycin• Daptomycin (Cubicin)• Linezolid (Zyvox)• Tedizolid (Sivextro)• Vancomycin• Dalbavancin (Dalvance)• Oritavancin (Orbactiv)

PrescribersLetter;August2014;Vol:30

“Mycins”

Clindamycin (Cleocin)• POdose, 5-10

days: $10/day• IVdose, 7-14

days: $25/day• S/E:Myopathy,

peripheralneuropathy

Daptomycin (Cubicin)• IVdose, 5-14days: $200/day

• S/E:Myopathy,peripheralneuropathy

• Generic:June,2016

“Zolids”Linezolid(Zyvox)• Oral(generic now)orIV

• Severepurulent STI• S/E:myeolosuppression/serotonergic effects

• WeeklyCBCrequired

• $275/day

Tedizolid (Sivextro)• OralorIV• Severepurulent SSTI• S/E:thrombocytopenia

• NoCBCrequired• Mayhaveserotonergic effects

• $235/day IV;$295/day PO

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“Vancins”Televancin (Vibativ)

• Cousinofvancomycin• Longerdurationthanvanc

• S/E:Nephrotoxicity,redmansyndrome

• $300/day,7-10days

Dalbavancin (Dalvance)

• Cousinofvancomycin• Longerdurationthanvanc• 2infusionsoneweekapart• S/E:Redmansyndrome• $4500/2infusions

Vancomycin (Vancocin)• Requiresbloodlevels• Generic• S/E:Redmansyndrome• $20/day,7-14days

10AdultRecommendations(> 19yearsold)

• Influenza• Tdap• Varicella• HPV• Zoster• MMR• PCV13,PPSV23• Meningococcal• Hepatitis A, B• Hib

Impactinghealthofcommunities

PneumococcalInfection

MostCommonDiseases

• Pneumonia• Meningitis• Bacteremia• ABRS• OM

PneumococcalDisease• Verycommon!!!!• Pneumococcal disease spreadbyrespiratorydroplet

• Pneumococcal pneumonia fatality rateis7%but higherin elderly,co-morbids

• 25-30% ofpneumococcal pneumonia patientsgetbacteremia

PneumococcalDisease• Pneumococcal disease iscaused byStreptococcus pneumoniae

• Thereare90different serotypes(PPSV23immunizes against 23serotypes)

PneumococcalVaccine:2Forms

13valent;23valent• 13valent pneumococcal conjugate vaccine(PCV13,Prevnar)

• 23valent pneumococcal polysaccharidevaccine (PPSV23,Pneumovax)

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PneumococcalVaccine:

13valent• 13valent pneumococcal conjugate vaccine(PCV13,Prevnar)

• Approved for6weeksto18years• Approved > 50years

PneumococcalVaccine:

23valent• 23valent pneumococcal polysaccharidevaccine (PPSV23,Prevnar)

• Approved forage> 2years

A68yearoldpatientdoesnotknowwhetherhereceivedapneumococcalvaccineornot.How shouldthis behandled?

1. Don’tadminister.2. Administernow.

PPSV23:Who?• Age65yearsorolderwithnoorunknownhistoryofpriorreceiptofPPSV

WhoelseneedsPPSV23?Age 19-64years with no orunknown history ofprior receipt ofPPSVandanyof the following:

• Cigarettesmokerage19andolder• CVdisease(HF,cardiomyopathies,etc.)• Chronicpulmonarydisease(COPD,asthma)• DM,alcoholism,chronicliverdisease• Candidateforacochlearimplant,CSFleak• Functionaloranatomicasplenia(SCA,splenectomy)• HIV,congenitalimmunodeficiency,hematologicandsolid

tumors(immunocompromising conditions)• Immunosuppressivetherapy(alkylatingagents,antimetabolites,

long termsystemic steroids, radiation therapy)

• Chronicrenalfailureornephrotic syndrome;Solidorganorbonemarrowtransplantation

PPSV23andPCV13WhogetsasecondPPSV23?

• Functionaloranatomicasplenia(SCA,splenectomy)• HIV,congenitalimmunodeficiency,hematologicorsolidtumors(immunocompromising conditions)

• Immunosuppressivetherapy(alkylatingagents,antimetabolites,longtermsystemicsteroids,radiation therapy)

• Chronicrenalfailureornephrotic syndrome;Solidorganorbonemarrowtransplantation

These patientsneedPCV13also!!!!!!

