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Bresges C, Bresges K, Hewitt C, Sharma S, Davies B. Three-years of dalbavancin use at a UK tertiary referral hospital serving a population with high numbers of people who inject drugs. JAC Antimicrob Resist 2024; 6:dlae066. [PMID: 38716401 PMCID: PMC11073745 DOI: 10.1093/jacamr/dlae066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 04/04/2024] [Indexed: 06/29/2024] Open
Abstract
Background Dalbavancin's unique properties have led to an increase in its off-licence use in complex infection and in vulnerable populations including people who inject drugs (PWID), but data remain limited. In this retrospective cohort study, we describe the characteristics, treatment rationale and outcomes for all adult inpatients treated with dalbavancin at a UK tertiary hospital. Results Fifty-eight inpatients were treated with dalbavancin between 1 January 2018 and 1 January 2021, 98.3% for off-licence diagnoses. Acute bacterial skin and skin structure infection, infective endocarditis and endovascular infections were each diagnosed in 22.4% of patients. Bone and joint infections were diagnosed in 18.9%, discitis in 12.1% and central line-associated bloodstream infections in 5.2%. Sixty-nine percent of patients were bacteraemic; 52.5% Staphylococcus aureus, 5.0% MRSA. Two mild adverse reactions were attributed to dalbavancin. Treatment was successful in 43 (75.4%) patients, and failed in seven (12.3%). Seven (12.3%) were lost to follow-up.Thirty-five patients (60.3%) were PWID, with low median age (41.0 years) and Charlson Comorbidity scores (0). Self-discharge was taken by 17.1% of PWID, and 20.6% were lost to follow-up. At 90 days, three (8.6%) PWID were deceased. Conclusions In this first UK cohort, dalbavancin was used off licence and in persons facing barriers to conventional therapies. Where data is available, it was safe and effective. Dalbavancin appears a potentially valuable tool in improving outcomes for PWID.
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Affiliation(s)
- Carolin Bresges
- Brighton and Sussex Medical School Department of Global Health and Infection, University of Sussex, 94 N–S Road, Falmer, Brighton BN1 9PX, UK
- The Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton BN2 5BE, UK
| | - Kristina Bresges
- Department of Anaesthetics, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Claudette Hewitt
- The Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton BN2 5BE, UK
| | - Sunil Sharma
- The Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton BN2 5BE, UK
| | - Bethany Davies
- Brighton and Sussex Medical School Department of Global Health and Infection, University of Sussex, 94 N–S Road, Falmer, Brighton BN1 9PX, UK
- The Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton BN2 5BE, UK
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Rebold N, Alosaimy S, Pearson JC, Dionne B, Taqi A, Lagnf A, Lucas K, Biagi M, Lombardo N, Eudy J, Anderson DT, Mahoney MV, Kufel WD, D'Antonio JA, Jones BM, Frens JJ, Baumeister T, Geriak M, Sakoulas G, Farmakiotis D, Delaportas D, Larew J, Veve MP, Rybak MJ. Dalbavancin Sequential Therapy for Gram-Positive Bloodstream Infection: A Multicenter Observational Study. Infect Dis Ther 2024; 13:565-579. [PMID: 38427289 DOI: 10.1007/s40121-024-00933-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Long-acting lipoglycopeptides such as dalbavancin may have utility in patients with Gram-positive bloodstream infections (BSI), particularly in those with barriers to discharge or who require prolonged parenteral antibiotic courses. A retrospective cohort study was performed to provide further multicenter real-world evidence on dalbavancin use as a sequential therapy for Gram-positive BSI. METHODS One hundred fifteen patients received dalbavancin with Gram-positive BSI, defined as any positive blood culture or diagnosed with infective endocarditis, from 13 centers geographically spread across the United States between July 2015 and July 2021. RESULTS Patients had a mean (SD) age of 48.5 (17.5) years, the majority were male (54%), with many who injected drugs (40%). The most common infection sources (non-exclusive) were primary BSI (89%), skin and soft tissue infection (SSTI) (25%), infective endocarditis (19%), and bone and joint infection (17%). Staphylococcus aureus accounted for 72% of index cultures, coagulase-negative Staphylococcus accounted for 18%, and Streptococcus species in 16%. Dalbavancin started a median (Q1-Q3) of 10 (6-19) days after index culture collection. The most common regimen administered was dalbavancin 1500 mg as one dose for 50% of cases. The primary outcome of composite clinical failure occurred at 12.2%, with 90-day mortality at 7.0% and 90-day BSI recurrence at 3.5%. CONCLUSIONS Dalbavancin may serve as a useful tool in facilitating hospital discharge in patients with Gram-positive BSI. Randomized controlled trials are anticipated to validate dalbavancin as a surrogate to current treatment standards.
