Implementing a PNA FISH test to identify Candida species from yeast-positive blood cultures in conjunction with a pharmacy-driven antimicrobial stewardship protocol decreased the time to targeted antifungal therapy and the time to culture clearance.

Purpose The implementation of targeted interventions aimed at decreasing the frequency of antiretroviral errors in hospitalized patients with human immunodeficiency virus (HIV) is described. Summary A prospective investigation conducted at our institution reported at least one error in the initial antiretroviral regimen in 49 out of 68 patients (72%). Since this analysis, several interventions aimed at decreasing this error rate have been instituted including computer alerts for incorrect doses and drug interactions added to the pharmacy entry system, an educational pocket card distributed among the staff, addition of commercially available combination antiretroviral products to the hospital formulary, computerized physician ordering system updates to include common dosing regimen defaults, involvement of the infectious diseases consult service to evaluate prescribed regimens of newly admitted patients with HIV, and daily review of newly initiated antiretroviral regimens by a clinical pharmacist trained in HIV care. A prospective follow up analysis was conducted after these interventions were in place to evaluate their effectiveness. A total of 78 patients were identified during the study period and were included in the analysis. Twelve (15%) of the patients experienced at least one error in their initial drug regimen compared to 49 (72%) of the control patients from the data collected prior to the interventions (p < 0.001). Conclusion A significant reduction in the frequency of antiretroviral medication errors among hospitalized patients with HIV was observed after the implementation of several interventions. The striking impact of these interventions supports a comprehensive and proactive approach to preventing antiretroviral medication errors in hospitalized patients with HIV.

Clostridium difficile infection (CDI) has become a significant healthcare-associated infection and is strongly associated with antibiotic use. Practice guidelines have recently been revised incorporating updated recommendations for diagnosis, treatment, and prevention. Areas covered: This review discusses updated aspects of CDI management. New and emerging pharmacologic options for treatment and prevention are reviewed. Expert opinion: Metronidazole is associated with lower rates of treatment success compared to vancomycin and should no longer be used as primary therapy for the first episode of CDI or recurrent disease. Vancomycin or fidaxomicin are now recommended for first-line therapy for most cases of CDI. Fecal microbiota transplant is effective and safe for the treatment of recurrent CDI. Evidence supports the use of fidaxomicin and bezlotoxumab for prevention of recurrent CDI; however, the costs associated with these therapies may limit their use. Validated risk prediction tools are needed to identify patients most likely to benefit from these treatments. Future advancements in microbiota targeting treatments will emerge as promising alternatives to standard CDI treatments. Antibiotic stewardship and infection control measures will remain essential components for CDI management.

To our knowledge, there are no published case reports of severe sepsis caused by A. haemolyticum. While treatment options are numerous, we recommend the use of intravenous penicillin or a cephalosporin as first-line pharmacologic management of deep-seated infections caused by this rare organism.

Bloodstream infections (BSI) are a leading cause of morbidity and mortality. In 2009, BSI were the cause of nearly 36,000 deaths in the United States (1). Health care-associated BSI are a major contributor to these statistics, being associated with nearly 75,000 infections a year with a mortality rate of approximately 25% (2). Enterococci are the third leading cause of health careassociated BSI (3), and inappropriate antimicrobial therapy has been shown to be an independent risk factor for the increased mortality of BSI (4). The Nanosphere Verigene Gram-positive blood culture (BC-GP) assay (Nanosphere, Northbrook, IL) is an on-demand FDA-cleared test for the identification of 15 targets from positive blood culture bottles. Previous studies have shown this assay to be an effective method for determining the identity of Gram-positive organisms, showing 92 to 95% overall concordance for organism identification (5, 6); however, the implementation of an algorithm for treatment based on BC-GP test results has not been proposed. The current work focuses on the performance of the assay specifically in cultures where streptococci and enterococci are suspected based on the primary Gram stain and on the algorithm we have developed for treatment based on the BC-GP results.We first performed an evaluation of the BC-GP assay on the Nanosphere Verigene system. Routine blood cultures were collected using FAN aerobic (FA), pediatric FAN (PF), and standard anaerobic (SA) bottles and subsequently incubated on the BacT/ Alert (bioMérieux, Durham, NC) system. Positive blood cultures were Gram stained, plated onto solid medium, and stored upright at 35°C for up to 5 days. Subcultures were evaluated according to standard laboratory protocols, and organisms were identified using a combination of morphological and phenotypic methods as well as matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (Vitek MS; bioMérieux). Notably, the Vitek MS accurately distinguishes between Streptococcus pneumoniae and Streptococcus mitis/Streptococcus oralis (7). Positive blood cultures with a Gram stain of Gram-positive cocci in pairs and/or chains were further evaluated with the BC-GP assay according to the manufacturer's recommendations. The BC-GP targets analyzed include Enterococcus faecalis, Enterococcus faecium, Streptococcus spp., Streptococcus agalactiae, Streptococcus anginosus group, S. pneumoniae, Streptococcus pyogenes, and the resistance determinants vanA and vanB.Seventy-eight consecutive positive blood cultures from 74 patients with an initial Gram stain result containing Gram-positive cocci in pairs and/or chains were evaluated with the BC-GP assay, of which 72 had at least one target detected. Of the six cultures for which no target was detected, three grew organisms (Acinetobacter sp., Atopobium sp., B. cereus group) for which the assay does not target, and two grew Streptococcus vestibularis, which has not been evaluated by the manufacturer according to the package insert. The remaining negative BC...