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FactstoRemember• PCV13:administer 12monthsafterPPSV23• PPSV23:administer(at least)5yearsafterpreviousPPSV23

12PediatricRecommendations

• Influenza• Rotavirus• DTaP <7years• TdaP > 7 years• Varicella• IPV• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib• HPV

What’snewsince2016?Historiclowinmeningococcal

diseaseincidence(0.18/100,000persons)

• CurrentQuadrivalent vaccinecovers(serogroups A,C,W,Y)

• SerogroupBmeningococcal disease israrebutlifethreatening, notcurrentlycoveredinquadrivalent vaccine

MMWR,October23,2015/64(41);1171-6

What’snewsince2016?Recommendation

• Alladolescents 11-18years: AdministerMenACWY,singledoseat11-12yearswithabooster atage16years iffirstdosebeforeage 16years

• “MenB maybeadministered toadolescents and young adults aged16-23years”; preferredage: 16-18years

MMWR,October23,2015/64(41);1171-6

FDAlicensedtwoMenBvaccines,June2015

• Approvedinpersons 10-25years• MenB-FHbp (Trumenba)• MenB-4C(Bexsero)

MMWR,October23,2015/64(41);1171-6

MeningococcalUpdatesMeningococcal Vaccine• FDAapproved first serogroup Bmeningococcal(MenB)vaccine (MenB-FHbp [Trumenba, WyethPharmaceuticals, Inc.]) asa3-doseseries

• January 2015,FDAapproved asecondMenBvaccine (MenB-4C[Bexsero, Novartis Vaccines])asa2-doseseries

• Bothvaccines wereapproved foruseinpersonsaged10–25years

MMWRJuly31,2015/64(29);806June12,2015/64(22);608-612

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12PediatricRecommendations

• Influenza• Rotavirus• DTaP <7years• TdaP > 7 years• Varicella• IPV• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib• HPV

HPVUpdate

9-valentHPVVaccine9-valent humanpapillomavirus (HPV)vaccine(9vHPV) (Gardasil 9,MerckandCo.,Inc.)as oneofthreeHPVvaccinesthatcan beused forroutinevaccination

MMWRMarch27,2015/64(11);300-304

HPVUpdate

9-valentHPVVaccine• Recommended forroutinevaccinationatage 11or12years ACIPalsorecommends vaccination forfemalesaged 13through 26years andmalesaged 13through 21years notvaccinatedpreviously.

MMWRMarch27,2015/64(11);300-304

HPVUpdate

9-valentHPVVaccine• Recommended throughage 26years formenwhohave sexwithmenand forimmunocompromised persons(including thosewithHIVinfection)ifnotvaccinated previously

MMWRMarch27,2015/64(11);300-304

HPVUpdate

9-valentHPVVaccine• 9vHPV isanoninfectious, virus-like particle(VLP)vaccine

• 9vHPVcontains HPV6,11,16,and18(likeHPV4)

• Alsocontains HPV31,33,45,52,and 58• 9vHPVtargets fiveadditional cancer causingtypes, whichaccount forabout15%ofcervicalcancers

MMWRMarch27,2015/64(11);300-304

HPVUpdate

HPVVaccines• 2vHPV,4vHPV,and9vHPV allprotect againstHPV16and18,typesthat cause about66%ofcervical cancersandthemajorityofother HPV-attributable cancersin theUnitedStates4vHPV and9vHPV alsoprotect againstHPV6and11,types that causeanogenitalwarts.

MMWRMarch27,2015/64(11);300-304

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HPVUpdate

HPVVaccines• 9vHPVand4vHPVarelicensedforuseinfemalesandmales• BivalentHPVvaccine(2vHPV)containsHPV16,18,islicensedforuseinfemales

MMWRMarch27,2015/64(11);300-304

HPVUpdate

HPVVaccines• 2vHPV,4vHPV,and9vHPVareeachadministeredina3-doseschedule

MMWRMarch27,2015/64(11);300-304

Supposea16yearoldhasreceived2previousdoseswith4vHPV vaccine.Can9vHPV besubstitutedforlastdoseofseries?a. Yesb. Noc. I’mnotsure

Quiz Thankyou!Forquestionsortocontact

me:

Dr.Amelie Hollier

[email protected] Practice Education Associates

outline before you prescribe an antibiotic…....if local resistance rate >20% or sulfa allergy: •...

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