Bivalirudin dosing during prolonged intermittent renal replacement therapy: a case report.

As patients transition between dialysis modalities, and from the intra- to the inter-dialytic period, medications with a narrow therapeutic index that are cleared in dialysis may require dose adjustments and close monitoring. Three cases of patients receiving bivalirudin while converting from continuous to prolonged intermittent renal replacement therapy are reported. Details provided include flow rates and ultrafiltrate volume. In these cases, it appears pre-emptive dose adjustments may be unwarranted, and clinicians should be aware of potential rebound after cessation of dialysis.

Oral Vancomycin for Secondary Prophylaxis of Clostridium difficile Infection.

OBJECTIVE: To summarize and critically appraise the evidence regarding oral vancomycin prophylaxis (OVP) to prevent recurrent Clostridium difficile infections (RCDIs), identify potential consequences of this emerging practice, and highlight future directions of study. DATA SOURCES: A MEDLINE literature search of English-language publications from 1947 through September 2018 was performed using the search terms vancomycin and C difficile and prophylaxis. Clinical trials were identified on the National Library of Medicine clinical trials registry. STUDY SELECTION AND DATA EXTRACTION: All clinical studies (n = 3) assessing oral vancomycin for secondary prophylaxis of C difficile infection (CDI) were evaluated by all authors. Other search results and references in selected publications were used for background and discussion. DATA SYNTHESIS: OVP reduced the risk of RCDI in high-risk patients taking systemic antibiotics. Variable dosing regimens and lack of safety data are limitations. OVP may have an adverse impact on the gastrointestinal microbiome, but this was not examined in the clinical studies. Relevance to Patient Care and Clinical Practice: Although current studies are limited by methodological concerns, clinicians can consider vancomycin 125 mg orally once or twice daily in high-risk patients receiving broad-spectrum antibacterial agents. Results of ongoing trials will define the most appropriate regimen and its impact on outcomes, including collateral damage. CONCLUSIONS: OVP reduces the risk of RCDIs and should be considered on a case-by-case basis. Caution is warranted before routine use is implemented because the impact on long-term outcomes has not been assessed and the optimal regimen has not been defined.

Antibiotic Use and Respiratory Pathogens in Adults With Sickle Cell Disease and Acute Chest Syndrome.

Background: Acute chest syndrome (ACS) is an acute complication of sickle cell disease (SCD). Historically, the most common pathogens were Chlamydophila pneumoniae, Mycoplasma pneumoniae, and respiratory syncytial virus. Pediatric patients receiving guideline-adherent therapy experienced fewer ACS-related and all-cause 30-day readmissions compared with those receiving nonadherent therapy. This has not been evaluated in adults. Objectives: The primary objectives were to characterize antibiotic use and pathogens. The secondary objective was to assess the occurrence of readmissions associated with guideline-adherent and clinically appropriate treatment compared with regimens that did not meet those criteria. Methods: A retrospective cohort analysis was conducted for adults with SCD hospitalized between August 1, 2014, and July 31, 2017, with pneumonia (PNA) or ACS. The study was approved by the institutional review board. Results: A total of 139 patients with 255 hospitalizations were reviewed. Among 41 respiratory cultures, 3 organisms were isolated: Cryptococcus neoformans, Pseudomonas aeruginosa, and budding yeast. Respiratory panels were collected on 121 admissions, with 17 positive for 1 virus; all were negative for Chlamydophila pneumoniae and M pneumoniae. There were significantly more ACS-/PNA-related 7-day readmissions from patients on guideline-adherent regimens compared with nonadherent regimens (3.7% vs 0%; P = 0.04). Conclusion and Relevance: These findings challenge existing knowledge regarding the most common pathogens in adults with SCD with ACS or PNA. Routine inclusion of a macrolide may not be necessary. Future studies focused on pathogen characterization with standardized assessment are necessary to determine appropriate empirical therapy in this population.

Accuracy of Valproic Acid Concentration Correction Based on Serum Albumin.

