The vast majority of infants in the NICU receive peripheral intravenous (PIV) therapy for administration of fluids, nutrition, medications, and blood products. The potential complications of infiltration and extravasation are common in this population. Consequences of inf.ltration and extravasation may be prevented or mitigated by early detection and prompt treatment. In addition, innovative therapies for wound care are constantly evolving. In order to improve outcomes, a practice guideline for intravenous (IV) infiltration prevention, management, and treatment is presented based on literature review and consultation with wound care experts. The guideline includes preventive measures, standardized IV assessment, staging, an algorithm outlining injury, and wound care recommendations.

ABSTRACTObjectives:The aim of the study was to determine the acute and long‐term outcomes of preterm infants treated with an intravenous fish oil–based lipid emulsion (FishLE) for parenteral nutrition–associated liver disease (PNALD).Methods:Preterm infants 14 days to 24 months of age with anatomic short gut or severe intestinal dysmotility, serum direct bilirubin ≥4 mg/dL, and requiring >60% calories from parenteral nutrition were eligible. Enrolled infants received 1 g · kg–1 · day−1 of FishLE until resolution of direct hyperbilirubinemia or return of enteral nutrition. Acute clinical effects and biochemical markers of liver function were monitored. Growth and developmental scores at 6 and 12 months postmenstrual age (PMA) were assessed and compared with controls matched by gestational age (GA).Results:Thirteen patients with mean GA of 28 ± 4 weeks were treated and compared with 119 GA‐matched controls. Their mean direct bilirubin was 9.8 ± 6.4 mg/dL at enrollment. All infants had resolution of cholestasis after study completion. There were no acute adverse events, deaths, or liver/intestinal transplants. Weight and head circumference were similar between FishLE‐treated patients and controls at 6‐ and 12‐month PMA. Cognitive and motor scores were decreased at 6 and 12 months PMA in FishLE‐treated infants. Logistic regression analysis showed that prolonged hospitalization was detrimental to cognitive and motor development, whereas treatment was not.Conclusions:The use of intravenous FishLEs in premature infants appears to be safe and reverses PNALD despite significant liver disease and intestinal failure. This therapy should be used in preterm infants with PNALD and followed long term to evaluate development.

BACKGROUND:Phenytoin is standard of care for seizure prophylaxis following traumatic brain injury (TBI). Levetiracetam, an alternative antiepileptic drug, is utilized for seizure prophylaxis despite limited data supporting its use.OBJECTIVE:Our primary outcome was post-TBI seizure activity measured by electroencephalogram (EEG) for levetiracetam versus phenytoin. Secondary outcomes were length of intensive care unit (ICU) stay, requirement for additional antiepileptic drugs (AED), and drug and monitoring costs.METHODS:A retrospective review was performed of patients admitted to neurosurgical or surgical trauma ICU. Adult patients with at least 1 day of EEG monitoring were included. Patients were excluded if they had history of epilepsy, prior TBI, less than 48 hours of AED therapy, or additional AED prior to EEG monitoring.RESULTS:A total 90 patients met inclusion criteria, with 18 receiving levetiracetam and 72 receiving phenytoin. Prevalence of EEG-confirmed seizure activity was similar between the levetiracetam and phenytoin groups (28% vs 29%; P = .99). ICU length of stay (13 vs 18 days; P = .28), time to EEG-confirmed seizure activity (4 vs 6 days; P = .24), and duration of seizure prophylaxis (9 vs 14 days; P = .18) were also similar. The median daily cost of levetiracetam therapy was $43 compared to $55 for phenytoin therapy and monitoring (P = .08). When all anticonvulsant therapy and monitoring were included, costs were lower for the levetiracetam group ($45 vs $83; P = .02).CONCLUSION:Levetiracetam may provide an alternative treatment option for seizure prevention in TBI patients in the ICU. Total antiepileptic drug and monitoring costs were lower for levetiracetam patients.

