Eravacycline, the first four years: health outcomes and tolerability data for 19 hospitals in 5 U.S. regions from 2018 to 2022.

IMPORTANCE: The rise of multidrug-resistant (MDR) pathogens, especially MDR Gram-negatives, poses a significant challenge to clinicians and public health. These resilient bacteria have rendered many traditional antibiotics ineffective, underscoring the urgency for innovative therapeutic solutions. Eravacycline, a broad-spectrum fluorocycline tetracycline antibiotic approved by the FDA in 2018, emerges as a promising candidate, exhibiting potential against a diverse array of MDR bacteria, including Gram-negative, Gram-positive, anaerobic strains, and Mycobacterium. However, comprehensive data on its real-world application remain scarce. This retrospective cohort study, one of the largest of its kind, delves into the utilization of eravacycline across various infectious conditions in the USA during its initial 4 years post-FDA approval. Through assessing clinical, microbiological, and tolerability outcomes, the research offers pivotal insights into eravacycline's efficacy in addressing the pressing global challenge of MDR bacterial infections.

Evaluation of traditional initial vancomycin dosing versus utilizing an electronic AUC/MIC dosing program.

BACKGROUND: Area under the curve to minimum inhibitory concentration (AUC/MIC) has been recommended by the 2020 updated vancomycin guidelines for dosing vancomycin for both efficacy and safety. Previously, AUC/MIC has been cumbersome to calculate so surrogate trough concentrations of 15-20 mg/dL were utilized. However, trough-based dosing is not a sufficient surrogate as AUC/MIC targets of 400-600 can usually be reached without achieving troughs of 15-20 mg/dL. Targeting higher trough levels may also lead to adverse events including acute kidney injury (AKI) and nephrotoxicity. OBJECTIVE: To compare the mean total first day vancomycin dose in traditional trough-based dosing versus dosing recommended by an AUC/MIC dosing program. METHODS: Adult inpatients who received at least 24 hours of IV vancomycin treatment were included in this single-center, retrospective cohort study. The primary endpoint was difference in mean total first day vancomycin dose in milligrams (mg) received between patients' traditional trough-based dosing and recommended dose via AUC/MIC electronic dosing calculator. Patients served as their own control by analyzing both actual dose received and dose recommended by the electronic AUC/MIC program. Rates of vancomycin induced adverse events, including acute kidney injury, elevated steady-state trough concentrations, and Red Man's syndrome were also compared between patients who received doses consistent with the AUC/MIC dosing recommendation versus those who did not. RESULTS: 264 patients were included in this study. Initial 24-hour vancomycin exposure was significantly lower with the recommended AUC/MIC dose versus the dose received (2380.7; SD 966.6 mg vs 2649.6; SD 831.8 mg, [95% CI 114.7:423.1] p=0.0007). CONCLUSIONS: Utilizing an electronic AUC/MIC vancomycin dosing calculator would result in lower total first day vancomycin doses.

Evaluation of traditional initial vancomycin dosing versus utilizing an electronic AUC/MIC dosing program

BACKGROUND: Area under the curve to minimum inhibitory concentration (AUC/MIC) has been recommended by the 2020 updated vancomycin guidelines for dosing vancomycin for both efficacy and safety. Previously, AUC/MIC has been cumbersome to calculate so surrogate trough concentrations of 15-20 mg/dL were utilized. However, trough-based dosing is not a sufficient surrogate as AUC/MIC targets of 400-600 can usually be reached without achieving troughs of 15-20 mg/dL. Targeting higher trough levels may also lead to adverse events including acute kidney injury (AKI) and nephrotoxicity. OBJECTIVE: To compare the mean total first day vancomycin dose in traditional trough-based dosing versus dosing recommended by an AUC/MIC dosing program. METHODS: Adult inpatients who received at least 24 hours of IV vancomycin treatment were included in this single-center, retrospective cohort study. The primary endpoint was difference in mean total first day vancomycin dose in milligrams (mg) received between patients' traditional trough-based dosing and recommended dose via AUC/MIC electronic dosing calculator. Patients served as their own control by analyzing both actual dose received and dose recommended by the electronic AUC/MIC program. Rates of vancomycin induced adverse events, including acute kidney injury, elevated steady-state trough concentrations, and Red Man's syndrome were also compared between patients who received doses consistent with the AUC/MIC dosing recommendation versus those who did not. RESULTS: 264 patients were included in this study. Initial 24-hour vancomycin exposure was significantly lower with the recommended AUC/MIC dose versus the dose received (2380.7; SD 966.6 mg vs 2649.6; SD 831.8 mg, [95% CI 114.7:423.1] p = 0.0007). CONCLUSIONS: Utilizing an electronic AUC/MIC vancomycin dosing calculator would result in lower total first day vancomycin doses