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Affiliation(s)
- Nicholas Rebold
- Wayne State University, Detroit, MI, USA.
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA.
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, 2300 4th St NW, Office 114, Washington, DC, 20059, USA.
| | - Sara Alosaimy
- Wayne State University, Detroit, MI, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Jeffrey C Pearson
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Brandon Dionne
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
- School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Ahmad Taqi
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Abdalhamid Lagnf
- Wayne State University, Detroit, MI, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
- Detroit Medical Center, Detroit Receiving Hospital, Detroit, MI, USA
| | - Kristen Lucas
- Wayne State University, Detroit, MI, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA
| | - Mark Biagi
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
- Department of Pharmacy, Swedish American Health System, Rockford, IL, USA
| | - Nicholas Lombardo
- Department of Pharmacy, Swedish American Health System, Rockford, IL, USA
| | - Joshua Eudy
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Daniel T Anderson
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Monica V Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Wesley D Kufel
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
| | - Joseph A D'Antonio
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
| | - Bruce M Jones
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, GA, USA
| | - Jeremy J Frens
- Department of Pharmacy, Moses H. Cone Memorial Hospital, Cone Health, Greensboro, NC, USA
| | - Tyler Baumeister
- Department of Pharmacy, Moses H. Cone Memorial Hospital, Cone Health, Greensboro, NC, USA
| | - Matthew Geriak
- Sharp Memorial Hospital, Sharp Healthcare, San Diego, CA, USA
| | - George Sakoulas
- Sharp Rees-Stealy Medical Group, San Diego, CA, USA
- University of California San Diego School of Medicine, Division of Host-Microbe Systems and Therapeutics, La Jolla, CA, USA
| | - Dimitrios Farmakiotis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Transplant and Oncology Infectious Diseases, Rhode Island Hospital, Providence, RI, USA
| | | | | | - Michael P Veve
- Wayne State University, Detroit, MI, USA
- College of Pharmacy, University of Tennessee, Knoxville, TN, USA
- Department of Pharmacy, Henry Ford Health System, Detroit, MI, USA
| | - Michael J Rybak
- Wayne State University, Detroit, MI, USA.
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI, 48201, USA.
- Detroit Medical Center, Detroit Receiving Hospital, Detroit, MI, USA.
- School of Medicine, Wayne State University, Detroit, MI, USA.
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Douglass AH, Mayer H, Young K, Sikka MK, Strnad L, Makadia J, Sukerman E, Lewis JS, Streifel AC. The hidden cost of dalbavancin: OPAT RN time required in coordination for persons who use drugs. Ther Adv Infect Dis 2023; 10:20499361231189405. [PMID: 37581105 PMCID: PMC10423448 DOI: 10.1177/20499361231189405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/05/2023] [Indexed: 08/16/2023] Open
Abstract
Background Serious infections in persons who use drugs (PWUD) are rising. Dalbavancin, due to its extended half-life, offers an alternative treatment for patients in whom standard of care antibiotics are not feasible or practical, allowing for reduced hospital days and the avoidance of central line placement or the use of complex oral regimens. Objectives We aim to describe the time and effort required for coordination of dalbavancin courses by outpatient registered nurses (RNs) and other outpatient parenteral antimicrobial therapy (OPAT) staff. Design and methods We conducted a retrospective review of adult patients with documented substance use who received at least one dose of dalbavancin and quantified the number of interventions required by our OPAT RNs and other OPAT staff for coordination of dalbavancin courses. Additionally, detailed data on time spent per intervention were prospectively collected for a 1-month period. Results A total of 52 patients with 53 dalbavancin courses were included. Most substance use was intravenous. Infectious diagnoses included bone and joint infections (61%) and endocarditis (7%), in addition to skin and soft tissue infections (19%). Infections were most commonly caused by Staphylococcus aureus (62%). RN intervention was required in the coordination of 60% of all courses and in 77% of courses in which at least one outpatient dose was needed. Adverse reactions occurred in one patient (2%) and 90-day readmissions due to infectious complications occurred in two patients (4%). Detailed time analysis was performed for seven consecutive patients, with a total of 179 min spent by OPAT RNs on coordination. Conclusions The ease of dalbavancin administration does not eliminate the need for extensive RN coordination for successful administration of doses in the outpatient setting for PWUD. This need should be accounted for in program staffing to help increase successful dalbavancin course completion.
