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1 GUIDE TO ANTIMICROBIALS San Francisco VA Medical Center 2017

2 Guide to Antimicrobials 2017 Daniel Maddix, Pharm.D. Harry Lampiris, M.D. Mai Vu, Pharm.D. Drug Category may be changed from time to time. Please consult the hospital computer for current classification. Category I agents are available without prior approval although some restrictions may apply. Category II agents are restricted and require approval prior to use. To obtain approval for a Category II agent, page digital beeper (415) prior to ordering. Current antimicrobial sensitivity patterns and UCSF/SFGH/VASF Guidelines for Antimicrobial Use in Adults are available on the Antibiotic Stewardship Program page on Sharepoint (http://vaww.visn21.portal.va.gov/sanfrancisco/ic/sitepages/antibioticste wardship.aspx ). Acknowledgments: Thanks to past and current staff of the Pharmacy Service and Infectious Diseases Section for preparing, compiling, and reviewing the materials contained in this pamphlet. This material has been endorsed by the San Francisco VA Medical Center Infectious Diseases Section, and represents recommended Medical Center policy.

3 Table of Contents I. Sensitivity Patterns of Unique Isolates 2 II. Guidelines for the Use of Antimicrobial Agents in Febrile 4 Neutropenic Cancer Patients III. Guidelines for the Use of Antimicrobial Agents in the 5 Prevention of Bacterial Infection in Cirrhotic Patients IV. Guidelines for the Empiric Therapy of Community-Acquired 7 Pneumonia and Urinary Tract Infections V. Guidelines for the Treatment of Diarrhea Associated with 8 Clostridium difficile Infection 8a Va. SSTI Empiric Therapy Guidelines VI. Administration of ß-lactam antibiotics to penicillin-allergic patients 9 VII. Antimicrobial Agents Acyclovir Amikacin Amoxicillin/Clavulanic Acid Amphotericin B Atovaquone. Aztreonam. Cefazolin. Cefepime.... Ceftazidime. Ceftriaxone. Cidofovir.... Ciprofloxacin..... Clindamycin... Dapsone Daptomycin Ertapenem Ethambutol.. 26 Fluconazole Foscarnet 29 Ganciclovir.. 31 Gentamicin/Tobramycin Imipenem/Cilastatin Isoniazid.. 34 Itraconazole Levofloxacin Linezolid.. 38 Meropenem.. 39 Metronidazole 40 Micafungin. 41 Nafcillin 42 Nitrofurantoin Pentamidine.. 44 Piperacillin/Tazobactam.. 45 Posaconazole 46 Primaquine Pyrazinamide 49 Pyrimethamine.. 50 Rifabutin Rifampin.. 53 Sulfadiazine 55 Trimethoprim-Sulfamethoxazole 56 Vancomycin. 58 Voriconazole 59 Adverse Effects of ß-Lactam Antibiotics VIII. Drugs for HIV Infection Antiretroviral Agent Dosing Guidelines.. 62

4 Sensitivity Patterns of NON-URINE Isolates (First isolate per patient per organism) San Francisco VA Medical Center January-December 2016 Confidential: For official use by San Francisco VA Medical Center Employees and Students only. Percent Sensitive TOTAL ORGANISM #ISO* AMP ZOS ERTA CIP T/S CTRI CPIM GEN Enterobacter cloacae 23 NA NA NA 100 Escherichia coli Klebsiella pneumoniae Proteus mirabilis Pseudomonas aeruginosa 51 NA 82 NA 90 NA NA VANC OXAC T/S ERYT CLIN TCN Staphylococcus aureus MRSA NA MSSA NA Staphylococcus coag neg NA = not available AMP - ampicillin, ZOS - Zosyn, ERTA - ertapenem, CIP - ciprofloxacin, T/S - trimethoprim/sulfamethoxazole, CZOL - cefazolin, CTRI - ceftriaxone, CPIM - cefepime ERTA - ertapenem, GEN - gentamicin, TOB - tobramycin, VANC - vancomycin, OXAC - oxacillin, ERYT - erythromycin, CLIN - clindamycin, TCN - tetracycline *Statistical validity of % susceptible is decreased if fewer than 30 isolates are tested. 7.8% (33/424) of all enterococcal isolates were vancomycin-resistant Extended-Spectrum Beta-Lactamase (ESBL) Positive - E. coli - 13%; K. pneumoniae - 6% 2 Prepared by D. Maddix, Pharm.D. 1/08/2017

Museums and galleries frequently need to have their collections photographed. Much of this type of work involves copy work of paintings and documents. To control the light and expose items evenly, many photographers will opt for using two or more Speedlites placed at a 45-degree angle to the artwork.

Corporate and portrait photographers pressed for time often opt for Speedlites to save time and improve their mobility. By carrying less, they can produce more shots, and travel without a crew. Speedlites can be used with many common light modifiers such as umbrellas and softboxes. Fortunately, the 600EX-RT and Buy Cheap View Enjoy Sheer Marquisette Stretchmesh Briefs Beige Calvin Klein Underwear Excellent Cheap Sale Deals 5DRKg5
guide numbers of 197 and 141, respectively, are powerful enough to be used with a variety of modifiers.

