A comparison of safety and outcomes with cefazolin versus nafcillin for methicillin-susceptible Staphylococcus aureus bloodstream infections.

BACKGROUND: Methicillin-susceptible Staphylococcus aureus (MSSA) is a frequent cause of bloodstream infections (BSI). Treatment with nafcillin (NAF) has been preferred to cefazolin (CFZ). However, comparable outcomes have been found with CFZ with possibly lower risk for side-effects. This study compared safety and effectiveness of NAF versus CFZ for MSSA BSI. METHODS: This single center retrospective study evaluated adults admitted with MSSA BSI who received NAF or CFZ. Patients receiving ≥24 h of antibiotics were included for safety analyses. Patients receiving NAF or CFZ for ≥75% of a 14 day minimum treatment course were assessed for clinical effectiveness. The primary safety outcome was incidence of renal toxicity with multiple secondary safety endpoints. Clinical success was defined as symptom resolution, repeat negative cultures, lack of additional therapy for presumed failure, and lack of recurrence within 30 days. RESULTS: A total of 130 patients receiving NAF (n = 79) or CFZ (n = 51) were included for safety analysis. Of those, 90 met criteria for effectiveness assessment (NAF n = 40, CFZ n = 50). Baseline characteristics were well matched. NAF was associated with a higher incidence of nephrotoxicity compared to CFZ (25% vs. 2%, RR 1.31, 95% CI 1.15-1.5, p < 0.001), allergic reactions (p = 0.01) and a trend for hepatotoxicity (p = 0.08). Clinical success was achieved in 82% NAF and 94% CFZ treated patients (p = 0.1). CONCLUSION: CFZ was associated with less nephrotoxicity and no difference in clinical success compared to NAF for MSSA BSI. A prospective study comparing NAF to CFZ for MSSA BSI should be conducted to elucidate differences in therapies.

Oral Vancomycin Prophylaxis as Secondary Prevention Against Clostridioides difficile Infection in the Hematopoietic Stem Cell Transplantation and Hematologic Malignancy Population.

Clostridioides difficile infection (CDI) is a common complication in the hematopoietic stem cell transplantation (HSCT) and hematologic malignancy (HM) population. CDI is associated with increased hospital length of stay, health care and societal costs, morbidity, and mortality. Identifying strategies for secondary prevention of CDI is of extreme importance in the HSCT/HM population. In this study, our primary objective was to evaluate the effectiveness and safety of an oral vancomycin prophylaxis (OVP) protocol for secondary prevention of CDI in a retrospective cohort of adult autologous/allogeneic HSCT recipients and patients with HM who did not undergo HSCT with a first CDI episode treated with concomitant broad-spectrum antibiotics (BSA). Patients were diagnosed and treated for CDI as inpatients and/or outpatients and were divided into 2 groups based on a preprotocol versus postprotocol analysis: the OVP group, comprising patients who received planned monotherapy with oral vancomycin 125 mg every 6 hours for 14 days for a first episode of CDI and subsequently received OVP posttreatment and a no OVP (NOVP) group, comprising patients who received planned monotherapy with oral vancomycin 125 mg every 6 hours for 14 days for a first episode of CDI and subsequently did not receive OVP posttreatment. OVP was defined as vancomycin 125 mg every 12 hours for up to 7 days after BSA discontinuation. The primary endpoint was recurrent CDI (rCDI), defined as symptoms of loose stools/diarrhea with high clinical suspicion for CDI prompting empiric therapy within 60 days of completion of treatment/prophylaxis for the first CDI episode. The incidence of vancomycin-resistant enterococcal (VRE) infection and 60-day mortality were also compared between the 2 groups. Multivariate logistic regression was created from associated variables to identify independent associations with rCDI. A total of 50 patients were included, 21 in the OVP group (42%) and 29 in the NOVP group (58%). The mean patient age was 58 years, and the cohort was 60% male and 86% Caucasian. HSCT was performed in 60% of the patients, and 76% of CDI cases were diagnosed during hospitalization. The rate of rCDI was significantly lower in the OVP group compared with the NOVP group (5% [1 of 21] versus 35% [10 of 29]; P= .016), with no subsequent increase in VRE infection rate (14% [3 of 21] versus 10% [3 of 29]; P = .686). By multivariable logistic regression, rCDI was inversely associated with OVP (odds ratio [OR], .14; 95% confidence interval [CI], .007 to .994; P = .049) and directly associated with outpatient CDI diagnosis (OR, 8.72; 95% CI, 1.816 to 49.158; P = .007). No between-group differences were found in 60-day mortality (10% [2 of 21] for OVP versus 7% [2 of 29] for NOVP; P > 0.999). OVP appears to be safe and effective for secondary prevention of CDI in the HSCT/HM population. Prospective trials are needed to validate the effectiveness of OVP in this vulnerable population to prevent rCDI.

