Outcomes Associated with De-escalation of Antibiotics to Target Positive Cultures when Treating Febrile Neutropenia

Background: Patients with hematologic malignancies frequently develop febrile neutropenia (FN) and subsequently receive long courses of broad-spectrum antibiotics. Limited data is available on de-escalation strategies. Methods: This was a retrospective observational cohort study of adult patients with a hematologic malignancy, FN, and positive culture results from June 2017 to June 2020. A conventional group (patients who remained on empiric, broad-spectrum agents) was compared to a de-escalation group (patients whose antibiotic therapy was de-escalated based on culture results). The primary outcome was the incidence of recurrent fever or antibiotic escalation due to infection while neutropenic. Results: Of the 123 patients included, the composite primary outcome occurred in 35.3% in the de-escalation group and 39.3% in the conventional group (P = .83). For secondary outcomes, median time to recurrent fever was 7 days in the de-escalation group and 7 days in the conventional group (P = .73). Incidence of Clostridioides difficile was 5.9% in the de-escalation group and 6.7% in the conventional group (P = 1.00). Development of multidrug resistant pathogens during hospital admission was 20.6% in the de-escalation group and 14.6% in the conventional group (P = .59). Median length of broad-spectrum antibiotics was 3 days in the de-escalation group and 8 days in the conventional group (P < .001). All-cause mortality within 30 days was 0 in the de-escalation group and 5.6% in the conventional group (P = .32). Conclusion: In a small sample of patients with a hematologic malignancy and FN, de-escalating antibiotics based on positive cultures decreased the duration of antibiotic therapy without increasing the rate of antibiotic failure.

A population pharmacokinetic model of polymyxin B based on prospective clinical data to inform dosing in hospitalized patients

OBJECTIVES

To develop a population pharmacokinetic (PK) model with data from the largest polymyxin B-treated patient population studied to date to optimize its dosing in hospitalized patients.

METHODS

Hospitalized patients receiving intravenous polymyxin B for ≥48 hours were enrolled. Blood samples were collected at steady state and drug concentrations were analysed by liquid chromotography tandem mass spectrometry (LC-MS/MS). Population PK analysis and Monte Carlo simulations were performed to determine the probability of target attainment (PTA).

RESULTS

One hundred and forty-two patients received intravenous polymyxin B (1.33-6 mg/kg/day), providing 681 plasma samples. Twenty-four patients were on renal replacement therapy, including 13 on continuous veno-venous hemodiafiltration (CVVHDF). A 2-compartment model adequately described the PK with body weight as a covariate on the volume of distribution that affected Cmax, but it did not impact clearance or exposure. Creatinine clearance was a statistically significant covariate on clearance, although clinically relevant variations of dose-normalized drug exposure were not observed across a wide creatinine clearance range. The model described higher clearance in CVVHDF patients than in non-CVVHDF patients. Maintenance doses of ≥2.5 mg/kg/day or ≥150 mg/day had a PTA ≥90% (for non-pulmonary infections target) at a steady state for minimum inhibitory concentrations ≤2 mg/L. The PTA at a steady state for CVVHDF patients was lower.

DISCUSSION

Fixed loading and maintenance doses of polymyxin B seemed to be more appropriate than weight-based dosing regimens in patients weighing 45-90 kg. Higher doses may be needed in patients on CVVHDF. Substantial variability in polymyxin B clearance and volume of distribution was found, suggesting that therapeutic drug monitoring may be indicated.

Race and Remdesivir: Examination of Clinical Outcomes in a Racially and Ethnically Diverse Cohort in New York City

Objective

To compare clinical characteristics and examine in-hospital length of stay (LOS) differences for COVID-19 patients who received remdesivir, by race or ethnicity.

Design

Retrospective descriptive analysis comparing cumulative LOS as a proxy of recovery time.

Setting

A large academic medical center serving a minoritized community in Northern Manhattan, New York City.

Participants

Inpatients (N=1024) who received remdesivir from March 30, 2020–April 20, 2021.

Methods

We conducted descriptive analyses among patients who received remdesivir. Patients were described by proxies of social determinants of health (SDOH): race and ethnicity, residence, insurance coverage, and clinical characteristics. We calculated median hospital LOS as the cumulative incidence of hospitalized patients who were discharged alive, and tested differences between groups by using the Gray test. Patients who died or were discharged to hospice were censored at 29 days.

Main Outcome Measures

The primary outcome was hospital LOS. The secondary outcome was in-hospital mortality.

Results

Median LOS was 11.9 days (95% CI, 10.8-13.2) overall, with Black patients having the shortest (10.0 days, 95% CI, 8.0-13.2) and Asian patients having the longest (16.2 days, 95% CI, 8.3-27.2) LOS. A total of 214 patients (21%) died or were discharged to hospice, ranging from 16.5% to 23.7% of patients who identified as Black and Other (multiracial, biracial, declined), respectively.

Conclusions

COVID-19 has disproportionately burdened communities of color. We observed no difference in median LOS between racial or ethnic groups, which supports the notion that the heterogeneous effect of remdesivir in the literature may be explained in part by underrecruitment or participation of Black, Hispanic, and Asian patients in clinical trials.

892. Clinical Impact of Early Antifungal De-escalation (≤ 2 days) based on Rapid Species Identification in Patients with Azole-susceptible Candidemia

Background

Echinocandins are first-line therapy of candidemia with an option to de-escalate (DE) to oral azoles based on clinical response and susceptibilities. There are no universally accepted DE criteria but rapid diagnostic testing (RDT) allows for earlier Candida sp. identification. The objective of this study was to compare outcomes between early DE (≤ 2 days) and late DE ( &gt; 2 days) using RDT as an antifungal stewardship strategy.

Methods

This was a retrospective study in adults with candidemia caused by C. albicans, C. tropicalis, and C. parapsilosis from 2017-2021. Patients with neutropenia or deep-seated/uncontrolled source were excluded. Primary outcome was 30-day global response (clinical and microbiological success). Secondary outcomes included clinical and microbiologic success, length of stay after candidemia, development of resistance, infection recurrence, and mortality. Comparisons were performed using Chi-squared or Fischer’s exact test for categorical variables and Student’s t test or Mann-Whitney U for continuous variables. A multivariable logistic regression model was constructed to identify independent factors for global response using DE strategy, ICU status, and considering all variables with a p-value &lt; 0.1 on univariate analysis.

