Due to the inconsistent correlation of vancomycin trough concentrations with 24-hour area under the curve (AUC) and a desire to reduce rates of vancomycin-associated acute kidney injury, an institutional guideline was implemented by the Antimicrobial Stewardship Team in September 2017 to monitor vancomycin using AUC. Three stages were utilized to organize the process: preparation, implementation, and evaluation. The preparation stage was used to present literature to key stakeholders, and pharmacy meetings focused on the development of a dosing and monitoring guideline. Along with institution-wide education, the implementation stage included information technology development and support. The evaluation stage was comprised of quality improvement and clinical research. Future plans include dissemination of the results and analyses. Numerous lessons were learned due to barriers experienced during the process, but the transition was successful.

Background: Evidence suggests the standard vancomycin trough goal of 15 to 20 mg/L for serious Staphylococcus aureus infections is associated with acute kidney injury, whereas appropriate monitoring of 24-hour area under the curve (AUC) may decrease nephrotoxicity. As a result, institutions have transitioned to AUC monitoring, the predictive pharmacokinetic/pharmacodynamic parameter of vancomycin to improve safety outcomes. However, this method may require increased pharmacist time and effort. Pharmacist perception of the practice change is largely unknown and warrants investigation. Methods: An electronic survey was disseminated via e-mail to pharmacists 5 months post-AUC implementation. Items of interest were focused on pharmacist perception, including quantity of patients monitored using AUC, justification of the practice change, differences in efficacy and safety, and changes in monitoring time requirements. Results: The pharmacist survey was distributed to 196 pharmacists and 84 responded (43% response rate). Eighty-one pharmacists had monitored patients using AUC methods. Sixty-nine percent of these respondents perceived the change to result in increased or slightly increased patient safety, 27% described no difference, and 4% stated safety was decreased or slightly decreased. Forty-two percent perceived the transition to result in increased or slightly increased efficacy, while 48% noted no difference and 10% responded that efficacy was decreased or slightly decreased. Pharmacists stated the creation of an institutional calculator decreased the time required to calculate AUC. Conclusion: After the change to AUC monitoring, pharmacists perceived improvements in safety outcomes while efficacy was at least similar if not increased.

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Introduction: Mycobacterium abscessus is a non-tuberculous mycobacterium ubiquitous in the environment, which rarely causes endovascular infections. We report the first published case, to the best of our knowledge, of M. abscessus endocarditis in a patient with Marfan syndrome. Case presentation: A female in her 40s with a history of Marfan syndrome status-post mechanical aortic valve replacement and a chronic indwelling venous access port presented with a 2-day history of confusion and 3-month history of intermittent fevers. Her blood cultures grew M. abscessus. An echocardiogram revealed a 1 cm vegetation attached to the prosthetic aortic valve and a perivalvular abscess. The patient was started on imipenem/cilastatin, amikacin and linezolid. Her course was complicated by septic emboli to the brain and subarachnoid haemorrhage. She was deemed a poor surgical candidate. The patient ultimately developed cardiac arrest and died. Conclusion: M. abscessus endocarditis is rare and is associated with high mortality. Late recognition of M. abscessus as a causative pathogen of endovascular infection, extensive antimicrobial resistance and limited surgical options at the time of diagnosis make the management of M. abscessus endocarditis very challenging.