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Patient preferences for treatment of acute bacterial skin and skin structure infections in the emergency department.

BACKGROUND: Limited research has assessed patient preferences for treatment disposition and antibiotic therapy of acute bacterial skin and skin structure infection (ABSSSI) in the emergency department (ED). Understanding patient preference for the treatment of ABSSSI may influence treatment selection and improve satisfaction. METHODS: A survey was conducted across 6 US hospital EDs. Patients with ABSSSI completed a baseline survey assessing preferences for antibiotic therapy (intravenous versus oral) and treatment location. A follow-up survey was conducted within 30-40 days after ED discharge to reassess preferences and determine satisfaction with care. RESULTS: A total of 94 patients completed both baseline and follow-up surveys. Sixty (63.8%) participants had a history of ABSSSI, and 69 (73.4%) were admitted to the hospital. Treatment at home was the most common preference reported on baseline and follow-up surveys. Patients with higher education were 82.2% less likely to prefer treatment in the hospital. Single dose intravenous therapy was the most commonly preferred antibiotic regimen on baseline and follow-up surveys (39.8 and 19.1%, respectively). Median satisfaction scores for care in the ED, hospital, home, and with overall antibiotic therapy were all 8 out of a maximum of 10. CONCLUSIONS: In these patients, the most common preference was for outpatient care and single dose intravenous antibiotics. Patient characteristics including higher education, younger age, and current employment were associated with these preferences. Opportunities exist for improving ABSSSI care and satisfaction rates by engaging patients and offering multiple treatment choices.

Variability in Emergency Medicine Provider Decisions on Hospital Admission and Antibiotic Treatment in a Survey Study for Acute Bacterial Skin and Skin Structure Infections: Opportunities for Antimicrobial Stewardship Education.

BACKGROUND: Acute bacterial skin and skin structure infections (ABSSSIs) are a frequent cause of emergency department (ED) visits. Providers in the ED have many decisions to make during the initial treatment of ABSSSI. There are limited data on the patient factors that influence these provider decisions. METHODS: An anonymous survey was administered to providers at 6 EDs across the United States. The survey presented patient cases with ABSSSIs ≥75 cm2 and escalating clinical scenarios including relapse, controlled diabetes, and sepsis. For each case, participants were queried on their decision for admission vs discharge and antibiotic therapy (intravenous, oral, or both) and to rank the factors that influenced their antibiotic decision. RESULTS: The survey was completed by 130 providers. For simple ABSSSI, the majority of providers chose an oral antibiotic and discharged patients home. The presence of recurrence or controlled diabetes resulted in more variation in responses. Thirty-four (40%) and 51 (60%) providers chose intravenous followed by oral antibiotics and discharged the recurrence and diabetes cases, respectively. Presentation with sepsis resulted in initiation with intravenous antibiotics (122, 95.3%) and admission (125, 96.1%) in most responses. CONCLUSIONS: Variability in responses to certain patient scenarios suggests opportunities for education of providers in the ED and the development of an ABSSSI clinical pathway to help guide treatment.

Urinary Catheter Colonization by Multidrug-Resistant Cedecea neteri in Patient with Benign Prostatic Hyperplasia.