Results

87 patients were included, 34 (39%) in early DE group and 53 (61%) in late DE group. Groups were well matched except early DE patients were less likely to be in the ICU at time of candidemia (18% vs 38%; p=0.079). C. albicans was the most common Candida sp. (54%) and a vascular catheter was the most common source (45%). Overall global response was 93% with an in-hospital mortality of 8%. At the time of DE, 45% were considered hemodynamically unstable. No difference in global response between early and late DE was identified (94% vs 96%, p=1.0). On multivariable analysis, no independent predictors were identified and late DE was not associated with improved global response [OR 0.82 (95% CI 0.08, 8.24)]. No differences were identified in secondary outcomes.

Conclusion

There were no differences in outcomes between early and late DE in the treatment of azole-susceptible candidemia. Early DE within 2 days based on rapid species identification should be considered as an antifungal stewardship strategy based on local susceptibilities.

Disclosures

All Authors: No reported disclosures.

Characteristics of procalcitonin in hospitalized COVID-19 patients and clinical outcomes of antibiotic use stratified by procalcitonin levels

We examined the characteristics of pro-calcitonin (PCT) in hospitalized COVID-19 patients (cohort 1) and clinical outcomes of antibiotic use stratified by PCT in non-critically ill patients without bacterial co-infection (cohort 2). Retrospective reviews were performed in adult, hospitalized COVID-19 patients during March-May 2020. For cohort 1, we excluded hospital transfers, renal disease and extra-pulmonary infection without isolated pathogen(s). For cohort 2, we further excluded microbiologically confirmed infection, 'do not resuscitate ± do not intubate' status, and intensive care unit (ICU). For cohort 1, PCT was compared between absent/low-suspicion and proven bacterial co-infections. Factors associated with elevated PCT and sensitivity/specificity/PPV/NPV of PCT cutoffs for identifying bacterial co-infections were explored. For cohort 2, clinical outcomes including mechanical ventilation within 5 days (MV5) were compared between the antibiotic and non-antibiotic groups stratified by PCT ≥ 0.25 µg/L. Nine hundred and twenty four non-ICU and 103 ICU patients were included (cohort 1). The median PCT was higher in proven vs. absent/low-suspicion of bacterial co-infection. Elevated PCT was significantly associated with proven bacterial co-infection, ICU status and oxygen requirement. For PCT ≥ 0.25 µg/L, sensitivity/specificity/PPV/NPV were 69/65/6.5/98% (non-ICU) and 75/33/8.6/94% (ICU). For cohort 2, 756/1305 (58%) patients were included. Baseline characteristics were balanced between the antibiotic and non-antibiotic groups except PCT ≥ 0.25 µg/L (antibiotic:non-antibiotic = 59%:24%) and tocilizumab use (antibiotic:non-antibiotic = 5%:2%). 23% (PCT < 0.25 µg/L) and 58% (PCT ≥ 0.25 µg/L) received antibiotics. Antibiotic group had significantly higher rates of MV5. COVID-19 severity inferred from ICU status and oxygen requirement as well as the presence of bacterial co-infections were associated with elevated PCT. PCT showed poor PPV and high NPV for proven bacterial co-infections. The use of antibiotics did not show improved clinical outcomes in COVID-19 patients with PCT ≥ 0.25 µg/L outside of ICU when bacterial co-infections are of low suspicion.

Assessing the predictive performance of population pharmacokinetic models for intravenous polymyxin B in critically ill patients

Polymyxin B (PMB) has reemerged as a last‐line therapy for infections caused by multidrug‐resistant gram‐negative pathogens, but dosing is challenging because of its narrow therapeutic window and pharmacokinetic (PK) variability. Population PK (POPPK) models based on suitably powered clinical studies with appropriate sampling strategies that take variability into consideration can inform PMB dosing to maximize efficacy and minimize toxicity and resistance. Here we reviewed published PMB POPPK models and evaluated them using an external validation data set (EVD) of patients who are critically ill and enrolled in an ongoing clinical study to assess their utility. Seven published POPPK models were employed using the reported model equations, parameter values, covariate relationships, interpatient variability, parameter covariance, and unexplained residual variability in NONMEM (Version 7.4.3). The predictive ability of the models was assessed using prediction‐based and simulation‐based diagnostics. Patient characteristics and treatment information were comparable across studies and with the EVD (n = 40), but the sampling strategy was a main source of PK variability across studies. All models visually and statistically underpredicted EVD plasma concentrations, but the two‐compartment models more accurately described the external data set. As current POPPK models were inadequately predictive of the EVD, creation of a new POPPK model based on an appropriately powered clinical study with an informed PK sampling strategy would be expected to improve characterization of PMB PK and identify covariates to explain interpatient variability. Such a model would support model‐informed precision dosing frameworks, which are urgently needed to improve PMB treatment efficacy, limit resistance, and reduce toxicity in patients who are critically ill.

Clinical Outcomes Associated With Methylprednisolone in Mechanically Ventilated Patients With COVID-19

BACKGROUND

The efficacy and safety of methylprednisolone in mechanically ventilated patients with acute respiratory distress syndrome resulting from coronavirus disease 2019 (COVID-19) are unclear. In this study, we evaluated the association between use of methylprednisolone and key clinical outcomes.

METHODS

Clinical outcomes associated with the use of methylprednisolone were assessed in an unmatched, case-control study; a subset of patients also underwent propensity-score matching. Patients were admitted between 1 March and 12 April, 2020. The primary outcome was ventilator-free days by 28 days after admission. Secondary outcomes included extubation, mortality, discharge, positive cultures, and hyperglycemia.

RESULTS

A total of 117 patients met inclusion criteria. Propensity matching yielded a cohort of 42 well-matched pairs. Groups were similar except for hydroxychloroquine and azithromycin use, which were more common in patients who did not receive methylprednisolone. Mean ventilator-free days were significantly higher in patients treated with methylprednisolone (6.21 ± 7.45 vs 3.14 ± 6.22; P = .044). The probability of extubation was also increased in patients receiving methylprednisolone (45% vs 21%; P = .021), and there were no significant differences in mortality (19% vs 36%; P = .087). In a multivariable linear regression analysis, only methylprednisolone use was associated with a higher number of ventilator-free days (P = .045). The incidence of positive cultures and hyperglycemia were similar between groups.

CONCLUSIONS

Methylprednisolone was associated with increased ventilator-free days and higher probability of extubation in a propensity-score matched cohort. Randomized, controlled studies are needed to further define methylprednisolone use in patients with COVID-19.