Catheter-related bloodstream infections have dramatically increased in 1993-2006 in patients receiving long-term hemodialysis.1Marschall J. Catheter-associated bloodstream infections: looking outside of the ICU.Am J Infect Control. 2008; 36 (suppl 3): S172.e5-S172.e8Abstract Full Text Full Text PDF Scopus (31) Google Scholar Gram-negative organisms cause a significant portion (21%-30%) of these infections.2Patel P.R. Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients.Am J Kidney Dis. 2010; 56: 566-577Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 3Alexandraki I. Sullivan R. Zaiden R. et al.Blood culture isolates in hemodialysis vascular catheter-related bacteremia.Am J Med Sci. 2008; 336: 297-302Crossref PubMed Scopus (22) Google Scholar, 4National Kidney FoundationK/DOQI Clinical Practice Guidelines for Vascular Access: update 2000.Am J Kidney Dis. 2001; 37 (suppl 1): S137-S181Abstract Full Text Full Text PDF PubMed Google Scholar Intravenous (IV) cefepime, a broad-spectrum cephalosporin efficacious for Gram-negative bacteremia,5Schrank J.H. Kelly J.W. McAllister C.K. Randomized comparison of cefepime and ceftazidime for treatment of hospitalized patients with gram-negative bacteremia.Clin Infect Dis. 1995; 20: 56-58Crossref PubMed Scopus (26) Google Scholar currently is dosed at 1 g daily in long-term hemodialysis patients.6Tam V.H. McKinnon P.S. Akins R.L. et al.Pharmacokinetics and pharmacodynamics of cefepime in patients with various degrees of renal function.Antimicrob Agents Chemother. 2003; 47: 1853-1861Crossref PubMed Scopus (95) Google Scholar Pharmacokinetic data suggest that administering cefepime at 2 g thrice weekly exclusively after hemodialysis sessions maintains serum concentrations above the minimum inhibitory concentration for susceptible Gram-negative organisms (8 μg/mL, per the Clinical and Laboratory Standards Institute) during the entire dosing interval.7Schmaldienst S. Traunmuller F. Burgmann H. et al.Multiple-dose pharmacokinetics of cefepime in long-term hemodialysis with high-flux membranes.Eur J Clin Pharmacol. 2000; 56: 61-64Crossref PubMed Scopus (30) Google Scholar We report our clinical experience with this novel regimen. Between 2005 and 2010, adults undergoing 3.5-hour high-flux hemodialysis sessions thrice weekly were included if they had at least 1 blood culture with Gram-negative bacteria and received adequate antibiotics as determined by susceptibility testing. Patients were excluded if follow-up blood cultures documenting eradication of primary infection were not performed. Other exclusion criteria included polymicrobial infection, active antibiotic use outside the time necessary for culture finalization, and susceptibility results in addition to or before the regimen evaluated (≥72 hours) and/or hemodialysis therapy for ≤30 days. The primary outcome was a composite end point including clinical cure, microbiological eradication, microbiologic failure, and safety; meeting all 4 conditions was necessary for success. Clinical cure was defined as complete resolution of objective and subjective infectious signs and symptoms; microbiological eradication, as documented elimination of the pretherapy infecting pathogen. In contrast, clinical failure was either no improvement or the need for other antibiotics to be added/substituted before improvement occurred, and microbiological failure was a persisting pathogen or superinfecting pathogen at 30 days post-therapy. Safety was evaluated using adverse events attributable to antibiotic therapy documented in the medical record. Secondary outcomes included time to microbiological cure, time to resolution of infectious signs and symptoms, length of hospital stay, and duration of therapy. Thirty-three patients received the novel regimen and 23 patients were included in the comparator group: cefepime, 1 g, IV daily (n = 13); cefazolin, 1-2 g, IV posthemodialysis (n = 6); and ciprofloxacin, 400 mg IV/500 mg orally daily (n = 4). Baseline characteristics were similar between groups (Table 1). The source of infection was primarily intravascular dialysis catheters (75%), followed by urinary tract infections (18%). Escherichia coli was the most frequently isolated pathogen, accounting for 34% of infections, followed by Enterobacter cloacae (25%) and Pseudomonas aeruginosa (16%; Table S1).Table 1Baseline Patient ComparisonsCharacteristicOverall (n = 56)Cefepime, 2 g, Post-HD (n = 33)Comparator Group (n = 23)PAge (y)57 [32-79]57580.6Men21 (38)11 (33)10 (43)0.6Weight (kg)72 [62-81]74 [58-90]68 [56-80]0.9Race or ethnic group Hispanic46 (82)26 (79)20 (87)0.5 White9 (16)6 (18)3 (13)0.3 Asian1 (2)1 (3)0 (0)0.9Signs SBP (mm Hg)126 [102-146]129 [103-148]119 [98-146]0.4 Pulse (bpm)81 [72-92]85 [77-92]76 [68-90]0.2 WBC count (×103/μL)11 [8-14]11 [8-13]10 [9-14]0.8HD vintage (y)1 [0.5-1.5]1 [0.5-1]1 [0.5-2]0.3Comorbid conditions Diabetes type 250 (89)29 (88)21 (91)0.9 Liver disease17 (30)11 (33)6 (26)0.8 Hypertension56 (100)33 (100)23 (100)— Coronary artery disease25 (45)16 (48)9 (39)0.6 Congestive heart failure23 (41)14 (42)9 (39)0.9 Malignancy6 (11)6 (18)0 (0)0.04 Substance abuse1 (2)0 (0)1 (4)0.4 Other7 (13)4 (12)3 (13)0.9Presenting signs/symptoms Fever > 38°C49 (88)28 (85)21 (91)0.7 Temperature (°C)38 (37.1-38.6)38 (36.9-38.7)38.1 (37.3-39.1)0.6 Malaise47 (84)28 (85)19 (83)0.9 Nausea32 (57)13 (39)19 (83)0.002 Vomiting29 (52)12 (36)17 (74)0.01 Headache26 (46)17 (52)9 (39)0.4 Abdominal pain24 (43)14 (42)10 (43)0.9 Chills49 (88)29 (88)20 (87)0.9Note: Continuous variables are median [25th-75th percentile] or mean (range); categorical variables are number (percentage).Abbreviations: bpm, beats per minute; HD, hemodialysis; SBP, systolic blood pressure; WBC, white blood cell. Open table in a new tab Note: Continuous variables are median [25th-75th percentile] or mean (range); categorical variables are number (percentage). Abbreviations: bpm, beats per minute; HD, hemodialysis; SBP, systolic blood pressure; WBC, white blood cell. Overall, 91% of patients met the composite end point for success, 94% receiving the novel cefepime regimen compared with 87% in the comparator group (P = 0.4; Table 2). Five patients failed to meet the composite end point for success because they were lost to follow-up and could not be assessed for recurrent infection at 30 days post-treatment. Secondary outcomes did not differ between groups (Table 2).Table 2Primary and Secondary Outcome ResultsOutcomeOverall (n = 56)Cefepime, 2 g, Post-HD (n = 33)Comparator GroupPTotal (n = 23)Cefepime, 1 g/d (n = 13)Cefazolin (n = 6)Ciprofloxacin (n = 4)Primary Composite51 (91)31 (94)20 (87)12 (92)5 (83)3 (75)0.4 Clinical cure56 (100)33 (100)23 (100)13 (100)6 (100)4 (100) Microbiological eradication56 (100)33 (100)23 (100)13 (100)6 (100)4 (100) Microbiological failureaIncludes 5 patients lost to follow-up.5 (9)2 (6)3 (13)1 (8)1 (17)1 (25) Safety56 (100)33 (100)23 (100)13 (100)6 (100)4 (100)Secondary Time to microbiological cure (d)1 [1-2]2 [1-2]1 [1-2]1 [1-2]1 [1-2]2 [2]0.6 Time to defervescence (d)1 [0-2]2 [0-2]1 [0-2]1 [1-2]1 [0-2]0 [0-1]0.6 Hospital length of stay (d)6 [4-9]6 [4-9]6 [4-8]6 [5-8]8 [6-12]4 [3-5]0.8 Duration of therapy (d)16 [14-18]16 [14-19]12 [14-18]16 [14-20]15 [14-18]15 [14-16]0.3 Time to catheter removal (d)2 [1-2]2 [1-2]2 [1-2]1 [1-2]1 [1-2]2 [1-4]0.6 ICU admission5 (9)2 (6)3 (13)2 (15)1 (17)0 (0)0.4Note: Continuous variables are median [25th-75th percentile]; categorical variables are number (percentage). Dosing and outcomes as described in text.Abbreviations: HD, hemodialysis; ICU, intensive care unit.a Includes 5 patients lost to follow-up. Open table in a new tab Note: Continuous variables are median [25th-75th percentile]; categorical variables are number (percentage). Dosing and outcomes as described in text. Abbreviations: HD, hemodialysis; ICU, intensive care unit. Patients undergoing hemodialysis are at increased risk of infections due to nosocomial Gram-negative pathogens, which more likely are resistant to a variety of antibiotics and have fewer treatment options.1Marschall J. Catheter-associated bloodstream infections: looking outside of the ICU.Am J Infect Control. 2008; 36 (suppl 3): S172.e5-S172.e8Abstract Full Text Full Text PDF Scopus (31) Google Scholar, 2Patel P.R. Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients.Am J Kidney Dis. 2010; 56: 566-577Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 3Alexandraki I. Sullivan R. Zaiden R. et al.Blood culture isolates in hemodialysis vascular catheter-related bacteremia.Am J Med Sci. 2008; 336: 297-302Crossref PubMed Scopus (22) Google Scholar, 4National Kidney FoundationK/DOQI Clinical Practice Guidelines for Vascular Access: update 2000.Am J Kidney Dis. 2001; 37 (suppl 1): S137-S181Abstract Full Text Full Text PDF PubMed Google Scholar, 7Schmaldienst S. Traunmuller F. Burgmann H. et al.Multiple-dose pharmacokinetics of cefepime in long-term hemodialysis with high-flux membranes.Eur J Clin Pharmacol. 2000; 56: 61-64Crossref PubMed Scopus (30) Google Scholar Cefepime is well tolerated and has a broad spectrum of activity.5Schrank J.H. Kelly J.W. McAllister C.K. Randomized comparison of cefepime and ceftazidime for treatment of hospitalized patients with gram-negative bacteremia.Clin Infect Dis. 1995; 20: 56-58Crossref PubMed Scopus (26) Google Scholar Cefepime's prolonged half-life in patients with kidney failure allows for higher doses administered less frequently while maintaining the necessary time above the minimum inhibitory concentration to achieve successful outcomes. Previously, Schmaldienst et al7Schmaldienst S. Traunmuller F. Burgmann H. et al.Multiple-dose pharmacokinetics of cefepime in long-term hemodialysis with high-flux membranes.Eur J Clin Pharmacol. 