BACKGROUND: Patient-specific factors can alter the pharmacokinetic disposition of valproic acid. Specifically, the free fraction of valproic acid can increase substantially in patients with hypoalbuminemia or as serum drug concentrations rise due to saturable protein binding. Direct measurement of free serum drug concentrations allows for accurate assessment of drug levels, but the assay may not be readily available in all institutions. The effect of hypoalbuminemia on free fraction has been quantified and serves as the basis of an equation used to "correct" measured total valproic acid concentrations. The aim of this study was to evaluate the accuracy of the equation. METHODS: This retrospective study included adult patients with measurable free and total valproic acid concentrations between July 2014 and June 2017. The primary aim was to assess the relationship between measured and predicted free valproic acid concentrations. Free levels were categorized as subtherapeutic, therapeutic, or supratherapeutic based on the reference range of 7-23 mg/L. Concordance was defined as measured and predicted concentrations falling within the same category. RESULTS: The analysis included 174 patients with a median age of 58 years and a median albumin of 3 g/dL. The majority of patients were hospitalized (88.5%). Concordance occurred in 56.9% of samples. A Spearman's correlation coefficient of 0.60 (p < 0.001) was found between the measured and predicted free valproic acid concentrations. Concordance of concentrations was 42% for ICU patients, 63% for floor patients, and 65% for outpatients. Of those with discordant concentrations, 97% of the predicted concentrations underestimated the measured concentrations. CONCLUSIONS: There is discordance between predicted and measured free serum valproic acid concentrations when using the proposed equation. Because of the potential impact of underestimation and variability of free valproic acid concentrations, a measured free level is the ideal option for therapeutic drug monitoring of valproic acid.

Rapidity of Correction of Hyponatremia Due to Syndrome of Inappropriate Secretion of Antidiuretic Hormone Following Tolvaptan.

BACKGROUND: Tolvaptan effectively corrects hyponatremia due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), but undesired overcorrection can occur. We hypothesized that pretherapy parameters can predict the rapidity of response to tolvaptan in SIADH. STUDY DESIGN: Multicenter historical cohort study. SETTING & PARTICIPANTS: Adults with SIADH or congestive heart failure (CHF) treated with tolvaptan for a serum sodium concentration ≤ 130 mEq/L at 5 US hospitals. PREDICTORS: Demographic and laboratory parameters. OUTCOMES: Rate of change in serum sodium concentration. MEASUREMENTS: Spearman correlations, analysis of variance, and multivariable linear mixed-effects models. RESULTS: 28 patients with SIADH and 39 patients with CHF treated with tolvaptan (mean baseline serum sodium, 120.6 and 122.4 mEq/L, respectively) were studied. Correction of serum sodium concentration > 12 mEq/L/d occurred in 25% of patients with SIADH compared to 3% of those with CHF (P<0.001). Among patients with SIADH, the increase in serum sodium over 24 hours was correlated with baseline serum sodium concentration (r=-0.78; P<0.001), serum urea nitrogen concentration (SUN; r=-0.76; P<0.001), and estimated glomerular filtration rate (r=0.58; P=0.01). Baseline serum sodium and SUN concentrations were identified as independent predictors of change in serum sodium concentration in multivariable analyses. When patients were grouped into 4 categories according to baseline serum sodium and SUN median values, those with both low baseline serum sodium (≤121 mEq/L) and low baseline SUN concentrations (≤10mg/dL) exhibited a significantly greater rate of increase in serum sodium concentration (mean 24-hour increase of 15.4 mEq/L) than the other 3 categories (P<0.05). Among patients with CHF, only baseline SUN concentration was identified as an independent predictor of change in serum sodium concentration over time. LIMITATIONS: Lack of uniformity in serial serum sodium concentration determinations and documentation of water intake. CONCLUSIONS: Baseline serum sodium and SUN values are predictive of the rapidity of hyponatremia correction following tolvaptan use in SIADH. We advise caution when dosing tolvaptan in patients with both low serum sodium and SUN concentrations.

Effectiveness and safety of oral anticoagulants in patients with sickle cell disease and venous thromboembolism: a retrospective cohort study.

Patients with sickle cell disease (SCD) experience initial and recurrent venous thromboembolism (VTE) more commonly and at a younger age than the general population, and it confers a higher mortality for patients with SCD. However, limited evidence is available to guide anticoagulant use for VTE treatment in this population. The primary objective of this study is to characterize the effectiveness and safety of direct oral anticoagulants (DOAC) and warfarin for VTE treatment among patients with SCD. This single-center retrospective study includes adult patients with SCD who were diagnosed with VTE. Data was obtained from review of electronic health records for the 6 months after VTE diagnosis. Among the 22 patients treated initially with a DOAC, 6 (27%) developed recurrent VTE, none experienced major bleeding, and 3 (14%) experienced clinically relevant non-major bleeding (CRNMB). Similarly, of 15 patients initially treated with warfarin, 3 (20%) developed a recurrent VTE, 1 (7%) experienced major bleeding, and 2 (13%) experienced CRNMB. Twelve patients received more than one oral anticoagulant during the study period, most commonly due to a recurrent VTE, concern for non-adherence, or subtherapeutic INR. Overall, the incidence of VTE recurrence and bleeding events were similar between groups, but occurred at a higher rate than those found in major clinical trials of anticoagulant agents. Prescribers should continue to individualize therapeutic decision-making regarding oral anticoagulant therapy for VTE treatment for individuals with SCD based on patient-specific factors and anticipated ability to adhere to the drug regimen or required monitoring.