Characterization of Bacterial and Fungal Infections in Hospitalized Patients With Coronavirus Disease 2019 and Factors Associated With Health Care-Associated Infections

Background

Patients hospitalized with coronavirus disease 2019 (COVID-19) are at increased risk of health care–associated infections (HAIs), especially with prolonged hospital stays. We sought to identify incidence, antimicrobial susceptibilities, and outcomes associated with bacterial/fungal secondary infections in a large cohort of patients with COVID-19.

Methods

We evaluated adult patients diagnosed with COVID-19 between 2 March and 31 May 2020 and hospitalized >24 hours. Data extracted from medical records included diagnoses, vital signs, laboratory results, microbiological data, and antibiotic use. Microbiologically confirmed bacterial and fungal pathogens from clinical cultures were evaluated to characterize community- and health care–associated infections, including describing temporal changes in predominant organisms on presentation and throughout hospitalization. Univariable and multivariable logistic regression analyses were performed to investigate risk factors for HAIs.

Results

A total of 3028 patients were included and accounted for 899 positive clinical cultures. Overall, 516 (17%) patients with positive cultures met criteria for infection. Community-associated coinfections were identified in 183 (6%) patients, whereas HAIs occurred in 350 (12%) patients. Fifty-seven percent of HAIs were caused by gram-negative bacteria and 19% by fungi. Antibiotic resistance increased with longer hospital stays, with incremental increases in the proportion of vancomycin resistance among enterococci and ceftriaxone and carbapenem resistance among Enterobacterales. Intensive care unit stay, invasive mechanical ventilation, and steroids were associated with HAIs.

Conclusions

HAIs occur in a small proportion of patients hospitalized with COVID-19 and are most often caused by gram-negative and fungal pathogens. Antibiotic resistance is more prevalent with prolonged hospital stays. Antimicrobial stewardship is imperative in this population to minimize unnecessary broad-spectrum antibiotic use.

Antimicrobial stewardship perspectives from a New York City hospital during the COVID-19 pandemic: Challenges and opportunities

Purpose

To share challenges and opportunities for antimicrobial stewardship programs based on one center’s experience during the early weeks of the coronavirus disease 2019 (COVID-19) pandemic.

Summary

In the spring of 2020, New York City quickly became a hotspot for the COVID-19 pandemic in the United States, putting a strain on local healthcare systems. Antimicrobial stewardship programs faced diagnostic and therapeutic uncertainties as well as healthcare resource challenges. With the lack of effective antivirals, antibiotic use in critically ill patients was difficult to avoid. Uncertainty drove antimicrobial use and thus antimicrobial stewardship principles were paramount. The dramatic influx of patients, drug and equipment shortages, and the need for prescribers to practice in alternative roles only compounded the situation. Establishing enhanced communication, education, and inventory control while leveraging the capabilities of the electronic medical record were some of the tools used to optimize existing resources.

Conclusion

New York City was a unique and challenging environment during the initial peak of the COVID-19 pandemic. Antimicrobial stewardship programs can learn from each other by sharing lessons learned and practice opportunities to better prepare other programs facing COVID-19 case surges.

Cardiac Corrected QT Interval Changes Among Patients Treated for COVID-19 Infection During the Early Phase of the Pandemic

IMPORTANCE

Critical illness, a marked inflammatory response, and viruses such as SARS-CoV-2 may prolong corrected QT interval (QTc).

OBJECTIVE

To evaluate baseline QTc interval on 12-lead electrocardiograms (ECGs) and ensuing changes among patients with and without COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 3050 patients aged 18 years and older who underwent SARS-CoV-2 testing and had ECGs at Columbia University Irving Medical Center from March 1 through May 1, 2020. Patients were analyzed by treatment group over 5 days, as follows: hydroxychloroquine with azithromycin, hydroxychloroquine alone, azithromycin alone, and neither hydroxychloroquine nor azithromycin. ECGs were manually analyzed by electrophysiologists masked to COVID-19 status. Multivariable modeling evaluated clinical associations with QTc prolongation from baseline.

EXPOSURES

COVID-19, hydroxychloroquine, azithromycin.

MAIN OUTCOMES AND MEASURES

Mean QTc prolongation, percentage of patients with QTc of 500 milliseconds or greater.

RESULTS

A total of 965 patients had more than 2 ECGs and were included in the study, with 561 (58.1%) men, 198 (26.2%) Black patients, and 191 (19.8%) aged 80 years and older. There were 733 patients (76.0%) with COVID-19 and 232 patients (24.0%) without COVID-19. COVID-19 infection was associated with significant mean QTc prolongation from baseline by both 5-day and 2-day multivariable models (5-day, patients with COVID-19: 20.81 [95% CI, 15.29 to 26.33] milliseconds; P < .001; patients without COVID-19: -2.01 [95% CI, -17.31 to 21.32] milliseconds; P = .93; 2-day, patients with COVID-19: 17.40 [95% CI, 12.65 to 22.16] milliseconds; P < .001; patients without COVID-19: 0.11 [95% CI, -12.60 to 12.81] milliseconds; P = .99). COVID-19 infection was independently associated with a modeled mean 27.32 (95% CI, 4.63-43.21) millisecond increase in QTc at 5 days compared with COVID-19-negative status (mean QTc, with COVID-19: 450.45 [95% CI, 441.6 to 459.3] milliseconds; without COVID-19: 423.13 [95% CI, 403.25 to 443.01] milliseconds; P = .01). More patients with COVID-19 not receiving hydroxychloroquine and azithromycin had QTc of 500 milliseconds or greater compared with patients without COVID-19 (34 of 136 [25.0%] vs 17 of 158 [10.8%], P = .002). Multivariable analysis revealed that age 80 years and older compared with those younger than 50 years (mean difference in QTc, 11.91 [SE, 4.69; 95% CI, 2.73 to 21.09]; P = .01), severe chronic kidney disease compared with no chronic kidney disease (mean difference in QTc, 12.20 [SE, 5.26; 95% CI, 1.89 to 22.51; P = .02]), elevated high-sensitivity troponin levels (mean difference in QTc, 5.05 [SE, 1.19; 95% CI, 2.72 to 7.38]; P < .001), and elevated lactate dehydrogenase levels (mean difference in QTc, 5.31 [SE, 2.68; 95% CI, 0.06 to 10.57]; P = .04) were associated with QTc prolongation. Torsades de pointes occurred in 1 patient (0.1%) with COVID-19.