Bicyclist photographed with two remote flash units

In general, it’s easy to see that the benefits of shooting with off-camera flash outweigh the difficulties. Best of all, Speedlites are easy to carry and fast to set up. Your Speedlite may be triggered with a synch cord, optical pulse, infrared, or radio frequency. Sync cords are good for short distances such as the length of your arm. Optical pulse and infrared are appropriate for line-of-sight flash triggering or in enclosed spaces that are small enough to reflect the pulse or infrared to the flash sensor. Radio frequency triggering is useful for short and long distances up to the limits of your specific equipment. Many photographers simply set it and forget it by choosing radio triggering.

The first step to wireless shooting is to access the flash items on your Canon camera’s menu. While the following example is for a camera with a pop-up flash, cameras without pop-up flashes are almost identical. Simply insert and power-on a Speedlite on non pop-up flash cameras.

Back view; Canon Speedlite 430EX III-RT

The second step to wireless shooting is to access the menu items on your Canon Speedlite 600EX-RT or Canon Speedlite 430EX III-RT .

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mounts on the hot shoe of your camera and functions as a master controller. The advantages of using the ST-E3-RT instead of a Speedlite, which can perform the same function, are reduced weight and bulk, lower cost, and a flat LED screen that’s easy to view from above. The set-up procedure for the ST-E3-RT is same as for the Speedlites.

Canon ST-E3-RT Speedlite Transmitter

Using off-camera Speedlite in a softbox to add light to an outdoor portrait

Using off-camera Speedlite to create "hatchet" lighting in a masculine portrait

Shooting with multiple Speedlites will open up a world of photographic possibilities. However, before heading off to your next shoot, get to know your Speedlites better by spending a few hours testing them in a variety of scenarios. Thanks to the well-organized and intuitive menus, you will quickly become a Speedlite ninja. We look forward to reading your comments.

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Fusobacterium nucleatum Interaction with Host Cells
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Citation: Han Y. 2011. Fusobacterium nucleatum Interaction with Host Cells, p 221-232. Kolenbrander P (ed), . ASM Press, Washington, DC. doi: 10.1128/9781555817107.ch15
/content/10.1128/9781555817107.ch15.ch15fig01
FIGURE 1
Kinetic study of intravenous injection of F. nucleatum into pregnant mice. Mice were infected with a dose of 1 × 10 7 to 2.5 × 10 7 CFU of F. nucleatum 12230. At each time point, i.e., 6, 18, 24, 48, and 72 h postinfection, three or four mice were dissected. The bacterial counts in the placentas, liver, spleen, fetuses, and amniotic fluid (A.F.) of each mouse are expressed as log 10 CFU per gram of tissue or per milliliter of fluid. The results shown are the averages for all mice dissected at each time point. The standard deviations were <20% for values of >1 log 10 CFU/g but >50% for those of <1 log 10 CFU/g. Reproduced from Infection and Immunity ( 29 ) with permission.
10.1128/9781555817107/f0222-01_thmb.gif
10.1128/9781555817107/f0222-01.gif

Kinetic study of intravenous injection of F. nucleatum into pregnant mice. Mice were infected with a dose of 1 × 10 7 to 2.5 × 10 7 CFU of F. nucleatum 12230. At each time point, i.e., 6, 18, 24, 48, and 72 h postinfection, three or four mice were dissected. The bacterial counts in the placentas, liver, spleen, fetuses, and amniotic fluid (A.F.) of each mouse are expressed as log 10 CFU per gram of tissue or per milliliter of fluid. The results shown are the averages for all mice dissected at each time point. The standard deviations were <20% for values of >1 log 10 CFU/g but >50% for those of <1 log 10 CFU/g. Reproduced from Infection and Immunity ( 29 ) with permission.

Citation: Han Y. 2011. Fusobacterium nucleatum Interaction with Host Cells, p 221-232. Kolenbrander P (ed), . ASM Press, Washington, DC. doi: 10.1128/9781555817107.ch15
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/content/10.1128/9781555817107.ch15.ch15fig02
FIGURE 2
Transmission electron microscopy image of murine placenta at 24 h after infection with F. nucleatum 12230. R, red blood cells in the blood vessel. The solid arrows point to bacteria attached to or internalized in the endothelial cells lining the veins. The open arrows point to the bacteria in the blood vessel. Magnification, ×6,000. Reproduced from Infection and Immunity ( 29 ) with permission.
10.1128/9781555817107/f0223-01_thmb.gif
10.1128/9781555817107/f0223-01.gif

Transmission electron microscopy image of murine placenta at 24 h after infection with F. nucleatum 12230. R, red blood cells in the blood vessel. The solid arrows point to bacteria attached to or internalized in the endothelial cells lining the veins. The open arrows point to the bacteria in the blood vessel. Magnification, ×6,000. Reproduced from Infection and Immunity ( 29 ) with permission.

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