Appropriateness of direct oral anticoagulant dosing for venous thromboembolism treatment.

Adherence to FDA-approved dosing for the direct oral anticoagulants (DOACs) based on renal function, hepatic function, and concomitant medications in a real-world setting has not been evaluated. The purpose of this retrospective cohort analysis was to determine the prescribing accuracy of DOAC dosing for venous thromboembolism (VTE) treatment compared with enoxaparin. The secondary outcomes were to describe the incidence of in-hospital VTE recurrence and bleeding on DOAC therapy. The study included 168 patients with 261 admissions for the DOAC group and 639 patients with 841 admissions for the enoxaparin group. Dosing was appropriate in 235/261 (90.0%) of patient admissions in the DOAC group. Among the DOAC doses administered, 233/2246 (10.4%) were contraindicated based on renal function, hepatic function, or drug interactions compared with 322/7293 (4.4%) of administered enoxaparin doses evaluated based on renal function, p < 0.001. Three recurrent VTEs, 3 major bleeding events, 1 probable major bleeding event, and 3 clinically relevant non-major bleeding events were observed during the study period. Although a majority of DOAC doses administered were appropriate, further education and close monitoring of these agents are warranted to increase appropriateness of therapy and improve patient safety.

Evaluating the safety and effectiveness of venous thromboembolism prophylaxis in patients with sickle cell disease.

Nearly every component of hemostasis is altered in sickle cell disease (SCD), yet little evidence exists to guide utilization of venous thromboembolism prophylaxis (VTEP) in this population. This retrospective cohort study included 135 adult patients admitted with a diagnosis of SCD vaso-occlusive crisis to the general medicine service at a tertiary care academic medical center from August 1, 2011 to August 1, 2013. If VTEP was discontinued, the medical record was reviewed for suspicion of VTE, hemorrhage, heparin-induced thrombocytopenia (HIT), or other adverse events. The primary objective was to characterize the safety and effectiveness of VTEP in SCD. The secondary objective was to assess the correlation of VTE with risk factors documented in the general medical population. Most patients (116/135, 85.9%) were prescribed VTEP upon admission, with early discontinuation in 23 patients (19.8%). Reasons for discontinuation included suspicion of VTE (10/116, 8.6%), hemorrhage (5/116, 4.3%), and/or HIT (4/116, 3.4%). Since patients with SCD receiving standard VTEP regimens appear to have similar outcomes compared to medically ill patients in prospective studies, using these regimens appears to be safe when indicated in the opinion of the provider. Once daily injections may be preferred in order to optimize adherence.

Case-control study and case series of pseudohyperphosphatemia during exposure to liposomal amphotericin B.

Pseudohyperphosphatemia due to an interaction between liposomal amphotericin B and the Beckman Coulter PHOSm assay occurs sporadically and remains underrecognized in clinical practice. This retrospective case-control study compares the incidences of hyperphosphatemia in adult inpatients exposed to liposomal amphotericin B or a triazole. A case series of patients with confirmed pseudohyperphosphatemia is described. A total of 80 exposures to liposomal amphotericin B and 726 exposures to triazoles were identified. Among subjects without chronic kidney disease and no concomitant acute kidney injury, hyperphosphatemia occurred more often during liposomal amphotericin B therapy than during triazole therapy (40% [14/35 cases] versus 10% [47/475 cases] of cases; P < 0.01; adjusted odds ratio, 5.2 [95% confidence interval {CI}, 2.3 to 11.9]). Among individuals with chronic kidney disease and no concomitant acute kidney injury, hyperphosphatemia also occurred more often during liposomal amphotericin B exposure (59% [10/17 cases] versus 20% [34/172 cases] of cases; P < 0.01; adjusted odds ratio, 6.0 [95% CI, 2.0 to 18.0]). When acute kidney injury occurred during antifungal exposure, the frequencies of hyperphosphatemia were not different between treatments. Seven episodes of unexpected hyperphosphatemia during liposomal amphotericin B exposure prompted a confirmatory test using an endpoint-based assay that found lower serum phosphorus levels (median difference of 2.5 mg/dl [range, 0.6 to 3.6 mg/dl]). Liposomal amphotericin B exposure confers a higher likelihood of developing hyperphosphatemia than that with exposure to a triazole antifungal, which is likely attributable to pseudohyperphosphatemia. Elevated phosphorus levels in patients receiving liposomal amphotericin B at institutions using the Beckman Coulter PHOSm assay should be interpreted cautiously.