CONCLUSIONS AND RELEVANCE

In this cohort study, COVID-19 infection was independently associated with significant mean QTc prolongation at days 5 and 2 of hospitalization compared with day 0. More patients with COVID-19 had QTc of 500 milliseconds or greater compared with patients without COVID-19.

Guideline-Discordant Preoperative Gentamicin Dosing and the Risk of Gentamicin Associated Nephrotoxicity in Urologic Surgery

OBJECTIVE

To determine the rate of and predictors for guideline-discordant preoperative gentamicin dosing in urologic surgery and to assess the risk of nephrotoxicity in patients who receive the recommended high-dose prophylaxis.

MATERIALS AND METHODS

We retrospectively reviewed all adult patients who received preoperative gentamicin for urologic surgery from January 1, 2017 - October 3, 2019. Doses were categorized as guideline-concordant or -discordant using a cutoff of 4.5 mg/kg dosing weight. We used multivariable logistic regression to identify predictors for guideline-discordant dosing. Postoperative kidney injury was assessed using RIFLE criteria.

RESULTS

Among 2134 patients, 89% received a preoperative dose ≤ 4.5 mg/kg. Older age (70+ years) and endoscopic surgery were significant risk factors for guideline-discordant dosing (OR 2.54, P< 0.001; OR 6.21, P<0.001). Among 735 patients with complete data, there was no significant difference in the risk of kidney injury between those who received a dose less than 4.5 mg/kg and those who received a higher dose (OR 0.89, 95% CI: 0.26 - 2.99, P = 0.75).

CONCLUSION

Preoperative gentamicin is commonly administered at lower than recommended doses for urologic surgery. Older age and endoscopic surgery are significant predictors of guideline-discordant dosing. The risk of kidney injury following high-dose preoperative gentamicin for urologic procedures is likely comparable to the risk at lower doses.

1579. Burkholderia Returns: Are Two Drugs Better or Back to Bactrim?

Background

Trimethoprim-sulfamethoxazole (T/S) and levofloxacin are considered first line agents for the treatment of Burkholderia cepacia complex (Bcc). Combination therapy (CT) is frequently utilized despite limited clinical evidence supporting this. The objective of this study is to compare outcomes associated with different regimens for the treatment of Bcc infections.

Methods

This is a retrospective cohort study in non-cystic fibrosis adult patients with infection caused by Bcc from 2015 to 2019. The primary outcome is the composite of overall treatment failure defined as clinical failure, microbiologic failure, or mortality at 30 days. Secondary outcomes include mortality, clinical failure, microbiological failure, development of resistance, recurrence, and safety. Comparisons were performed using Chi-squared or Fischer’s exact test for categorical variables and Student’s t test or the Mann-Whitney U test for continuous variables, as appropriate. Multivariable logistic regression analysis was used to identify independent risk factors for overall treatment failure.

Results

Sixty-eight patients were included, 50 (74%) received monotherapy (MT) and 18 (26%) received CT. MT regimens included meropenem (n=19), ceftazidime (n=15), T/S (n=10), and other (n=6). Various combination regimens were utilized. MT recipients were significantly older, more likely to have renal disease, less likely to have an immunosuppression, and had a higher severity of illness. The most common site of infection was respiratory (78%). No difference was found for overall treatment failure between MT and CT (36.0% vs. 38.9%; p=0.947). No differences were found in the secondary outcomes (Table 1). Overall treatment failure did not differ by treatment regimens utilized. On multivariable analysis controlling for age, renal disease, CCI, immunosuppression, ICU admission, SOFA score, and receipt of MT, only SOFA score was associated with treatment failure [OR 1.43 (95% CI 1.15 to 1.77); p=0.001] and not MT [OR 1.22 (95% CI 0.25 to 5.97); p=0.808].

Table 1: Treatment Outcomes – MT versus CT

Conclusion

There were no differences in outcomes between MT and CT groups for the treatment of Bcc infection. Treatment outcomes appeared to be driven primarily by disease severity. Additional studies are needed to identify the optimal treatment regimens.

Disclosures

All Authors: No reported disclosures

2439. Outcomes of Minocycline Use on Gram-Negative Infections and Implications of MIC

Background

Minocycline (MINO) is a treatment option for Acinetobacter baumannii and Stenotrophomonas maltophilia infections due to high in vitro susceptibility. Literature suggests it may also be an option for carbapenamase-producing enterobacteriaceae. MINO minimum inhibitory concentrations (MICs) vary by organism and dosing varies by center. Additional data are needed to assess MINO effectiveness in Gram-negative infections and determine if a relationship exists between MIC and treatment outcomes.

Methods

Retrospective study evaluating MINO use in adults at NewYork-Presbyterian Hospital from 2012 to 2017. Patients included received MINO ≥2 days for a culture-positive Gram-negative infection (CDC/NHSN criteria) susceptible to MINO. Patients with MINO started >5 days after positive culture or with untreated polymicrobial infections were excluded. The primary outcome was clinical failure at the end of therapy. Secondary outcomes included 30-day mortality, development of resistance or recurrence within 90 days.

Results

114 patients were included: majority were male (51%) with median age 57 years. Median duration was 12 days with 8 patients receiving high-dose MINO (≥150 mg q12H). S. maltophilia was the most prevalent pathogen (72%) followed by Klebsiella pneumoniae (16%) with a median MINO MIC of 1 mg/L. 68% of patients received combination therapy. Treatment success was observed in 71 patients (63%). Patients with treatment failure had higher median Charlson Comorbidity Index (5 vs. 3; P = 0.026), SOFA score (7 vs. 5; P = 0.028), and were more likely to have underlying leukemia or lymphoma (39% vs. 7%; P < 0.001). No differences were seen in primary or secondary outcomes between combination and monotherapy regimens. MICs had no impact on failure outcome, 30-day mortality or 90-day recurrence (all P > 0.05); however, MICs ≤ 2 mg/L were associated with increased development of resistance (34% vs. 12%; P = 0.021). In a multivariable analysis, vasopressor use (OR 2.79; 95% CI 1.05,7.41; P = 0.04) and underlying leukemia/lymphoma (OR 4.49; 95% CI 1.26,15.95; P = 0.02) were associated with increased risk of treatment failure.

Conclusion

MINO MIC impacted resistance, but did not correlate with treatment failure, mortality or recurrence. Severity of illness and comorbidities but not choice of MINO may be associated with clinical failures.

Disclosures

All authors: No reported disclosures.