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Affiliation(s)
- Alyse H. Douglass
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Heather Mayer
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Kathleen Young
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Luke Strnad
- School of Public Health, Epidemiology Programs, School of Public Health, Epidemiology Programs, Oregon Health & Science University and Portland State University, Portland, OR, USA
| | - Jina Makadia
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ellie Sukerman
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - James S. Lewis
- Department of Pharmacy, Oregon Health & Science University, Portland, OR, USA
| | - Amber C. Streifel
- Department of Pharmacy, Oregon Health & Science University, Portland, OR, USA
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Barlow G, Wilke M, Béraud G. Tackling Extended Hospital Stays in Patients with Acute Bacterial Skin and Skin Structure Infections. EUROPEAN MEDICAL JOURNAL 2022. [DOI: 10.33590/emj/10095006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Hospitalisation rates for acute bacterial skin and skin structure infection (ABSSSI) are rising and represent a large pharmacoeconomic burden as treatment may involve an extended number of days of antibiotic therapy. This article first aims to provide a review of treatment challenges associated with ABSSSIs in both hospital and outpatient settings, and shows that while more traditionally treatment has been conducted in a hospital setting, for a number of patients, a variety of considerations, including pharmacoeconomics, infection control, and patient preference, has led to the development of recommendations to assess the eligibility of patients for early discharge from hospital to complete their antibiotic regimen in the outpatient setting. However, such patients require monitoring for drug adherence to oral regimens or complications associated with daily intravenous administration, such as injection site reactions and infection. This review also focuses on one of a number of new antibiotics for ABSSSI, dalbavancin, as the long-acting glycopeptide with the most clinical experience to date. This antibiotic has been shown to be as effective as a daily/twice daily regimen with similar safety profiles. Health economic analysis of dalbavancin is also presented. It has shown that in some, though not all, clinical settings a reduction in the overall treatment cost is evident as, despite a higher medication cost, the lower hospitalisation time can lead to greater cost savings. In conclusion, while the burden of ABSSSI is rising, new treatment options provide additional therapeutic choice, although pharmacoeconomic considerations might limit use in some cases.
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Dua A, Sutphin PD, Siedner MJ, Moran J. Case 16-2021: A 37-Year-Old Woman with Abdominal Pain and Aortic Dilatation. N Engl J Med 2021; 384:2054-2063. [PMID: 34042393 DOI: 10.1056/nejmcpc2100278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Anahita Dua
- From the Departments of Surgery (A.D.), Radiology (P.D.S.), Medicine (M.J.S.), and Pathology (J.M.), Massachusetts General Hospital, and the Departments of Surgery (A.D.), Radiology (P.D.S.), Medicine (M.J.S.), and Pathology (J.M.), Harvard Medical School - both in Boston
| | - Patrick D Sutphin
- From the Departments of Surgery (A.D.), Radiology (P.D.S.), Medicine (M.J.S.), and Pathology (J.M.), Massachusetts General Hospital, and the Departments of Surgery (A.D.), Radiology (P.D.S.), Medicine (M.J.S.), and Pathology (J.M.), Harvard Medical School - both in Boston
| | - Mark J Siedner
- From the Departments of Surgery (A.D.), Radiology (P.D.S.), Medicine (M.J.S.), and Pathology (J.M.), Massachusetts General Hospital, and the Departments of Surgery (A.D.), Radiology (P.D.S.), Medicine (M.J.S.), and Pathology (J.M.), Harvard Medical School - both in Boston
| | - Jakob Moran
- From the Departments of Surgery (A.D.), Radiology (P.D.S.), Medicine (M.J.S.), and Pathology (J.M.), Massachusetts General Hospital, and the Departments of Surgery (A.D.), Radiology (P.D.S.), Medicine (M.J.S.), and Pathology (J.M.), Harvard Medical School - both in Boston
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Morrisette T, Miller MA, Montague BT, Barber GR, McQueen RB, Krsak M. On- and off-label utilization of dalbavancin and oritavancin for Gram-positive infections. J Antimicrob Chemother 2020; 74:2405-2416. [PMID: 31322694 DOI: 10.1093/jac/dkz162] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/04/2019] [Accepted: 03/21/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Long-acting lipoglycopeptides (laLGPs) are FDA approved only for acute bacterial skin and skin structure infections (ABSSSIs). However, these antibiotics show promise for off-label use, reductions in hospital length of stay (LOS) and healthcare cost savings. OBJECTIVES To assess the effectiveness, safety, impact on LOS and estimated cost savings from laLGP treatment for Gram-positive infections. METHODS Retrospective cohort of adult patients who received at least one dose of laLGPs at the University of Colorado Health system. Descriptive statistics were utilized for analysis. RESULTS Of 59 patients screened, 56 were included: mean age 47 years, 59% male and 30% injection drug users/polysubstance abusers (dalbavancin, 71%; oritavancin, 25%; both, 4%). Most common indications for laLGP: ABSSSIs (36%), osteomyelitis (27%) and endocarditis (9%). Most common isolated pathogens: MSSA and MRSA (25% and 19%, respectively), Enterococcus faecalis (11%) and CoNS (11%). Previous antibiotics were administered for a median of 13 days (IQR = 7.0-24.5 days) and laLGPs for a median of one dose (IQR = 1-2 doses). Ten (18%) patients were lost to follow-up. Clinical failure was found in 7/47 (15%) cases with adequate follow-up. Mild adverse effects occurred in six (11%) patients. Projected reduction in hospital LOS and health-system costs were 514 days (9.18 days/person average) and $963456.72 ($17204.58/person average), respectively. CONCLUSIONS Prospective trials are needed to validate the use of these antibiotics for Gram-positive infections in practice, with the hope that they will reduce hospital LOS and the need for daily antibiotic infusions to provide alternative options for patients not qualifying for outpatient parenteral antimicrobial therapy.
