b Nafcillin and oxacillin are used interchangeably in clinical practice, yet few studies have evaluated the safety of these two agents. Our objective was to compare the differential tolerabilities of nafcillin and oxacillin among hospitalized patients. We conducted a retrospective cohort study of all patients who received 12 g/day of nafcillin or oxacillin for at least 24 h. Two hundred twentyfour patients were included. Baseline characteristics and comorbidities were similar among patients receiving nafcillin (n ‫؍‬ 160) and those receiving oxacillin (n ‫؍‬ 64). Hypokalemia, defined as a potassium level of <3.3 mmol/liter or <2.9 mmol/liter or as a >0.5-mmol/liter decrease from the baseline level, occurred more frequently among patients who received nafcillin (51%, 20%, and 56%, respectively) than among those who received oxacillin (17%, 3%, and 34%, respectively; P < 0.0001, P ‫؍‬ 0.0008, and P ‫؍‬ 0.005, respectively). By multivariate logistic regression analysis, receipt of nafcillin was an independent predictor of severe hypokalemia (odds ratio [OR] ‫؍‬ 6.74; 95% confidence interval [CI], 1.46 to 31.2; P ‫؍‬ 0.02). Rates of hepatotoxicity did not differ between groups; however, acute kidney injury occurred more commonly with nafcillin than with oxacillin (18% versus 6%; P ‫؍‬ 0.03). Overall, 18% of patients who received nafcillin discontinued therapy prematurely due to adverse events, compared to 2% of patients who received oxacillin (P ‫؍‬ 0.0004). Nafcillin treatment is associated with higher rates of adverse events and treatment discontinuation than oxacillin among hospitalized adult patients. These findings have important implications for patients in both inpatient and outpatient settings, particularly patients who require long-term therapy and cannot be monitored routinely. Future randomized controlled studies evaluating the efficacy, costs, and tolerability of nafcillin versus oxacillin are warranted.

We conducted a retrospective study to determine the risk factors associated with vancomycin-resistant enterococci (VRE) acquisition/infection in newly diagnosed acute myeloid leukemia and myelodysplastic syndrome patients undergoing chemotherapy with the 7 + 3 regimen of cytarabine and idarubicin. Although only 2.5% (6/235) patients were colonized with VRE on admission, 59% (134/229) of patients acquired VRE during their hospitalization. Multivariable analysis identified the use of intravenous vancomycin (p = .024; HR: 1.548) and cephalosporin (p = .009; HR: 1.596) as the risk factors for VRE acquisition. VRE infection developed in 14% (33/229) of patients, with bloodstream infections accounting for 82% (27/33) of cases. VRE infection occurred in 25/126 (20%) of the VRE-colonized patients, but only 8/103 (8%) of those who were not (p = .01). Our study provides the evidence for the role of intravenous cephalosporin and vancomycin in VRE acquisition and highlights the clinical significance of VRE colonization in these patients.

Rhabdomyolysis is a clinical syndrome associated with electrolyte abnormalities and myoglobinuria. Signs and symptoms of rhabdomyolysis include elevated creatinine phosphokinase (CPK) and aspartate transaminase (AST), muscle pain, urine discoloration, fatigue, nausea, vomiting and fever. 1 If untreated, rhabdomyolysis can lead to renal failure and death. 2 Rhabdomyolysis can occur as a result of traumatic injury or chemical causes. 1-3 Prior case reports describing fluoroquinolone-induced rhabdomyolysis occurred within the first week of fluoroquinolone initiation. 4-10 Most of these involved the co-administration of simvastatin and either ciprofloxacin or levofloxacin. 4,5,7-10 We report a rare case of delayed-onset acute rhabdomyolysis that coincided with initiation of levofloxacin in a patient on long-term atorvastatin. A literature search of articles published in English through August 2018 was conducted using PubMed to identify other publications on fluoroquinolone-induced rhabdomyolysis with and without concomitant statin therapy. The following search terms were used alone and in combination: rhabdomyolysis, fluoroquinolone, statin, levofloxacin, atorvastatin. Citations of included articles were also reviewed to identify additional publications. | C A S E DE SCRIP TI ONA 65-year-old white male presented to an outside hospital with complaints of right knee pain, swelling, subjective fevers, chills, and inability to bear weight in the setting of prior right total knee arthroplasty. He was started on vancomycin and aztreonam for empiric treatment of a right knee prosthetic joint infection and was subsequently transferred to our facility for surgical intervention. The

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