Case report and cohort analysis of drug-induced liver injury associated with daptomycin.

A patient receiving daptomycin developed asymptomatic transaminitis and hyperbilirubinemia without concurrent multiorgan dysfunction or elevation of his creatinine kinase level. After ruling out other etiologies, the liver injury was attributed to daptomycin and was subsequently resolved. A single-center retrospective cohort analysis of baseline and follow-up liver function panels (n = 614) from all admissions from 2008 to 2013 during which daptomycin was administered did not reveal any other cases of probable or definite drug-induced liver injury associated with daptomycin.

Dabigatran-associated subdural hemorrhage: using thromboelastography (TEG(®)) to guide decision-making.

Novel oral anticoagulants present challenges and uncertainties in the management of hemorrhagic emergencies. An 84-year-old man taking dabigatran presented with a subdural hematoma requiring neurosurgical intervention. Routine coagulation assays were prolonged at admission and following administration of Factor VIII Inhibitor Bypassing Activity (FEIBA). Thromboelastography (TEG(®)) was utilized to assess clot dynamics prior to placement of a subdural drain, which was safely inserted despite a prolonged thrombin time (TT). Exclusive reliance on the TT may delay necessary interventions. TEG(®) may be a valuable tool to investigate hemostasis in patients on dabigatran requiring emergent procedures.

Evaluation of Ward Management of Diabetic Ketoacidosis.

Ward management of diabetic ketoacidosis (DKA) using subcutaneous insulin in specific patient populations is safe and effective, but insulin administered by continuous infusion has not been analyzed in this setting. This retrospective cohort study utilizing a nursing-driven, continuous infusion insulin calculator demonstrated safe and effective treatment of patients with DKA on medicine wards.

Daptomycin dosing strategies in patients receiving thrice-weekly intermittent hemodialysis.

OBJECTIVE: To determine the optimal dosing regimen of daptomycin in patients receiving thrice-weekly hemodialysis. DATA SOURCES: Literature was accessed via PubMed using the terms daptomycin and hemodialysis through July 2013. Reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: English language articles meeting the search criteria were evaluated. Studies were included if they addressed either thrice-weekly or intradialytic daptomycin administration. DATA SYNTHESIS: Daptomycin is approved for the treatment of bloodstream infections due to methicillin-resistant Staphylococcus aureus and other Gram-positive organisms. Rapid bactericidal activity and limited potential for drug interactions make daptomycin an attractive agent. However, the daptomycin prescribing information recommends dosing every 48 hours in patients receiving hemodialysis, which results in dyssynchrony of dosing and dialysis sessions every other week. Studies evaluating a dosing regimen of daptomycin thrice weekly, coinciding with dialysis, indicate that pharmacokinetic and pharmacodynamic parameters are appropriate for therapeutic success. However, to maintain adequate serum drug concentrations throughout the 72-hour interdialytic period, an additional 50% of the dose should be provided to account for the longer interval. Intradialytic dosing, with the administration of daptomycin infusion beginning during the final 30 minutes of dialysis, may also require a dose increase. Limited clinical outcomes data have been reported, but no significant safety concerns have been identified. CONCLUSIONS: Administration of daptomycin doses thrice weekly on hemodialysis days appears to be both safe and reasonable. Doses should be increased preceding the 72-hour interdialytic period or if daptomycin is infused during dialysis.

Hemarthrosis in a patient on warfarin receiving ceftaroline: a case report and brief review of cephalosporin interactions with warfarin.