Polymyxin B Pharmacokinetics in Adult Cystic Fibrosis Patients

OBJECTIVES

Polymyxin B pharmacokinetics (PK) in adults with cystic fibrosis (CF) are not well described. The goals of this pilot study were to identify a PK model for patients with CF receiving polymyxin B with exploration of covariate relationships of the PK parameters, to compare polymyxin B PK parameters in adults without CF, and to probe exposures associated with different dosing schemes through simulation.

METHODS

Adult patients with CF treated with polymyxin B at New York-Presbyterian Hospital had PK samples measured by liquid chromatography-mass spectrometry (MS)/MS. Multiple PK models were fit utilizing Pmetrics for R. Model covariates considered included: age, total body weight, creatinine clearance, albumin, and body mass index. PK parameters in CF patients were compared with PK parameters for 53 adults without CF who were receiving polymyxin B from the same institution. Simulations with target exposure (area under the curve)/minimum inhibitory concentration (MIC) of 20 mg*L/h were conducted for different dosing schemes and MIC ranges.

MAIN RESULTS

Nine patients with CF received between 58 and 240 mg of polymyxin B (median 1.47 mg/kg/dose [IQR (1.43-1.65)]). A two-compartment model adjusting polymyxin B clearance for patient CrCl was better than a standard two-compartment model (p=0.004) in CF patients. When compared to PK parameters for patients without CF, PK parameters of polymyxin B in CF were similar (p>0.05). Simulations for plasma concentrations showed all regimens performed adequately at MICs between 0.03125 and 0.125 mg/L but not at increasing MICs of 1 and 2 mg/L.

CONCLUSIONS

In this pilot study of polymyxin B PK in adults with CF, the PK parameters of polymyxin B were mostly similar to adults without CF. We observed a potential association between CrCl and polymyxin B clearance, which stands in contrast to the general adult population. However, this observation requires further study. Additional studies focusing on optimal and safe polymyxin B dosing in CF are needed.

Influence of Polymyxin B Dose on Development and Recovery of Acute Kidney Injury

Background

Nephrotoxicity is a common adverse effect of polymyxin B (PMB) with reported acute kidney injury (AKI) rates of 20% to &gt;60%. Data on PMB dosing to optimize efficacy while minimizing toxicity are limited. Previous studies suggest higher doses improve outcomes but are also associated with more AKI. Data are needed to evaluate optimal dosing and contributing factors to minimize AKI and to evaluate renal recovery.

Methods

Retrospective study evaluating PMB in adults at NewYork-Presbyterian Hospital from 2012 to 2016. Patients who received PMB dosed twice daily for ≥2 days were included. Patients on renal replacement therapy within 48 hours prior to PMB or with AKI at time of PMB initiation were excluded. A classification and regression tree (CART) analysis was performed to identify the PMB dose most predictive of AKI which defined the breakpoint for high- vs. low-dose PMB cohorts for all subsequent comparisons. The primary outcome was to determine whether high-dose PMB independently predicted AKI. Secondary outcomes included in-hospital mortality, time to AKI, and recovery of renal function.

Results

246 patients were included: majority were male (59%) with median age 41 years. Median PMB dose was 2.9 mg/kg/day or 180 mg/day for a median duration of 10 days. AKI occurred in 64% and 38% had recovery of renal function by hospital discharge. The breakpoint for high-dose PMB determined by CART was 160 mg/day, putting 104 in low-dose and 142 in high-dose groups. High-dose PMB was associated with AKI compared with low-dose PMB on univariable (75% vs.. 49%, P &lt; 0.001) and multivariable (OR 3.43; 95% CI 1.68,6.99; P = 0.001) analyses. Concomitant vancomycin (OR 3.34; 95% CI 1.74,6.41;P &lt; 0.001), history of transplant (OR 4.96; 95% CI 2.14,11.48;P &lt; 0.001), and previous PMB exposure (OR 2.37; 95% CI 1.23,4.57; P = 0.01) were also identified as independent predictors of AKI. No significant differences were found for in-hospital mortality (28% vs. 21%, P = 0.326), renal recovery (37% vs. 41%, P = 0.723), time to AKI (median 5 vs. 6 days, P = 0.125) between groups.

Conclusion

High-dose PMB (&gt;160 mg/day) was independently associated with AKI as well as concomitant vancomycin, history of transplant, and previous PMB exposure. High-dose PMB did not have a significant impact on in-hospital mortality, recovery of renal function, or time to development of AKI.

Disclosures

M. Yin, Gilead Sciences: Consultant, Consulting fee.

Outcomes Comparing Initial Short vs Long Course Echinocandin Therapy in Patients with Candidemia Caused by Fluconazole Susceptible Strains

Background

Guidelines for candidemia (CAND) treatment recommend initial echinocandin (ECHINO) therapy with transition to fluconazole (FLUC) after 5–7 days in patients with clinical stability, FLUC-susceptibility, and negative cultures; however, optimal timing for transition is unknown. In the era of rapid diagnostics and antimicrobial stewardship programs (ASP), studies are needed to evaluate the impact of earlier transition in CAND due to routinely FLUC-susceptible species.

Methods

Retrospective study of adult patients at NewYork-Presbyterian Hospital from 2012 to 2014. Inclusion criteria included ≥1 blood culture with C. albicans, C. tropicalis or C. parapsilosis, ≥1 dose ECHINO initial therapy, ≥3 days total treatment, and no prior episode of CAND within 30 days. Patients with polymicrobial bloodstream infection excluded. Patients de-escalated from ECHINO at ≤3 days (short-course; SC-ECH) were compared with those who received ≥4 days of ECHINO (long course; LC-ECH). The primary outcome was 14-day complete response (CR), defined as survival with clinical improvement and sterilization of blood cultures. Secondary outcomes included day 7 microbiological success (MicroS) and 28-day survival (SURV).

Results

76 patients included: 21 in SC-ECH, 55 in LC-ECH groups. C. albicans (58%) most common species. Majority were male (59%) with median age 64 years (IQR 49–74), 62% were in ICU at time of CAND, 50% had recent surgery. No significant baseline differences between SC-ECH and LC-ECH groups, including in PITT bacteremia score ≥4 (43% vs. 42%; P = 0.4) or median APACHE (20 vs. 20; P = 0.684). There was no difference between SC-ECH vs. LC-ECH in CR (52% vs. 49%; P = 1.0), early MicroS (81% vs. 87%; P = 0.484), or SURV (62% vs. 73%; P = 0.523). On multivariable analysis with duration of ECHINO therapy forced into the model, only PITT bacteremia score <4 remained an independent predictor of CR (OR 6.1, 95% CI 2.1, 17.9; P = 0.001).