2000; 56: 61-64Crossref PubMed Scopus (30) Google Scholar reported that cefepime, 2 g, IV administered exclusively after hemodialysis thrice weekly gave a mean predialysis cefepime serum trough level of 20.8 μg/mL, which is well in excess of the Gram-negative susceptibility breakpoint. However, clinical correlation of these pharmacokinetic results in patients with active infections has been lacking. Our results validate these data in patients with Gram-negative bacteremia. This novel regimen offers the additional benefits of simplifying treatment adherence (because of dialysis center administration), decreasing health care cost, and eliminating the need for additional catheter placement for antibiotic infusion in the outpatient setting. Total health care expenditures are decreased by decreasing the need for home health care services and obviating the need for daily transportation to a clinic for antibiotic infusion.7Schmaldienst S. Traunmuller F. Burgmann H. et al.Multiple-dose pharmacokinetics of cefepime in long-term hemodialysis with high-flux membranes.Eur J Clin Pharmacol. 2000; 56: 61-64Crossref PubMed Scopus (30) Google Scholar, 8Hayashi R. Huang E. Nissenson A.R. Vascular access for hemodialysis.Nat Clin Pract Nephrol. 2006; 2: 504-513Crossref PubMed Scopus (37) Google Scholar, 9Ramanathan V. Edwin J.C. Jim T.T. et al.Healthcare costs associated with hemodialysis catheter-related infections: a single-center experience.Infect Control Hosp Epidemiol. 2007; 28: 606-609Crossref PubMed Scopus (50) Google Scholar, 10Klevens R.M. Edwards J.R. Andrus M.L. et al.Dialysis Surveillance Report: National Healthcare Safety Network (NHSN)—data summary for 2006.Semin Dial. 2008; 21: 24-28Crossref PubMed Scopus (122) Google Scholar Reduction of vascular access burden would decrease infection rates compared with the regimen listed in the cefepime prescribing information.7Schmaldienst S. Traunmuller F. Burgmann H. et al.Multiple-dose pharmacokinetics of cefepime in long-term hemodialysis with high-flux membranes.Eur J Clin Pharmacol. 2000; 56: 61-64Crossref PubMed Scopus (30) Google Scholar, 8Hayashi R. Huang E. Nissenson A.R. Vascular access for hemodialysis.Nat Clin Pract Nephrol. 2006; 2: 504-513Crossref PubMed Scopus (37) Google Scholar It should be emphasized that this dosing regimen is indicated for only long-term hemodialysis patients receiving regularly scheduled dialysis sessions 3 times a week, not acutely ill patients with fluctuating kidney function or acute kidney injury. This is to our knowledge the first and only study of the clinical utility of this novel regimen. The results suggest that cefepime, 2 g, IV administered after each hemodialysis session is sufficient therapy and a safe alternative for treatment of susceptible Gram-negative bacteremia. Support: None. Financial Disclosure: The authors declare that they have no relevant financial interests. Download .pdf (.03 MB) Help with pdf files Table S1

PURPOSE:The effects of therapeutic drug monitoring (TDM) criteria in a computerized prescriber-order-entry (CPOE) system on the appropriateness of orders for vancomycin levels were evaluated.METHODS:Vancomycin TDM criteria were developed and implemented in a CPOE system. These criteria were displayed via a pop-up alert message when vancomycin levels were ordered and included directions for appropriate timing and justification for routine monitoring. Data for two groups of adult inpatients who had vancomycin levels ordered before and after criteria implementation were compared. Medical records were retrospectively reviewed for these patients to collect information regarding patient demographics, vancomycin dosage and indication, concurrent antibiotics and nephrotoxic agents during vancomycin therapy, length of stay, duration of vancomycin therapy, and number of vancomycin levels drawn. The primary outcome was the percent change in appropriate vancomycin levels ordered after criteria implementation.RESULTS:A total of 200 patients were analyzed, 100 in each group. The percentage of appropriate orders for vancomycin levels significantly increased after criteria implementation (from 58% to 68%, p = 0.02). The greatest effect on appropriateness occurred with the first level ordered (52% versus 70% in the preimplementation and postimplementation groups, respectively; p = 0.01). The majority of inappropriate levels were due to improper timing of sample collections, accounting for 55% of the inappropriate levels evaluated.CONCLUSION:A significant increase in the number of appropriately ordered and drawn serum vancomycin levels occurred after implementation of TDM criteria in the hospital's CPOE system. The majority of orders that were deemed inappropriate were due to improper timing of laboratory collection.

