Category Archives: Clinical practice

MRSA Isolates and E Test

Centegra lab will now perform an e-test on all MRSA isolates obtained from a sterile site with microscan mic >=2.

With additional testing e-testing many isolates may have lower had mic of <1.5 expanding options for treatment.

This additional step will take an additional day to report out.

Updated Guidelines for Prevention of Perinatal Hepatitis B

Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control and Prevention (CDC) published a summary of existing recommendations and provided updated and new recommendations on the prevention of hepatitis B virus infection in the United States.

The new and updated recommendations are:

General Recommendations:

  • For all medically stable infants weighing ≥2,000 grams at birth and born to HBsAg-negative mothers, the first dose of hepatitis B vaccine should be administered within 24 hours of birth.
  • Permissive language for delaying the birth dose that was previously used in the recommendations has been removed.

Identification and Management of HBV-Infected Pregnant Women:

  • All hepatitis B surface antigen (HBsAg) positive pregnant women should be tested for hepatitis B DNA to guide the use of maternal antiviral therapy during pregnancy for the prevention of hepatitis B virus transmission.
    • A brief summary of the American Association for the Study of Liver Diseases (AASLD) guidelines for the use of maternal antiviral therapy to reduce perinatal Hepatitis B virus transmission is also included in the MMWR.

Management of Infants Born to Women Who Are HBsAg-Positive:

  • Infants born to women for whom HBsAg testing results during pregnancy are not available but have other evidence suggestive of maternal hepatitis B virus infection (presence of maternal HBV DNA, maternal HBeAg is positive, or the mother is known to be chronically infected with hepatitis B) should be managed as if born to an HBsAg-positive mother.
  • For infants who are transferred to a different facility after birth, staff at the transferring and receiving facilities should communicate with each other regarding the infant’s HepB vaccination and receipt of hepatitis B immune globulin (HBIG) to ensure prophylaxis is administered in a timely manner.

Management of Infants Born to Women with Unknown HBsAg Status

  • If it is not possible to determine the mother’s HBsAg status (e.g., where confidential safe surrender of infant occurs shortly after birth), the vaccine series should be completed according to the recommended schedule for infants born to HBsAg-positive mothers. Post-vaccination serologic testing and revaccination, if needed, is recommended for these infants.
  • For HBsAg-negative infants born to HBsAg-positive women who show no serologic immune response after receiving the initial HepB vaccine series, revaccinate the infant with a single challenge dose of HepB vaccine and repeat serologic testing (HBsAg and anti-HBs) one to two months later. If the infant remains HBsAg negative and has an anti-HBs of <10 mIU/mL following single dose revaccination, complete the second series on schedule with the two additional Hep B vaccine doses followed by post-vaccination serologic testing one to two months after the final dose.
    • Alternatively,basedonclinicalcircumstancesorparentpreference,HBsAg-negative infants born to HBsAg-positive women who show no serologic immune response after receiving the initial HepB vaccine series may instead be revaccinated with a second 3- dose series and retested one to two months after the final dose of vaccine.
    • As a reminder, post vaccination serologic testing of the infant should include HBsAg and anti-HBs. Anti-HBs testing should be performed using a method that allows detection of the protective concentration of anti-HBs (> 10mIU/mL).

Influenza Vaccination in Patients with Egg Allergy


January 11, 2018

Influenza Vaccination in Patients with Egg Allergy

David J. Amrol, MD reviewing Greenhawt M et al. Ann Allergy Asthma Immunol 2018 Jan .

All available flu vaccines are safe in all egg-allergic patients.

Sponsoring Organizations: American Academy of Allergy, Asthma, and Immunology (AAAAI); American College of Allergy, Asthma, and Immunology (ACAAI)

Target Audience: All providers who administer influenza vaccines


Historically, patients with egg allergy have been told to avoid flu vaccines, because most flu vaccines are produced in embryonated chicken eggs; the concern was that a vaccine might contain residual egg protein, which could lead to anaphylaxis. Many studies have shown that flu vaccines are safe for egg-allergic patients, but many physicians still have been hesitant to vaccinate such patients. This updated practice parameter incorporates recent data on flu vaccine safety in egg-allergic patients, including children.