Conclusion

In adult patients with CAND due to routinely FLUC-susceptible species, early de-escalation from ECHINO was associated with similar outcomes, including day 7 MicroS. Early de-escalation based on early species identification has the potential to be a target for ASPs to optimize antifungal therapy without compromising clinical outcomes.

Disclosures

All authors: No reported disclosures.

Epidemiology and outcomes of carbapenem-resistant Klebsiella pneumoniae bacteriuria in kidney transplant recipients

BACKGROUND

Little is known about the epidemiology of carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteriuria following kidney transplantation. We determined the incidence of post-transplant CRKP bacteriuria in adults who underwent kidney transplant from 2007 to 2010 at 2 New York City centers.

METHODS

We conducted a case-control study to identify factors associated with CRKP bacteriuria compared with carbapenem-susceptible K. pneumoniae (CSKP) bacteriuria, assessed whether CRKP bacteriuria was associated with mortality or graft failure, and compared outcomes of treated episodes of CRKP and CSKP bacteriuria.

RESULTS

Of 1852 transplants, 20 (1.1%) patients developed CRKP bacteriuria. Factors associated with CRKP bacteriuria included receipt of multiple organs (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.1-20.4), deceased-donor allograft (OR 5.9, 95% CI 1.3-26.8), transplant admission length of stay (OR 1.1 per day, 95% CI 1.0-1.1), pre-transplant CRKP infection or colonization (OR 18.3, 95% CI 2.0-170.5), diabetes mellitus (OR 2.8, 95% CI 1.0-7.8), and receipt of antimicrobials other than trimethoprim-sulfamethoxazole (OR 4.3, 95% CI 1.6-11.2).

CONCLUSION

Compared to CSKP bacteriuria, CRKP bacteriuria was associated with increased mortality (30% vs. 10%, P = 0.03) but not graft failure. Treated episodes of CRKP bacteriuria were less likely to achieve microbiologic clearance (83% vs. 97%; P = 0.05) and more likely to recur within 3 months (50% vs. 22%, P = 0.02) than CSKP episodes. CRKP bacteriuria after kidney transplant is associated with mortality and antimicrobial failure after treatment.

Clinical outcomes associated with polymyxin B dose in patients with bloodstream infections due to carbapenem-resistant Gram-negative rods

There is significant variation in the use of polymyxin B (PMB), and optimal dosing has not been defined. The purpose of this retrospective study was to evaluate the relationship between PMB dose and clinical outcomes. We included patients with bloodstream infections (BSIs) due to carbapenem-resistant Gram-negative rods who received ≥48 h of intravenous PMB. The objective was to evaluate the association between PMB dose and 30-day mortality, clinical cure at day 7, and development of acute kidney injury (AKI). A total of 151 BSIs were included. The overall 30-day mortality was 37.8% (54 of 151), and the median PMB dosage was 1.3 mg/kg (of total body weight)/day. Receipt of PMB dosages of <1.3 mg/kg/day was significantly associated with 30-day mortality (46.5% versus 26.3%; P = 0.02), and this association persisted in multivariable analysis (odds ratio [OR] = 1.58; 95% confidence interval [CI] = 1.05 to 1.81; P = 0.04). Eighty-two percent of patients who received PMB dosages of <1.3 mg/kg/day had baseline renal impairment. Clinical cure at day 7 was not significantly different between dosing groups. AKI was more common in patients receiving PMB dosages of ≥250 mg/day (66.7% versus 32.0%; P = 0.03), and this association persisted in multivariable analysis (OR = 4.32; 95% CI = 1.15 to 16.25; P = 0.03). PMB dosages of <1.3 mg/kg/day were administered primarily to patients with renal impairment, and this dosing was independently associated with 30-day mortality. However, dosages of ≥250 mg/day were independently associated with AKI. These data support the use of PMB without dose reduction in the setting of renal impairment.

Appropriateness of gram-negative agent use at a tertiary care hospital in the setting of significant antimicrobial resistance

Background.  Practicing antimicrobial stewardship in the setting of widespread antimicrobial resistance among gram-negative bacilli, particularly in urban areas, is challenging. Methods.  We conducted a retrospective cross-sectional study at a tertiary care hospital with an established antimicrobial stewardship program in New York, New York to determine appropriateness of use of gram-negative antimicrobials and to identify factors associated with suboptimal antimicrobial use. Adult inpatients who received gram-negative agents on 2 dates, 1 June 2010 or 1 December 2010, were identified through pharmacy records. Clinical data were collected for each patient. Use of gram-negative agents was deemed optimal or suboptimal through chart review and according to hospital guidelines. Data were compared using χ(2) or Fischer's exact test for categorical variables and Student t test or Mann-Whitney U test for continuous variables. Results.  A total of 356 patients were included who received 422 gram-negative agents. Administration was deemed suboptimal in 26% of instances, with the most common reason being spectrum of activity too broad. In multivariable analysis, being in an intensive care unit (adjusted odds ratio [aOR], .49; 95% confidence interval [CI], .29-.84), having an infectious diseases consultation within the previous 7 days (aOR, .52; 95% CI, .28-.98), and having a history of multidrug-resistant gram-negative bacilli within the past year (aOR, .24; 95% CI, .09-.65) were associated with optimal gram-negative agent use. Beta-lactam/beta-lactamase inhibitor combination drug use (aOR, 2.6; 95% CI, 1.35-5.16) was associated with suboptimal use. Conclusions.  Gram-negative agents were used too broadly despite numerous antimicrobial stewardship program activities.

Risk factors and outcomes of infections caused by extremely drug-resistant gram-negative bacilli in patients hospitalized in intensive care units

BACKGROUND

Extremely drug-resistant gram-negative bacilli (XDR-GNB) increasingly cause health care-associated infections (HAIs) in intensive care units (ICUs).

METHODS

A matched case-control (1:2) study was conducted from February 2007 to January 2010 in 16 ICUs. Case and control subjects had HAIs caused by GNB susceptible to ≤1 antibiotic versus ≥2 antibiotics, respectively. Logistic and Cox proportional hazards regression assessed risk factors for HAIs and predictors of mortality, respectively.