OBJECTIVE: To report a possible interaction between warfarin and ceftaroline, resulting in hemarthrosis, and provide readers with an understanding of mechanisms of interaction between cephalosporins and warfarin. CASE SUMMARY: Ceftaroline was prescribed for an 85-year-old female with a therapeutic international normalized ratio (INR) hospitalized for the treatment of cellulitis. She was subsequently readmitted with shoulder pain and a supratherapeutic INR. The patient was diagnosed with hemarthrosis, presumably related to elevated INR. Evaluation using the drug interaction probability scale for warfarin and ceftaroline yielded a score consistent with a possible or probable interaction. DISCUSSION: Cephalosporins may interact with warfarin through a variety of mechanisms, including potentiation of hypoprothrombinemia related to certain side chain groups, inhibition of P-glycoprotein, or alteration of gastrointestinal flora. All mechanisms reported in the medical literature as of April 2012 are briefly examined, but the latter is the most reasonable mechanism for a ceftaroline interaction with warfarin. CONCLUSIONS: Health care providers should consider closely monitoring patients receiving antibiotics with activity against Enterobacteriaceae and warfarin, even if no direct mechanism of interaction has been reported. Further research regarding a ceftaroline-warfarin interaction is warranted.

Diagnosis and management of iron deficiency anemia in inflammatory bowel disease.

Inflammatory bowel disease (IBD) is associated with extraintestinal manifestations in more than one-quarter of patients. Anemia is one of the most common concerns. Patients with IBD and comorbid iron deficiency anemia (IDA) are at risk for hospitalization and surgery, and IDA impacts health-related quality of life. IDA in IBD is often underdiagnosed and undertreated. Prompt treatment has the potential to improve patient quality of life and clinical outcomes. Although the treatment goals for IDA in IBD are well-defined, selecting a treatment is not as straightforward. Traditional oral iron replacement therapies are generally only recommended in patients with mild anemia who do not have active inflammatory disease. Novel oral iron formulations may circumvent some of the limitations associated with traditional oral products.

The Effect of Sample Handling on Free Valproic Acid Levels.

BACKGROUND: Valproic acid (VPA) is a broad-spectrum anticonvulsant drug. Under normal conditions, this drug is highly protein bound. However, in patients with hypoalbuminemia, the free fraction can increase substantially while the total VPA levels remain in therapeutic range. The neurologic activity and toxicity of the drug are directly related to free drug levels. METHODS: Our in-house free VPA assay was validated using 20 patient samples obtained from a reference laboratory (RL1). It was further evaluated by parallel testing with RL1 using samples collected from our patients. Subsequently, sample handling effects were investigated by comparing free VPA levels measured in our laboratory to 3 selected RLs with different sample transportation conditions. RESULTS: No significant bias was observed between the in-house assay (y) and RL1 (x) assay in free VPA measurement (y = 1.12x + 0.072, r = 0.994). However, patient samples collected in our institution and sent to RL1 revealed significant negative bias (y = 0.776x - 3.861, r = 0.954). A large discrepancy in free VPA levels was further observed from identical aliquots of the same samples transported to 3 RLs in different conditions. CONCLUSIONS: Our study demonstrated that sample handling has significant impact on free VPA levels. The observed magnitude of variation exceeds a clinically acceptable limit and could alter clinical decisions.

Multidrug-resistant Enterococcus faecium endocarditis treated with combination tigecycline and high-dose daptomycin.

OBJECTIVE: To report a case of multidrug-resistant Enterococcus faecium requiring combination antibacterial therapy. CASE SUMMARY: A 39-year-old female presented with chest pain and a history of endocarditis 3 years prior to admission. Blood cultures were positive for E. faecium. She was treated initially with daptomycin 6 mg/kg daily, which was later increased to 8 mg/kg daily despite poor gentamicin clearance. A variety of antibiotics were used in combination with daptomycin, but the patient remained febrile, with positive blood cultures revealing vancomycin minimum inhibitory concentration (MIC) greater than 256 microg/mL and daptomycin MIC 3 microg/mL (and later, 4 microg/mL). Following the addition of tigecycline, the patient experienced rapid clinical and microbiologic improvement, and blood cultures remained negative 9 weeks after discharge. DISCUSSION: Limited clinical data support the use of daptomycin for the treatment of E. faecium endocarditis, and information regarding the effects of escalating doses and combination therapy is scant. After failing multiple combination regimens, this patient responded to a combination of tigecycline and daptomycin. Daptomycin 8 mg/kg daily did not result in creatine kinase elevation in the face of evidence of possible renal dysfunction. CONCLUSIONS: Increasing doses of daptomycin may enhance efficacy without compromising safety, even in patients with some renal dysfunction. The combination of daptomycin and tigecycline may be useful for the treatment of multidrug-resistant E. faecium.