Key Recommendations

  • Flu vaccines should be administered annually to patients with egg allergy of any severity, with no need to ask recipients about egg-allergy status and no special precautions beyond those recommended for administering any vaccine to any patient. This recommendation applies to both injected and intranasal formulations (although the latter should not be used in the 2017−2018 flu season).
  • Non−egg-containing vaccines can be used but are not necessary or preferred over standard vaccines.
  • The intranasal live attenuated flu vaccine also might be used, if it’s shown to be efficacious and is approved for use.

Egg-allergic patients can be vaccinated safely with any available age-appropriate flu vaccine, with no special precautions, regardless of egg-reaction history (including anaphylaxis). Concern for egg allergy only adds another barrier to universal flu vaccination, and this practice parameter concludes by stating the following: “Vaccine providers and screening questionnaires do not need to ask about the egg allergy status of recipients of influenza vaccine.”

Editor Disclosures at Time of Publication

Disclosures for David J. Amrol, MD at time of publication

Consultant / Advisory board CSL Behring; Horizon Pharmaceuticals

Greenhawt M et al. Administration of influenza vaccines to egg allergic recipients: A practice parameter update 2017. Ann Allergy Asthma Immunol 2018 Jan; 120:49. (

Did you know you can get ABIM MOC credits with

ABIM MOC completion can be done through 

Please see here for more information on the program.

Centegra offers access to for all providers in the health system. Just login from any network computer in the system.

Instructions on remote or mobile access can be found here.

Morphine Injection Shortage

Morphine Injection Shortage 10.18.2017

There is a nationwide shortage of morphine injection that expected to last until early to mid-November. The Pharmacy Department is running very low on supply and expects that the drug will become unavailable.  Please consider ordering an alternate injection product for pain management.  An opioid dose conversion chart is included below for your convenience.








Oral: Parenteral Ratio


Oral Morphine: Analgesic Ratio


Analgesic Duration


Half Life

Morphine 30 mg 10 mg 3 : 1 1 : 1 4 – 6 hrs 3 hrs
Oxycodone 20 mg 1.5 : 1 3 – 5 hrs 4 – 5 hrs
Hydromorphone 7.5 mg 2 mg  4: 1 4: 1 3 – 4 hrs 2 – 3 hrs
Fentanyl 100 mcg See Table B on page 2 1 hr 3 – 12 hrs
Methadone 20 mg 10 mg 2 : 1 See Table C on page 2 4 – 12 hrs 15 – 50 hrs
Codeine 200 mg 130 mg 1.5 : 1 1 : 7 4 – 6 hrs 3 hrs
Hydrocodone 30 mg 1 : 1 3 – 6 hrs 3 – 4 hrs
Meperidine 300 mg 75 mg 4 : 1 1 : 10 2 – 4 hrs 2 – 3 hrs
Nalbuphine 10 mg 1 : 1 3 – 6 hrs 5 hrs

New PTT Goal Range for All Campuses

Starting at 00:00 on Monday, October 2, 2017, the PTT Goal Range for patients at all Centegra hospital campuses will be 45 to 70, with alerts being triggered for values greater than 100.

All “Per Pharmacy Heparin” will be adjusted to the new range with PTT draws after this time.

pembrolizumab (KEYTRUDA) in Patients with Multiple Myeloma: FDA Statement – Two Clinical Trials On Hold