On- and off-label utilization of dalbavancin and oritavancin for Gram-positive infections.

BACKGROUND: Long-acting lipoglycopeptides (laLGPs) are FDA approved only for acute bacterial skin and skin structure infections (ABSSSIs). However, these antibiotics show promise for off-label use, reductions in hospital length of stay (LOS) and healthcare cost savings. OBJECTIVES: To assess the effectiveness, safety, impact on LOS and estimated cost savings from laLGP treatment for Gram-positive infections. METHODS: Retrospective cohort of adult patients who received at least one dose of laLGPs at the University of Colorado Health system. Descriptive statistics were utilized for analysis. RESULTS: Of 59 patients screened, 56 were included: mean age 47 years, 59% male and 30% injection drug users/polysubstance abusers (dalbavancin, 71%; oritavancin, 25%; both, 4%). Most common indications for laLGP: ABSSSIs (36%), osteomyelitis (27%) and endocarditis (9%). Most common isolated pathogens: MSSA and MRSA (25% and 19%, respectively), Enterococcus faecalis (11%) and CoNS (11%). Previous antibiotics were administered for a median of 13 days (IQR = 7.0-24.5 days) and laLGPs for a median of one dose (IQR = 1-2 doses). Ten (18%) patients were lost to follow-up. Clinical failure was found in 7/47 (15%) cases with adequate follow-up. Mild adverse effects occurred in six (11%) patients. Projected reduction in hospital LOS and health-system costs were 514 days (9.18 days/person average) and $963456.72 ($17204.58/person average), respectively. CONCLUSIONS: Prospective trials are needed to validate the use of these antibiotics for Gram-positive infections in practice, with the hope that they will reduce hospital LOS and the need for daily antibiotic infusions to provide alternative options for patients not qualifying for outpatient parenteral antimicrobial therapy.

Long-Acting Lipoglycopeptides: "Lineless Antibiotics" for Serious Infections in Persons Who Use Drugs.

BACKGROUND: Injection drug use is associated with serious infections. Due to challenges with medical management of addiction, relapses and additional infections are common. Persons who use drugs (PWUD) are more likely to leave against medical advice before completing treatment, which could result in treatment failure. Prolonged intravenous (IV) antimicrobial therapy in PWUD may be complicated by concern for IV catheter misuse, sometimes requiring prolonged hospitalization. Ideal alternatives would provide the following: (1) high success rate; (2) reduced rate of medical complications; (3) improved safety profiles; and (4) improved cost-effectiveness. Long-acting lipoglycopeptides present such opportunity for treatment of serious Gram-positive infections. METHODS: We performed a system-wide, retrospective analysis of adults admitted to University of Colorado Health from September 2015 to June 2018 and treated with dalbavancin or oritavancin based on clinical judgment of their treating physicians. RESULTS: Fifty-six patients met inclusion criteria (17 PWUD vs 39 non-PWUD). The PWUD group were younger, healthier by Charlson comorbidity index, more likely insured by Medicaid, and admitted for conditions requiring longer treatment. Ten patients were lost to follow-up. Of the patients with follow-up, clinical failure was met in 1 PWUD patient (6%) and 6 non-PWUD patients (15%) (P = .413). The median hospital length-of-stay reduction was 20 days (interquartile range [IQR], 10-30 days) in PWUD vs 11 days (IQR, 9-14 days) in non-PWUD; P = .133. Estimated median savings were $40 455.08 (IQR, $20 900.00-$62 700.00) in PWUD vs $19 555.08 (IQR, $15 375.08-$23 735.08) in non-PWUD; P = .065. CONCLUSIONS: Long-acting lipoglycopeptides may be equally effective as standard-of-care, present a safety advantage, and secure earlier discharge and significant cost-savings.

A Statewide Antibiotic Stewardship Collaborative to Improve the Diagnosis and Treatment of Urinary Tract and Skin and Soft Tissue Infections.