RESULTS

Overall, 103 case and 195 control subjects were enrolled. An immunocompromised state (odds ratio [OR], 1.55; P = .047) and exposure to amikacin (OR, 13.81; P < .001), levofloxacin (OR, 2.05; P = .005), or trimethoprim-sulfamethoxazole (OR, 3.42; P = .009) were factors associated with XDR-GNB HAIs. Multiple factors in both case and control subjects significantly predicted increased mortality at different time intervals after HAI diagnosis. At 7 days, liver disease (hazard ratio [HR], 5.52), immunocompromised state (HR, 3.41), and bloodstream infection (HR, 2.55) predicted mortality; at 15 days, age (HR, 1.02 per year increase), liver disease (HR, 3.34), and immunocompromised state (HR, 2.03) predicted mortality; and, at 30 days, age (HR, 1.02 per 1-year increase), liver disease (HR, 3.34), immunocompromised state (HR, 2.03), and hospitalization in a medical ICU (HR, 1.85) predicted mortality.

CONCLUSION

HAIs caused by XDR-GNB were associated with potentially modifiable factors. Age, liver disease, and immunocompromised state, but not XDR-GNB HAIs, were associated with mortality.

Comparison of 3 severity criteria for Clostridium difficile infection

Effective severity criteria are needed to guide management of Clostridium difficile infection (CDI). In this retrospective study, outcomes were compared between patients with mild-moderate versus severe CDI according to 3 different severity criteria: those included in the 2010 Society for Healthcare Epidemiology of America/Infectious Diseases Society of America guidelines, those from a recent clinical trial, and our hospital-specific guidelines.

Risk factors associated with Clostridium difficile infection after kidney and pancreas transplantation

BACKGROUND

Clostridium difficile infection (CDI) is a common cause of nosocomial antibiotic-associated diarrhea with an increased incidence reported in solid organ transplant recipients. We sought to determine if kidney and/or pancreas transplant recipients possess unique risk factors for CDI.

METHODS

Between January 2009 and February 2011, 942 kidney and 56 pancreas transplants were performed at the 2 centers. Of these, 28 recipients (kidney, n = 24; pancreas, n = 4) developed CDI. Cases were matched to controls (n = 56) in a 1:2 ratio.

RESULTS

Those with CDI were mostly male patients (82% vs. 48%, P = 0.003), deceased-donor organ recipients (86% vs. 64%, P = 0.045), more likely to have leukopenia (18% vs. 4%, P = 0.038), and had undergone a gastrointestinal procedure within 3 months preceding CDI diagnosis (18% vs. 4%, P = 0.038). Cases had higher cumulative and restricted antimicrobial exposure in days (37 ± 79 vs. 8 ± 12, P = 0.009 and 27 ± 69 vs. 7 ± 10, P = 0.032). Cephalosporin use was more common among cases (43% vs. 16%, P = 0.008).

CONCLUSION

Careful antimicrobial selection and assurance of optimal treatment duration in the kidney and pancreas transplant population is prudent. Clinicians should have a heightened awareness of CDI risk particularly during periods of leukopenia and in the setting of gastrointestinal procedures.

Clinicians' knowledge, attitudes, and practices regarding infections with multidrug-resistant gram-negative bacilli in intensive care units

OBJECTIVE

To assess how healthcare professionals caring for patients in intensive care units (ICUs) understand and use antimicrobial susceptibility testing (AST) for multidrug-resistant gram-negative bacilli (MDR-GNB).

DESIGN

A knowledge, attitude, and practice survey assessed ICU clinicians' knowledge of antimicrobial resistance, confidence interpreting AST results, and beliefs regarding the impact of AST on patient outcomes.

SETTING

Sixteen ICUs affiliated with NewYork-Presbyterian Hospital.

PARTICIPANTS

Attending physicians and subspecialty residents with primary clinical responsibilities in adult or pediatric ICUs as well as infectious diseases subspecialists and clinical pharmacists.

METHODS

Participants completed an anonymous electronic survey. Responses included 4-level Likert scales dichotomized for analysis. Multivariate analyses were performed using generalized estimating equation logistic regression to account for correlation of respondents from the same ICU.

RESULTS

The response rate was 51% (178 of 349 eligible participants); of the respondents, 120 (67%) were ICU physicians. Those caring for adult patients were more knowledgeable about antimicrobial activity and were more familiar with MDR-GNB infections. Only 33% and 12% of ICU physicians were familiar with standardized and specialized AST methods, respectively, but more than 95% believed that AST improved patient outcomes. After adjustment for demographic and healthcare provider characteristics, those familiar with treatment of MDR-GNB bloodstream infections, those aware of resistance mechanisms, and those aware of AST methods were more confident that they could interpret AST results and/or request additional in vitro testing.

CONCLUSIONS

Our study uncovered knowledge gaps and educational needs that could serve as the foundation for future interventions. Familiarity with MDR-GNB increased overall knowledge, and familiarity with AST increased confidence interpreting the results.

Lack of significant variability among different methods for calculating antimicrobial days of therapy

Days of therapy (DOTs) are an important measure to quantify antimicrobial use but may not reflect patients' true antimicrobial exposure. Three methods of calculating DOTs were compared to determine whether including "exposure days," when antimicrobials are given less frequently than daily due to renal dysfunction, makes a difference.

Incidence and predictors of acute kidney injury associated with intravenous polymyxin B therapy

BACKGROUND

Increases in multidrug-resistance among gram-negative organisms have necessitated the use of polymyxins. To date, the incidence of acute kidney injury (AKI) associated with polymyxin B has not been evaluated using RIFLE criteria.

METHODS

Adult patients who received polymyxin B were retrospectively evaluated to determine the incidence of AKI during polymyxin B therapy using RIFLE criteria. Predictors of AKI were identified by comparing characteristics of patients with and without AKI.

RESULTS

A total of 73 patients were included. The incidence of AKI was 60%. Ten (14%) patients discontinued therapy due to nephrotoxicity. Median duration of polymyxin B was 11 days with a median cumulative dose of 18 mg/kg. Concomitant nephrotoxins were received in 69 (95%). Patients with AKI had a higher median cumulative dose (1578 mg vs. 800 mg; p = 0.02), a higher body mass index (BMI) (27.2 vs. 24.5 kg/m(2); p = 0.03), and were more likely to receive vancomycin (82% vs. 55%; p = 0.03) compared to those without AKI. After controlling for polymyxin B duration, independent predictors of AKI were higher BMI and concomitant vancomycin.

CONCLUSIONS

The incidence of AKI during polymyxin B therapy was 60%. Further studies are needed to define dosing parameters that maximize efficacy and minimize nephrotoxicity.