Association between comorbid cancer and outcomes among admissions for acute ischemic stroke receiving systemic thrombolysis.

BACKGROUND: The impact of cancer on outcomes was not assessed in major trials of systemic thrombolysis in acute ischemic stroke. AIMS: To evaluate the association between comorbid cancer and hospital outcomes among patients receiving systemic thrombolysis for the treatment of acute ischemic stroke. METHODS: The 2013 and 2014 United States National Inpatient Sample was used to identify adult patients hospitalized for acute ischemic stroke who received systemic thrombolysis. Identified admissions were stratified into two cohorts based on the presence or absence of comorbid cancer. Multivariable logistic regression was performed to determine the association between comorbid cancer and the odds of in-hospital mortality and intracerebral hemorrhage after adjustment for age ≥75 years and comorbid atrial fibrillation. RESULTS: A total of 13,993 acute ischemic stroke admissions were treated with systemic thrombolysis. Of these, 3.0% ( n = 416) had comorbid cancer. The overall incidence of in-hospital mortality was 7.0% and intracerebral hemorrhage occurred in 7.6% of patients. Upon multivariable adjustment, comorbid cancer was not associated with an increased odds of in-hospital mortality (odds ratio = 1.24; 95% confidence interval = 0.88-1.76). However, the adjusted odds of intracerebral hemorrhage were higher among those with comorbid cancer (odds ratio = 1.60; 95% confidence interval = 1.17-2.17). CONCLUSIONS: In this retrospective study of admissions for acute ischemic stroke receiving thrombolysis, comorbid cancer was not associated with a higher odds of in-hospital mortality but was associated with an increased odds of intracerebral hemorrhage. Factors driving this observed association should be explored in data sets containing clinical variables.

Fosaprepitant for the Management of Refractory Pain in a Patient with Cancer-Related Dermatomyositis.

OBJECTIVE: Optimal pain management often requires multiple pharmacological interventions with the goal of disrupting the pain-signaling pathway and targeting the underlying pathophysiology. Off label use of nonpain medications may have a role in treating refractory pain syndromes. BACKGROUND: We report a case of a 60-year-old female with refractory nociceptive and neuropathic pain. Conventional therapies were either ineffective or fraught with side effects. Given the underlying inflammatory nature of her pain syndrome, and the role of substance P (SP) in pain transmission and modulation, we decided to use fosaprepitant, an SP and neurokinin-1 (NK1) receptor antagonist. The patient tolerated fosaprepitant and experienced acceptable analgesia without compromising her mental functioning. DESIGN: Study and analysis of a case of a patient with refractory mixed, nociceptive, and neuropathic pain syndrome treated with fosaprepitant. RESULTS AND DISCUSSION: Fosaprepitant is a potentially novel adjuvant therapy for the treatment of refractory inflammatory pain syndromes in palliative care.

Intravenous-only or Intravenous Transitioned to Oral Antimicrobials for Enterobacteriaceae-Associated Bacteremic Urinary Tract Infection.

OBJECTIVES: To characterize antibiotic regimens utilized for bacteremic Enterobacteriaceae urinary tract infections and assess treatment failure associated with intravenous-only compared to intravenous transitioned to oral antibiotic treatment. DESIGN: Retrospective cohort. SETTINGS: Tertiary care academic medical center. PATIENTS: 241 adult patients hospitalized between July 1, 2010, and June 30, 2015, with positive blood and urine cultures with the same Enterobacteriaceae pathogen. MAIN RESULTS: Hospital days on antibiotics as well as length of stay were less in the group treated with any oral antibiotics (intravenous/oral, median 5 [IQR 3-7] days vs intravenous-only antibiotics 6 [4-10] days, p<0.001; length of stay for intravenous/oral 4.6 [3.1-7.8] days vs intravenous-only 7.1 [4.0-17.5] days, p<0.001). No statistically significant difference was found in the composite outcome of treatment failure in patients who received intravenous-only antibiotics versus intravenous/oral antibiotics for the treatment of bacteremic urinary tract infections (intravenous-only 3.8% [95% CI: 1.0-9.4%] failure; intravenous/oral 8.2% [95% CI: 4.1-14.1%] failure; p=0.19). CONCLUSIONS: Intravenous transitioned to oral treatment (intravenous/oral) was associated with a shorter length of stay and fewer hospital antibiotic days compared with intravenous-only therapy. Transitioning from intravenous to oral antibiotic therapy is a viable treatment option to consider for patients with bacteremic Enterobacteriaceae urinary tract infection.