Background: Colorado hospitals participated in a statewide collaborative to improve the management of inpatient urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs). We evaluated the effects of the intervention on diagnostic accuracy and antibiotic use. Methods: The main collaborative outcomes were proportion of UTI diagnoses that met criteria for symptomatic UTI; exposure to fluoroquinolones (UTI only); duration of therapy (UTIs and SSTIs); and exposure to antibiotics with broad gram-negative activity (SSTIs only). Outcomes were compared between pre-intervention and intervention periods overall and by hospital. Secondary analyses were changes in outcome trends by time series analysis. Results: Twenty-six hospitals, including 9 critical access hospitals, participated in the collaborative. Data were reported for 4060 UTIs and 1759 SSTIs. Between the pre-intervention and intervention periods, the proportion of diagnosed UTIs that met criteria for symptomatic UTI was similar (51% vs 54%, respectively; P = .10), exposure to fluoroquinolones declined (49% vs 41%; P < .001), and the median duration of therapy was unchanged (7 vs 7 days; P = .99). Among SSTIs, exposure to antibiotics with broad gram-negative activity declined (61% vs 53%; P = .001) and the median duration of therapy declined (11 vs 10 days; P = .03). There was substantial variation in performance among hospitals. By time series analysis, only the declining trend of fluoroquinolone use was significant (P = .03). Conclusions: The collaborative model is a feasible approach to engage hospitals in a common antibiotic stewardship intervention. Performance improvement was observed for several outcomes but varied substantially by hospital.

Hypoglycemic effects of tramadol analgesia in hospitalized patients: a case-control study.

BACKGROUND: In outpatient populations, hypoglycemia has been associated with tramadol. We sought to determine the magnitude of risk for hypoglycemia associated with tramadol use in hospitalized patients. METHODS: During a 2-year period of observation, adult inpatients who received ≥1 dose of tramadol were identified and their medical records were reviewed. Patients were included if they had blood or plasma glucose (BG) concentrations measured on at least two occasions within five days after the initial administration of tramadol. A contemporary comparator group of hospitalized oxycodone recipients was similarly reviewed. RESULTS: Tramadol was administered to 2927 patients who met inclusion criteria. Among these, hypoglycemia (BG ≤70 mg/dL) was documented in 22 (46.8%) of 47 patients with type 1 diabetes, 113 (16.8%) of 673 patients with type 2 diabetes, and 103 (4.7%) of 2207 patients who did not have a diabetes mellitus diagnosis. In those without a diabetes diagnosis, the causality association between hypoglycemia and tramadol use was probable in 77 patients (3.5%). By comparison, hypoglycemia was documented in 8 (1.1%) of 716 matched oxycodone recipients without diabetes (p = 0.002). As compared with tramadol recipients who did not develop low BG concentrations, those who experienced tramadol-related hypoglycemia were relatively young (mean age 52.0 versus 59.8 years; p = 0.027) and predominantly female (74.0% versus 59.8%; p = 0.012). CONCLUSIONS: Tramadol use was causally associated with hypoglycemia in hospitalized patients. The proportion of patients without diabetes who developed hypoglycemia was higher among those who received tramadol than among those who received oxycodone. TRIAL REGISTRATION: Colorado Multiple Institutional Review Board Protocol № 15-2215. Registered/approved 8 December 2015.

Perioperative blood loss in total hip and knee arthroplasty: Outcomes associated with intravenous tranexamic acid use in an academic medical center.

OBJECTIVES: Clinical trials have reported decreased blood loss with the use of tranexamic acid during joint reconstruction. The purpose of this study was to assess the individual practice implications of tranexamic acid use in joint replacement surgery. METHODS: Health records of adults undergoing total knee arthroplasty and total hip arthroplasty over a 12-month period were retrospectively reviewed. The treatment group comprised patients who received intravenous tranexamic acid perioperatively. The control group comprised patients who did not receive tranexamic acid. RESULTS: Patients in the treatment group (n = 64) and the control group (n = 99) were well matched for demographics, orthopedic diagnosis, and comorbidities. In-hospital postsurgical mean decreases in hemoglobin concentrations were -4.05 g/dL and -4.94 g/dL in the treatment and control groups, respectively (p < 0.001). Postsurgical mean decreases in hematocrit levels were -11.2% and -14.2% in the treatment and control groups, respectively (p < 0.001). Three patients in the treatment group (5%) and 21 patients in the control group (21%) received red blood cell transfusions (p = 0.006). As compared to control, the relative risk of transfusion in the treatment group was 0.23 (95% confidence interval = 0.07-0.76) and the number needed to treat to avoid one transfusion was 7.0 (95% confidence interval = 3.8-14.4). No evidence of thromboembolism or other serious complications were observed in either group. CONCLUSIONS: In patients undergoing joint replacement surgery, perioperative administration of tranexamic acid was associated with diminished blood loss and lesser resource utilization.