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Affiliation(s)
- Taylor Morrisette
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy-Infectious Diseases, University of Colorado Hospital, Aurora, CO, USA
| | - Matthew A Miller
- Department of Pharmacy-Infectious Diseases, University of Colorado Hospital, Aurora, CO, USA
| | - Brian T Montague
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Gerard R Barber
- Department of Pharmacy-Infectious Diseases, University of Colorado Hospital, Aurora, CO, USA
| | - R Brett McQueen
- Department of Pharmaceutical Outcomes Research, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Martin Krsak
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Medicine, University of Colorado Hospital, Aurora, CO, USA
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Evaluation of OPAT in the Age of Antimicrobial Stewardship. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00217-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Morrisette T, Miller MA, Montague BT, Barber GR, McQueen RB, Krsak M. Long-Acting Lipoglycopeptides: "Lineless Antibiotics" for Serious Infections in Persons Who Use Drugs. Open Forum Infect Dis 2019; 6:ofz274. [PMID: 31281868 PMCID: PMC6602887 DOI: 10.1093/ofid/ofz274] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/04/2019] [Indexed: 12/11/2022] Open
Abstract
Background Injection drug use is associated with serious infections. Due to challenges with medical management of addiction, relapses and additional infections are common. Persons who use drugs (PWUD) are more likely to leave against medical advice before completing treatment, which could result in treatment failure. Prolonged intravenous (IV) antimicrobial therapy in PWUD may be complicated by concern for IV catheter misuse, sometimes requiring prolonged hospitalization. Ideal alternatives would provide the following: (1) high success rate; (2) reduced rate of medical complications; (3) improved safety profiles; and (4) improved cost-effectiveness. Long-acting lipoglycopeptides present such opportunity for treatment of serious Gram-positive infections. Methods We performed a system-wide, retrospective analysis of adults admitted to University of Colorado Health from September 2015 to June 2018 and treated with dalbavancin or oritavancin based on clinical judgment of their treating physicians. Results Fifty-six patients met inclusion criteria (17 PWUD vs 39 non-PWUD). The PWUD group were younger, healthier by Charlson comorbidity index, more likely insured by Medicaid, and admitted for conditions requiring longer treatment. Ten patients were lost to follow-up. Of the patients with follow-up, clinical failure was met in 1 PWUD patient (6%) and 6 non-PWUD patients (15%) (P = .413). The median hospital length-of-stay reduction was 20 days (interquartile range [IQR], 10–30 days) in PWUD vs 11 days (IQR, 9–14 days) in non-PWUD; P = .133. Estimated median savings were $40 455.08 (IQR, $20 900.00–$62 700.00) in PWUD vs $19 555.08 (IQR, $15 375.08–$23 735.08) in non-PWUD; P = .065. Conclusions Long-acting lipoglycopeptides may be equally effective as standard-of-care, present a safety advantage, and secure earlier discharge and significant cost-savings.
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Affiliation(s)
- Taylor Morrisette
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora.,Department of Pharmacy-Infectious Diseases, University of Colorado Hospital, Aurora
| | - Matthew A Miller
- Department of Pharmacy-Infectious Diseases, University of Colorado Hospital, Aurora
| | - Brian T Montague
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora
| | - Gerard R Barber
- Department of Pharmacy-Infectious Diseases, University of Colorado Hospital, Aurora
| | - R Brett McQueen
- Department of Pharmaceutical Outcomes Research, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | - Martin Krsak
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora
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