Cedecea neteri, a member of the Enterobacteriaceae family, has only been identified as a human pathogen in a few previous clinical cases, thus complicating assessment of this organism's pathogenicity and medical relevance. Documented infections attributed to C. neteri primarily involved bacteremia in severely immunocompromised patients. We report a rare case of urinary catheter colonization by a multidrug-resistant C. neteri strain in a patient of advanced age with benign prostatic hyperplasia and other chronic comorbidities. This C. neteri isolate was resistant or intermediate to second-generation cephalosporins, penicillins, and certain ß-lactamase inhibitor/ß-lactam combinations. Analysis of whole genome sequence information for a representative C. neteri strain indicated the presence of multiple open reading frames with sequence similarity to ß-lactamases, including a chromosome-encoded AmpC ß-lactamase and metallo-ß-lactamases, consistent with the resistance phenotype of this bacterium. The presence of an AmpR homolog suggests that the C. neteriampC may be inducible in response to ß-lactam exposure. Molecular insights into antibiotic resistance traits of this emerging opportunistic pathogen will be important for administering adequate antibiotic treatment to ensure favorable patient outcomes.

Pharmacy student involvement in a transition of care program.

BACKGROUND AND PURPOSE: Cape Fear Valley Medical Center (CFVMC) implemented a Community Paramedic Program (CPP) to improve the transition of hospitalized patients to the home setting. In this program, paramedics conduct home visits for 30 days after qualifying patients are discharged. This article describes pharmacy services provided to CPP patients by fourth-year pharmacy students on Advanced Pharmacy Practice Experiences (APPE) that assisted with home visits. EDUCATIONAL ACTIVITY AND SETTING: Students were oriented to the CPP and patient interview technique was assessed through a role-play scenario. A standardized form was created to record drug-related problems (DRP) identified and patient education provided to patients. The primary outcome describes types of DRP identified and education provided. Secondary outcomes compare the types and average number of DRP per patient identified by students as compared to the standard of care (pharmacist review of medications electronically) and trends in patients readmitted within 30 days following discharge. FINDINGS: Eleven students visited 124 patients and recorded 145 DRP. Extra/continuation of medications stopped at discharge and issues related to medication safety were the most common DRP. The most frequent type of education provided was medication use related. On average, students provided one counseling session per patient. DISCUSSION AND SUMMARY: Student involvement is an added benefit to the CPP by providing face to face education and re-assessment of medications at follow-up visits. This article summarizes a unique teaching platform utilizing students to extend care. Real world experiences in programs like the CPP provide students the opportunity to sharpen critical thinking and problem-solving skills necessary for maturing professionally.

The role of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea.

For the treatment of Clostridium difficile-associated diarrhea (CDAD), metronidazole and vancomycin remain the most commonly used agents. The major advantage of metronidazole is its low cost, while the advantage of oral vancomycin is a more favorable pharmacokinetic profile. The epidemiology and clinical severity of CDAD have changed due to the emergence of a hypervirulent strain (BI/NAP1/027). In 2010, the Infectious Diseases Society of America/Society for Health Care Epidemiology of America expert panel defined severe CDAD and recommended oral vancomycin to treat these patients. Metronidazole remains the preferred agent for treatment of mild to moderate CDAD.

Multidrug-resistant Ewingella americana: a case report and review of the literature.

OBJECTIVE: To describe and report a case of multidrug-resistant Ewingella americana associated with exacerbation of chronic obstructive pulmonary disease (COPD). CASE SUMMARY: A 77-year-old female presented to her physician with shortness of breath and an initial assessment of pneumonia. Her past medical history included COPD, Mycobacterium tuberculosis infection, recent Mycobacterium avium infection, and Crohn's disease. Blood and urine cultures revealed no growth; however, a sputum culture later revealed multidrug-resistant E. americana. The patient was ultimately treated with trimethoprim/sulfamethoxazole (TMP/SMX), with complete resolution of symptoms following a 10 day course. DISCUSSION: E. americana is a rare gram-negative bacillus that has infrequently been reported to cause infection. This organism has been reported in humans in the blood, sputum, conjunctiva, wounds, and peritoneal fluid. In several of these cases, as well as in our case, this organism appeared to occur more frequently in immunocompromised patients. Although generally susceptible to most antibiotics, our patient's organism was resistant to all antibiotics tested, with the exception of TMP/SMX, ticarcillin/clavulanate, and cefotetan. CONCLUSIONS: To our knowledge, this is only the second case of an E. americana respiratory infection, and the only one in which multidrug resistance has been reported.