Invasive Microascus trigonosporus Species Complex Pulmonary Infection in a Lung Transplant Recipient.

Because of the high incidence of morbidity and mortality associated with invasive fungal infections, antifungal prophylaxis is often used in solid organ transplant recipients. However, this prophylaxis is not universally effective and may contribute to the selection of emerging, resistant pathogens. Here we present a rare case of invasive infection caused by Microascus trigonosporus species complex in a human, which developed during voriconazole prophylaxis in a lung transplant recipient. Nebulized liposomal amphotericin B was used in addition to systemic therapy in order to optimize antifungal drug exposure; this regimen appeared to reduce the patient's fungal burden. Despite this apparent improvement, the patient's pulmonary status progressively declined in the setting of multiple comorbidities, ultimately leading to respiratory failure and death.

Electronic inventory systems and barcode technology: impact on pharmacy technical accuracy and error liability.

PURPOSE: To measure the effects associated with sequential implementation of electronic medication storage and inventory systems and product verification devices on pharmacy technical accuracy and rates of potential medication dispensing errors in an academic medical center. METHODS: During four 28-day periods of observation, pharmacists recorded all technical errors identified at the final visual check of pharmaceuticals prior to dispensing. Technical filling errors involving deviations from order-specific selection of product, dosage form, strength, or quantity were documented when dispensing medications using (a) a conventional unit dose (UD) drug distribution system, (b) an electronic storage and inventory system utilizing automated dispensing cabinets (ADCs) within the pharmacy, (c) ADCs combined with barcode (BC) verification, and (d) ADCs and BC verification utilized with changes in product labeling and individualized personnel training in systems application. RESULTS: Using a conventional UD system, the overall incidence of technical error was 0.157% (24/15,271). Following implementation of ADCs, the comparative overall incidence of technical error was 0.135% (10/7,379; P = .841). Following implementation of BC scanning, the comparative overall incidence of technical error was 0.137% (27/19,708; P = .729). Subsequent changes in product labeling and intensified staff training in the use of BC systems was associated with a decrease in the rate of technical error to 0.050% (13/26,200; P = .002). CONCLUSIONS: Pharmacy ADCs and BC systems provide complementary effects that improve technical accuracy and reduce the incidence of potential medication dispensing errors if this technology is used with comprehensive personnel training.

Weight-based versus set dosing of vancomycin for coronary artery bypass grafting or aortic valve surgery.

OBJECTIVES: This study was undertaken to identify a preferred dosing strategy for patients undergoing coronary artery bypass grafting or valve replacement procedures with cardiopulmonary bypass. METHODS: Patients undergoing coronary artery bypass grafting, valve replacement surgery, or both were randomly assigned to receive either standard 1-g dosing with vancomycin before and after cardiopulmonary bypass or a single weight-based 20-mg/kg dose before surgery. The primary outcome was the percentage of time plasma concentrations were greater than 15 µg/mL during cardiopulmonary bypass and at surgical closure. Secondary outcomes included concentration of vancomycin in endothoracic tissue after vancomycin infusion, average time patients had vancomycin concentrations greater than 15 µg/mL, and vancomycin plasma and tissue pharmacokinetic parameters. RESULTS: Baseline characteristics were similar between the study dosing group (n = 10) and the standard dosing group (n = 10). From postinfusion to end of bypass, the median percentage of time vancomycin concentrations remained greater than 15 µg/mL was 100% (interquartile range [IQR], 72.6%-100%) for weight-based dosing versus 43.7% (IQR, 28.7%-53.4%) for standard dosing (P = .0005). From postinfusion to surgical closure, the percentage of time vancomycin concentrations remained greater than 15 µg/mL was significantly higher in the weight-based group (100% [IQR, 58.3%-100%] vs 34.6% [IQR, 25.3%-41.6%]; P = .0005). Weight-based dosing increased calculated time with vancomycin concentrations greater than 15 µg/mL and resulted in higher endothoracic tissue vancomycin concentrations. CONCLUSIONS: Weight-based vancomycin dosing before coronary artery bypass grafting or valve replacement results in vancomycin concentrations greater than 15 µg/mL consistently more than does standard 1-g dosing.