Carbapenem-resistant Klebsiella pneumoniae bacteremia: factors correlated with clinical and microbiologic outcomes

We undertook a retrospective cohort study describing general outcomes and specific factors associated with positive outcomes in bacteremia due to carbapenem-resistant Klebsiella pneumoniae (CRKP). Forty-eight patients were included, of which 42% died at 30 days. Forty-two percent of patients were in septic shock at the time of the first positive blood culture, and 42% were recipients of solid organ transplants. Lack of microbiologic eradication at 7 days was independently associated with 30-day mortality. Adjunctive procedures performed for source control and microbiologic eradication at 7 days were associated with a favorable clinical response at 7 days. Time to initiation and receipt at any time of antimicrobials with in vitro activity against CRKP were not associated with improved survival. Breakthrough bacteremia occurred in 8 cases, all in patients receiving tigecycline. Our data suggest that severity of illness, rapid microbiologic eradication, and source control are crucial factors in the outcomes of patients with CRKP bacteremia.

A review of antimicrobial control strategies in hospitalized and ambulatory pediatric populations

Antimicrobial resistance is a growing crisis in healthcare. Various antimicrobial stewardship strategies have been used to control antibiotic use in efforts to reduce antibiotic resistance. We conducted a systematic review of antimicrobial stewardship programs in pediatric settings. Twenty-eight published studies met inclusion criteria. The majority (21 of 28) of studies had positive outcomes, but only 6 measured the impact of interventions on antimicrobial resistance. Prescriber education for a specific diagnosis (eg, otitis media) was the most effective intervention in the outpatient setting. Ancillary laboratory tests (eg, rapid diagnostic assays for viral pathogens) were most effective in the inpatient setting. Most studies had moderate to high risk of bias, mainly because of selection bias, inadequate preintervention data for time series analysis, and contamination between treatment groups. To date, there are a limited number of studies assessing antimicrobial stewardship in pediatric settings and these have heterogeneous study designs. Thus, it is difficult to determine the most effective interventions. Future studies should be designed to overcome the biases encountered in current publications.

Phase II, randomized, double-blind, multicenter study comparing the safety and pharmacokinetics of tefibazumab to placebo for treatment of Staphylococcus aureus bacteremia

Tefibazumab (Aurexis), a humanized monoclonal antibody that binds to the surface-expressed adhesion protein clumping factor A, is under development as adjunctive therapy for serious Staphylococcus aureus infections. Sixty patients with documented S. aureus bacteremia (SAB) were randomized and received either tefibazumab at 20 mg/kg of body weight as a single infusion or a placebo in addition to an antibiotic(s). The primary objective of the study was determining safety and pharmacokinetics. An additional objective was to assess activity by a composite clinical end point (CCE). Baseline characteristics were evenly matched between groups. Seventy percent of infections were healthcare associated, and 57% had an SAB-related complication at baseline. There were no differences between the treatment groups in overall adverse clinical events or alterations in laboratory values. Two patients developed serious adverse events that were at least possibly related to tefibazumab; one hypersensitivity reaction was considered definitely related. The tefibazumab plasma half-life was 18 days. Mean plasma levels were <100 microg/ml by day 14. A CCE occurred in six patients (four placebo and two tefibazumab patients) and included five deaths (four placebo and one tefibazumab patient). Progression in the severity of sepsis occurred in four placebo and no tefibazumab patients. Tefibazumab was well tolerated, with a safety profile similar to those of other monoclonal antibodies. Additional trials are warranted to address the dosing range and efficacy of tefibazumab.

Combination therapy with polymyxin B for the treatment of multidrug-resistant Gram-negative respiratory tract infections

BACKGROUND

The treatment of infections caused by multidrug-resistant (MDR) Gram-negative organisms poses a therapeutic challenge. The use of polymyxin B has been resurrected specifically for this purpose.

PATIENTS AND METHODS

We retrospectively reviewed the clinical and microbiological efficacy, and safety profile of polymyxin B in the treatment of MDR Gram-negative bacterial infections of the respiratory tract. Twenty-five critically ill patients received a total of 29 courses of polymyxin B administered in combination with another antimicrobial agent.

RESULTS

Patients were treated with intravenous, and/or aerosolized polymyxin B. Mean duration of polymyxin B therapy was 19 days (range 2-57 days). End of treatment mortality was 21%, and overall mortality at discharge was 48%. Nephrotoxicity was observed in three patients (10%) and did not result in discontinuation of therapy.

CONCLUSIONS

Polymyxin B in combination with other antimicrobials can be considered a reasonable and safe treatment option for MDR Gram-negative respiratory tract infections in the setting of limited therapeutic options.

Antimicrobial control programs

The use of broad spectrum antimicrobials, the emergence of multiresistant organisms, and the hospital drug costs associated with antimicrobials have all driven the need for institutions to develop strategies to control the use of antimicrobials. Formulary restrictions, prior approval mechanisms, treatment guidelines, order forms, stop orders, antimicrobial management teams, computer-assisted decision support tools, antimicrobial rotation, and combinations of these practices have all been evaluated as methods to encourage the appropriate use of these agents. While many programs have been successful in reducing antimicrobial costs without compromising patient care, limited data are available on the impact of these programs on the development of multiresistant organisms, particularly in neonatal intensive care units. The optimal means for controlling the emergence of resistance have yet to be determined, but ongoing surveillance of antimicrobial utilization and susceptibility patterns are necessary to identify opportunities for interventions, maximize patient care, and potentially minimize the development of resistance.

Vancomycin-resistant Enterococcus faecium meningitis successfully managed with linezolid: case report and review of the literature

Enterococci cause serious illness in immunocompromised patients and severely ill, hospitalized patients. Resistance to vancomycin has increased in frequency during the past few years. Limited therapeutic options are available for vancomycin-resistant enterococcal infections and the optimum therapy has not been established. We report a case of nosocomial vancomycin-resistant Enterococcus faecium meningitis in the setting of hyperinfection with Strongyloides stercoralis that was successfully treated with linezolid. We also review the previously reported cases of vancomycin-resistant E. faecium meningitis.

Delayed-onset ticlopidine-induced cholestatic jaundice

An 86-year-old man experienced a rash approximately 2 weeks after starting ticlopidine therapy, necessitating discontinuation of the drug. About 1 month later, despite discontinuation, he developed jaundice and liver test abnormalities. These resolved gradually over the next few months. Based on case reports and the drug's pharmacokinetic profile, a high index of suspicion for ticlopidine-induced jaundice is prudent in patients with recent exposure to the agent who have evidence of liver damage.