Reprint of Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors.

OBJECTIVES: The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP). PRACTICE DESCRIPTION: This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods. RESULTS: The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11). CONCLUSION: Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors.

OBJECTIVES: The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP). PRACTICE DESCRIPTION: This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods. RESULTS: The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11). CONCLUSION: Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

A Case of Pulmonary Histoplasmosis Presenting with Hypercalcemia and Altered Mental Status in a Patient Following Allogeneic Hematopoietic Stem Cell Transplantation.

BACKGROUND Histoplasmosis results from the inhalation of spores from the fungus, Histoplasma capsulatum. A case is presented of pulmonary histoplasmosis associated with altered mental state and hypercalcemia following allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia (AML). CASE REPORT A 75-year-old man with a five-day history of AML treated with allogeneic hematopoietic stem cell transplantation, presented with weakness, fatigue, and slow mentation. Computed tomography (CT) of the brain was unremarkable. Laboratory investigations showed serum albumin of 2.9 g/dL, calcium of 11.6 mg/dL, ionized calcium of 1.55 mmol/L, parathyroid hormone (PTH) <6.3 pg/mL, and 25-hydroxy vitamin D of 14.4 ng/mL. Treatment began with intravenous cefepime 1 gm bid, normal saline, and the bisphosphonate, pamidronate, administered as a single dose. Three days later, his clinical status declined. He developed a dry productive cough, his oxygen saturation (O2 Sat) was 90%, and his mental status worsened. Chest CT showed diffuse bilateral lung infiltrates with ground glass opacities. Bronchioalveolar lavage and transbronchial biopsy were negative for Pneumocystis jiroveci pneumonia (PJP). The CMV rival load was 195 IU/mL. Urinalysis for Histoplasma antigen and the Fungitell® assay were positive. Treatment commenced with intravenous voriconazole (250 mg, bid) and ganciclovir (5 mg/kg, bid). A left lower lobe transbronchial lung biopsy was positive for Histoplasma capsulatum and negative for CMV. CONCLUSIONS This case report has highlighted the need for awareness of the diagnosis of histoplasmosis in patients with allogeneic hematopoietic stem cell transplantation who present with an altered mental state in the setting of hypercalcemia.

Native valve infective endocarditis due to Micrococcus luteus in a non-Hodgkin's lymphoma patient.

Micrococcus species are typically considered contaminants from skin and mucous membranes. However, especially in severely immunocompromised patients, a blood culture with Micrococcus could be the cause of a significant infection. We report a 65-year-old female with non-Hodgkin's lymphoma who developed native valve infective endocarditis due to Micrococcus luteus. There is no defined therapeutic regimen for infective endocarditis due to Micrococcus luteus; however, our patient was successfully treated for six weeks with vancomycin and rifampin. To our knowledge, there is only one other case report of native valve endocarditis due to Micrococcus luteus.

Association Between Cardiac Surgery and Mortality Among Patients With Infective Endocarditis Complicated by Sepsis and Septic Shock.

BACKGROUND: Sepsis and septic shock are common presentations of infective endocarditis (IE), but little is known about clinical characteristics in this group of patients, use of surgical treatment, and their associations with outcome. We sought to determine the influence of cardiac surgery (CS) on the outcome of patients with IE in different stages of sepsis severity. METHODS: Two hundred ninety four patients with definite IE native or prosthetic valve IE admitted between 2000 and 2011. Prospective evaluation using multivariable logistic regression to evaluate clinical characteristics and outcomes (in-hospital and 1-year mortality) in surgically and medically treated patients stratified by severity of sepsis and using new Sepsis-3 definitions. RESULTS: The presence of sepsis or septic shock during IE showed a statistical relationship with increased in-hospital mortality (odds ratio [OR] 8.915, P < 0.001 and OR 35.969, P < 0.001, respectively) after adjusting for other risk factors of poor outcomes (neurological complications, congestive heart failure, and Staphylococcus aureus IE). Surgical treatment had a positive influence on in-hospital mortality in patients with sepsis or septic shock and IE (OR 5.157, P < 0.001) as well as on 1-year survival (hazard ratio 3.092, P < 0.001). CONCLUSIONS: The presence of sepsis or septic shock as defined in Sepsis-3 definitions is associated with unfavorable outcomes in patients with IE. Surgical treatment has a positive effect on outcomes (in-hospital mortality and 1-year survival) in patients with IE and sepsis or septic shock.