Fatal case of cephalexin-induced toxic epidermal necrolysis.

PURPOSE: To describe a case of toxic epidermal necrolysis likely caused by cephalexin with a review of the literature. CASE: An 80-year-old male with a known allergy to cephalosporins, residing at a long-term acute care hospital, received cephalexin for a urinary tract infection. And 1 day after starting therapy, the patient developed an extensive erythematous rash accompanied by skin sloughing; 4 days after receiving cephalexin, the patient was directly admitted to the burn intensive care unit and was diagnosed with toxic epidermal necrolysis involving 56% of the total body surface area. Progressive deterioration to multisystem organ failure ensued, and the patient died 5 days following his admission to the burn intensive care unit. At the time of death, ulcerations were noted over approximately 80% of his body. SUMMARY: The temporal association of the patient's ingestion of cephalexin for a urinary tract infection to his onset of toxic epidermal necrolysis suggests that this 80-year-old man developed toxic epidermal necrolysis following the administration of cephalexin for a urinary tract infection.

Implementing standardized intravenous antibiotic desensitizations among hospital inpatients.

PURPOSE: Patient safety improvements and increased efficiencies achieved through the establishment of standardized protocols and order sets for selected antibiotic desensitization procedures are described. SUMMARY: Errors in the ordering and administration of antimicrobial desensitization regimens can result in life-threatening complications. To enhance patient safety, the University of Colorado Hospital pharmacy department worked with allergy and immunology physicians (AIPs) to implement standardized desensitization protocols to reduce the potential for confusion surrounding the prescribing and administration of these complex regimens to acutely ill populations such as patients with cystic fibrosis, as many as 30% of whom develop one or more antimicrobial allergies. Nine i.v. antibiotics were identified as suitable for the standardization initiative; based on AIP experience and published guidelines, therapeutic doses of each targeted medication were determined. For each of the nine drugs, the interdisciplinary team developed an instruction sheet on preparing stock concentrations and compounding sequential doses for desensitization, with a corresponding preprinted order set detailing infusion procedures, monitoring requirements, guidance on the use of rescue medications and other steps for managing adverse reactions, and patient safeguards. Initial experience with the standardized protocols indicated that relative to previous practices (i.e., physician submission of handwritten patient-specific orders, with pharmacist calculation of required dilutions case by case), the standardization initiative (1) reduced the potential for errors, (2) sharply reduced order-entry and product preparation times, and (3) helped achieve antimicrobial stewardship goals. CONCLUSION: Standardized antimicrobial desensitization protocols helped to optimize patient care and antimicrobial stewardship while enabling more efficient use of pharmacy and AIP resources and fostering enhanced pharmacist-physician collaboration.

Statins and daptomycin: safety assessment of concurrent use and evaluation of drug interaction liability.

BACKGROUND: Acute muscle injury and potentially fatal rhabdomyolysis may occur with use of statins and certain interacting medications. This investigation assessed risk for myopathy in patients receiving treatment with a statin in combination with daptomycin, a medication also associated with muscle injury. METHODS: Patients hospitalized from July 1, 2005, through June 30, 2010, who received simvastatin or rosuvastatin concurrently with daptomycin were identified and their medical records were examined. Patients were judged to have treatment-related muscle injury if their records contained evidence of myalgia with or without weakness and secondarily impaired mobility together with elevated creatine kinase (CK) levels. These assessments were compared with similar data from hospitalized patients who received a statin alone. RESULTS: A total of 52 patients received 66 courses of concurrent treatment with simvastatin or rosuvastatin and daptomycin. Of these, no patient (0%) met evidentiary requirements for diagnosis of myopathy or related complications. No patient (0%) developed muscle pain or discomfort and none developed markedly elevated CK levels. The incidence of asymptomatic elevations of CK in these simvastatin or rosuvastatin plus daptomycin recipients (9%) was statistically indistinguishable from the incidence of CK elevations found in a cohort of 105 inpatients who received simvastatin or rosuvastatin alone (21%; p=0.135). CONCLUSIONS: In patients receiving treatment with simvastatin or rosuvastatin and daptomycin, no symptoms or objective evidence of muscle injury attributable to a drug interaction were identified. These findings are consistent with data indicating that the myopathic effects of statins and daptomycin are incited by disparate and perhaps unique pharmacological mechanisms. Risk of muscle injury therefore appears to be no greater when a statin is administered with daptomycin than when either medication is used alone.

