This report describes the first case of vancomycin-resistant Enterococcus pneumonia complicated with empyema and lung abscess in an HIV patient and reviews previously published cases of Enterococcus pleuro-pulmonary infection. Our case highlights the rarity of this entity and reviews the risk factors for Enterococcus pleuro-pulmonary infections.

Extended-infusion piperacillin-tazobactam has been used as a method of maximizing pharmacodynamic target attainment. Use of higher doses of piperacillin-tazobactam may be a reasonable method to compensate for drug loss due to residual volumes in large-bore intravenous pump tubing.

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BackgroundThe CDC encourages all long-term care facilities (LTCF) to develop antibiotic stewardship programs (ASP) consisting of seven core elements (CE). These CE include leadership commitment, accountability, drug expertise, action, tracking, reporting and education. However, action include three essential sub-elements (SE): policy development, practice implementation and pharmacist involvement. Similarly, tracking has two major SE; antibiotic use and outcome measures. Typically, a multi-component CE is considered met if any of the SE is present. We evaluated application of a strict definition that requires all major SE to be present for the action and tracking CE to be considered met.MethodsA group of consultant pharmacists (CP) was trained to evaluate and lead ASP in their LTCF. Baseline ASP evaluation was conducted by CP in 29 LTCF using the CDC CE checklist between November 2017 and January 2018. CE credits were assigned to LTCF ASP using conventional (any SE) and strict definitions (all SE required). Results were compared among LTCF ASP using both definitions.ResultsNone of the LTCF has all seven CE regardless of the definition. A median of two CE (range 1–6) were present based on conventional definition (CD) and 1 (range 0–5) using the strict definition (SD). Less than a quarter of LTCF (n = 6, 20.6%) met five or more CE with the CD and only one (3.5%) using the SD. Interestingly, when utilizing the CD, all (100%) LTCF met at least one CE as compared with only 16 (55.1%) when using the SD. The action CE is most frequently met when using CD and least frequently met when using SD (Figure 1). CP reviewing a proportion of antibiotic orders as a part of their monthly drug regimen review was the most common action and was met by 89.7% of LTCF. Only 2 (6.9%) LTCF had stewardship policies and 4 (13.8%) had implemented at least one stewardship practice. Similarly, 20 (69.0%) LTCF had tracking based on the CD with a majority (55.2%) tracking outcome measures and some (41.4%) tracking antibiotic use. However, only a quarter (27.6%) of LTCF were tracking both outcomes and antibiotic use. ConclusionMany LTCF have some components of action and tracking CE in place but are missing important SE. Data on CE should be collected in a manner that makes it easier to identify these deficiencies during LTCF ASP evaluation.Disclosures T. Vanschooneveld, Merck: Grant Investigator, Grant recipient. M. S. Ashraf, Merck & Co. Inc.: Grant Investigator, Research grant.

A 30-year-old man with advanced human immunodeficiency virusYinfection presented with worsening dysphagia and odynophagia of 4 months' duration. He had been on a revised combination antiretroviral regimen for 3 months with a recent CD4 count of 57 cells/mm 3 and human immunodeficiency virus viral load of less than 50 copies/mL. Esophagogastroduodenoscopy showed erosive esophagitis and esophageal ulcers. Histopathologic examination was negative for herpes viruses and cytomegalovirus but showed intracellular yeast consistent with histoplasmosis. Histoplasma antigenuria was more than 39 ng/mL, which confirmed the diagnosis of disseminated histoplasmosis. After 3 weeks of treatment with liposomal amphotericin B and significant improvement, antifungal therapy was changed to itraconazole suspension. Histoplasma capsulatum is well known to cause gastrointestinal involvement in patients with acquired immunodeficiency syndrome, but esophageal involvement is rare.