Keytruda (pembrolizumab) in Patients with Multiple Myeloma: FDA Statement – Two Clinical Trials on Hold
AUDIENCE: Oncology
ISSUE: Based on data from two recently halted clinical trials, the U.S. Food and Drug Administration today is issuing this statement to inform the public, health care professionals, and oncology clinical investigators about the risks associated with the use of Keytruda (pembrolizumab) in combination with dexamethasone and an immunomodulatory agent (lenalidomide or pomalidomide) for the treatment of patients with multiple myeloma. Keytruda (pembrolizumab) is not approved for treatment of multiple myeloma.
The FDA statement is based on review of data from two clinical trials (KEYNOTE-183 and KEYNOTE-185) evaluating the use of Keytruda (pembrolizumab) combined with other treatments in patients with multiple myeloma. On July 3, 2017, the FDA required that all patients in these trials be discontinued from further investigation with this drug, because interim results from both trials demonstrated an increased risk of death for patients receiving Keytruda (pembrolizumab) when it was combined with an immunomodulatory agent as compared to the control group (see statistical analysis section below). Merck & Co., Inc. was made aware of the issue through an external data monitoring committee recommendation and suspended the trials to enrollment on June 12, 2017. Continue reading

Johns Hopkins ABX Guides

Pharmacy Services has subscribed to Johns Hopkins ABX Guide for use by all associates at Centegra Health System to support our multidisciplinary approach to the Antimicrobial Stewardship Program Clinical Decision Support Tools and Education

Johns Hopkins ABX Guide is a comprehensive web source that provides regularly updated, evidence-based decision resources regarding antibiotics, diagnosis, pathogens, management of infections and vaccines.

Prior to the Guide, CHS did not have a specific detailed resource for antibiotics clinical decision support.

Johns Hopkins ABX Guide may be accessed through Unbound Medicine’s uCentral as follows:

FDA DRUG SAFETY COMMUNICATION: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women

Safety Announcement
[4-20-2017] The Food and Drug Administration (FDA) is restricting the use of codeine and tramadol medicines in children. Codeine is approved to treat pain and cough, and tramadol is approved to treat pain. These medicines carry serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years, and should not be used in these children. These medicines should also be limited in some older children. Single-ingredient codeine and all tramadol-containing products are FDA-approved only for use in adults. We are also recommending against the use of codeine and tramadol medicines in breastfeeding mothers due to possible harm to their infants. Continue reading

FDA MedWatch: Pioglitazone-containing Medicines


MedWatch – The FDA Safety Information and Adverse Event Reporting Program

Pioglitazone-containing Medicines: Drug Safety Communication – Updated FDA Review, Increased Risk of Bladder Cancer

Includes Actos, Actoplus Met, Actoplus Met XR, Duetact, and Oseni

AUDIENCE: Internal Medicine, Endocrinology, Urology

ISSUE: As a result of an updated review, the FDA has concluded that use of the type 2 diabetes medicine pioglitazone (Actos, Actoplus Met, Actoplus Met XR, Duetact, Oseni) may be linked to an increased risk of bladder cancer. The labels of pioglitazone-containing medicines already contain warnings about this risk, and FDA has approved label updates to describe the additional studies reviewed. See the FDA Drug Safety Communication for more details, including a data summary.

BACKGROUND: FDA alerted the public about the possible risk of bladder cancer in September 2010 and June 2011 based on interim results from a 10-year epidemiologic study. FDA changed the labels of pioglitazone-containing medicines in August 2011 to include warnings about this risk, and required the manufacturer to modify and continue the 10-year study.

Pioglitazone is approved to improve blood sugar control, along with diet and exercise, in adults with type 2 diabetes. Pioglitazone works by increasing the body’s sensitivity to insulin, a natural hormone that helps control blood sugar levels. Untreated, type 2 diabetes can lead to serious problems, including blindness, nerve and kidney damage, and heart disease.

RECOMMENDATION: Health care professionals should not use pioglitazone in patients with active bladder cancer, and should carefully consider the benefits and risks before using pioglitazone in patients with a history of bladder cancer.

Patients should contact their health care professionals if they experience any of the following signs or symptoms after starting pioglitazone, as these may be due to bladder cancer:

  • Blood or a red color in the urine
  • New or worsening urge to urinate
  • Pain when urinating

Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program:

  • Complete and submit the report Online:
  • Download form or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178

Read the MedWatch safety alert, including a link to the Drug Safety Communication, at:

You are encouraged to report all serious adverse events and product quality problems to FDA MedWatch at

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