Managing the Intravenous Calcium Shortage: Evaluation of Calcium Chloride Stability in 0.9% Sodium Chloride and Dextrose 5% Water Polyvinyl Chloride Bags.

BACKGROUND: Intravenous calcium chloride (CaCl) is commonly used by inpatient practitioners for a myriad of indications from electrolyte abnormalities to advanced cardiac life support. Currently, a paucity of data is available regarding the stability of CaCl after preparation of intravenous admixtures. PURPOSE: This study evaluated the physical and chemical stability of CaCl 10% diluted in 0.9% sodium chloride or dextrose 5% water polyvinyl chloride bags. METHOD: CaCl 10% solution (1000 mg) was diluted with 0.9% sodium chloride or dextrose 5% water 100 mL for injection to a final concentration of 10 mg/mL. CaCl 10% solution (2000 mg) was diluted with 0.9% sodium chloride or dextrose 5% water 150 mL for injection to a final concentration of 13.3 mg/mL. Each of the preparations were stored at room temperature (23-25°C) and exposed to fluorescent light. Samples of each preparation were analyzed on days 0, 2, 3, 5, and 7. Sterility and physical stability were assessed. Chemical stability of CaCl was evaluated by indirect potentiometry. RESULTS: CaCl 10 mg/mL and 13.3 mg/mL solutions in polyvinyl chloride bags were physically stable during the entire 7-day study period. CaCl retained >90% of the original concentration at 7 days after preparation in 0.9% sodium chloride and dextrose 5% water. CONCLUSION: CaCl diluted to 10 mg/mL or 13.3 mg/mL with 0.9% sodium chloride or dextrose 5% water for injection is both physically and chemically stable for a period of 7 days with ≤10% degradation under conditions of room temperature with fluorescent lighting.

Linezolid interaction with serotonin reuptake inhibitors: report of two cases and incidence assessment.

BACKGROUND: Prompted by the advent of potentially life-threatening neuromuscular symptoms following initiation of linezolid therapy in two patients receiving treatment with a serotonin reuptake inhibitor antidepressant, an evaluation was conducted to determine the incidence and characteristics of symptomatic serotonin toxicity among hospitalized patients receiving combined treatment with these medications. METHODS: Patients admitted between January 1, 2006 and August 30, 2008 who received linezolid concurrently with citalopram or escitalopram were identified and their medical records were examined. Patients were judged to have serotonin toxicity if their records contained documentation of clinical evidence adequate to fulfill requisites of the Hunter Serotonin Toxicity Criteria. Severity of serotonin-related symptoms was graded according to previously established criteria. RESULTS: During the period of observation, 24 patients received concurrent treatment with linezolid and citalopram or escitalopram. Of these, one patient (4%) treated with citalopram met evidentiary requirements for diagnosis of serotonin toxicity. The severity of symptoms in this patient was graded as mild. No evidence of serious harm related to a possible drug interaction was identified. CONCLUSIONS: Severe symptoms associated with serotonin toxicity were shown to be uncommon in patients receiving linezolid and selected serotonin reuptake inhibitors. Nonetheless, serious interaction-related toxicity has been observed at our institution and reported in detail by others. Accordingly, concurrent use of these medications is categorized as contraindicated. Alternative antimicrobial therapy should be instituted in most cases. If no suitable alternative is available, recipient patients should be hospitalized for expectant observation and rigorous monitoring.

A febrile neutropenic patient with Enterococcus gallinarum sepsis treated with daptomycin and gentamicin.

Gram-positive pathogens are increasingly implicated in today's changing epidemiology of hospital-acquired infections. Staphylococci, streptococci, and enterococci are among the most frequently identified causes of surgical site, complicated skin-structure, and bloodstream infections. In accordance, the use of antimicrobial agents with gram-positive activity, especially those with activity against resistant organisms, has also increased. We describe a septic, neutropenic patient with bacteremia due to Enterococcus gallinarum. Therapeutic options were restricted due to resistance factors of the organism, limited guidance in the medical literature, and the patient's history and underlying condition. Despite these challenges, the patient was successfully treated with a combination of daptomycin and gentamicin and replacement of her indwelling central line. As antimicrobial stewards and diagnosticians, we must bear in mind that selective pressures exerted by the increasing use of agents with gram-positive activity may result in an increased prevalence of organisms such as E. gallinarum.