Eric Gillett

Objective: To compare clinical outcomes in adults with uncomplicated enterococcal bacteremia treated with intravenous (IV) therapy alone versus an early oral (PO) transition and evaluate treatment characteristics and safety outcomes. Design: Retrospective cohort study between January 1, 2021, and August 1, 2024. The primary outcome was clinical cure at 90 days after antibiotic completion. Secondary outcomes included treatment failure, infection-related readmission, hospital length of stay (HLOS), and 90-day mortality. Setting: Massachusetts General Hospital and Brigham and Women’s Hospital, two tertiary care centers in Boston, MA. Patients: Adult patients with at least one positive blood culture with Enterococcus spp. Patients were excluded if they had polymicrobial or persistent bacteremia, invasive infection, incomplete source control, died before completing therapy, or received fewer than 7 days of antibiotics. Results: 209 patients were included, of which 119 received IV therapy alone and 90 underwent early PO transition. Gastrointestinal (41.6%) and genitourinary (32.1%) sources were most common, and 86 patients (41.1%) had immunocompromising conditions. Clinical cure was similar between the IV and early PO transition groups (73.9% vs 82.2%; P = .156), with no significant differences in secondary and safety outcomes. HLOS was significantly shorter in the early PO transition group (9 days vs 20 days; P < .001). Conclusion: Early PO transition appears to be a safe and effective strategy for uncomplicated enterococcal bacteremia and was associated with reduced HLOS.

Human immunodeficiency virus (HIV) viral suppression was evaluated after receipt of crushed or dissolved bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) administered via enteral tube during hospitalization. Eighty-nine percent of patients (17/19) were virally suppressed (<200 copies/mL) within 1 year of receiving B/F/TAF via tube, suggesting that administration via tube is a reasonable alternative to changing antiretroviral regimens.

In outpatient parenteral antimicrobial therapy, weekly lab monitoring is often standard practice, even for antimicrobials with low complication rates. We reviewed 420 patients treated with cefazolin: lab abnormalities associated with readmission or treatment changes occurred in 2% of patients. Reduced-frequency monitoring may be reasonable for patients treated with cefazolin outpatient.

Background: Current vancomycin monitoring guidelines recommend monitoring 24-hour area under the concentration-time curve (AUC) to minimum inhibitory concentration ratios for patients with serious methicillin-resistant Staphylococcus aureus infections. However, there are sparse data on the safety, feasibility, and efficacy of vancomycin AUC monitoring for outpatients. Traditional AUC pharmacokinetic calculations require 2 concentrations, while bayesian software allows for single-concentration AUC estimations. Methods: We conducted a single-center, quasi-experimental, interrupted time series study of patients enrolled in the outpatient parenteral antimicrobial therapy program at our institution for vancomycin management. Our institution implemented a pharmacist-driven vancomycin AUC monitoring program from September 2019 to February 2020, and again from September 2022 to March 2023. Patients enrolled underwent vancomycin monitoring using an AUC goal of 400–600 mg⋅h/L, estimated through bayesian modeling. Patients enrolled in the outpatient parenteral antimicrobial therapy program from July 2021 through August 2022 for trough-based monitoring were used for comparison. The primary outcome was nephrotoxicity incidence, defined as a serum creatinine increase by ≥0.5 mg/dL or ≥50% during outpatient vancomycin therapy. Results: We enrolled 63 patients in the AUC group and 60 patients in the trough-based group. Nephrotoxicity was significantly lower in the AUC cohort (6.3% vs 23.3%; P = .01). The number of unusable vancomycin concentrations was also significantly lower in the AUC cohort (0% vs 6%; P < .01). There was no difference in composite 90-day all-cause mortality or readmission (33.3% vs 38.3%; P = .56). Conclusions: Following implementation of a pharmacist-driven AUC monitoring program, patients were less likely to develop nephrotoxicity during outpatient vancomycin therapy.