Contrast-induced nephropathy (CIN) is associated with long-term morbidity, mortality, and increased health care costs. It has been suggested that statins have pleiotropic effects countering inflammatory and oxidative stress involved in CIN. Several studies support this theory; however, previously published studies have not evaluated the potential differences between statins in reducing the incidence of CIN. The purpose of this retrospective, single-center trial was to compare the incidence of CIN in patients receiving simvastatin or pravastatin therapy undergoing percutaneous coronary intervention (PCI). A total of 261 patients were included (145 received simvastatin and 116 received pravastatin) with the majority undergoing elective PCI. The population was predominantly male (65%), Hispanic (65%), and diabetic (62%), with a mean age of 59 years and a low-density lipoprotein (LDL) of 85 mg/dL. No significant differences were found between groups for risk factors or prophylactic strategies (eg, hydration). Contrast-induced nephropathy occurred in 26 patients (17.9%) in the simvastatin group versus 10 (8.6%) in the pravastatin group (P < .05). No patients required dialysis as a result of contrast administration. Acute kidney injury (AKI) occurred in 21 patients (14.5%) in the simvastatin group compared to 8 (6.9%) in the pravastatin group (P < .05). In multivariate analysis, the difference between statins remained an independent predictor for the development of CIN. In conclusion, patients on pravastatin had a significantly lower incidence of CIN compared to patients on simvastatin.

The use of combination antibiotic therapy for severe pseudomonal infections is a standard practice in many hospitals; however, the data supporting its use are somewhat unclear. Possible benefits of combination therapy for Pseudomonas aeruginosa infections include in vitro antibiotic synergy, prevention of the emergence of bacterial resistance while receiving therapy, and improved adequacy of empiric therapy. Unfortunately, the potential disadvantages are also considerable, the most worrisome of which are drug toxicity and creation of multidrug‐resistant organisms in the environment. Many in vitro and animal studies have attempted to shed light on this clinically challenging issue; however, these studies have often yielded conflicting results and used different study methods, which limits the clinical utility of the results. Clinical studies have also attempted to clarify this issue, particularly in patients with serious pseudomonal infections such as bacteremia and ventilator‐associated pneumonia, but again, often resulted in conflicting conclusions. Thus, we performed a MEDLINE search (1950‐May 2010) of clinical and in vitro studies evaluating the use of antibiotic combination therapy and monotherapy for bacteremia and pneumonia due to P. aeruginosa . Although a clear answer still eludes this controversy, combination therapy for seriously ill patients suspected of having pseudomonal infection has been shown, with considerable evidence, to improve the likelihood of an active agent being included in the initial antibiotic regimen of these patients. The clinical status of the patient and true likelihood of encountering a multidrug‐resistant organism should be evaluated before deciding on empiric combination therapy. Future research may be able to better identify which patient populations might receive the most benefit from combination therapy rather than using combination therapy for everyone at risk for these infections.

Purpose Outline steps taken at a university teaching health system to meet The Joint Commission's (TJC's) National Patient Safety Goal (NPSG) for anticoagulation therapy. Description The aim of NPSG 3E (recently renumbered as 03.05.01) was to reduce the likelihood of patient harm associated with anticoagulation therapy. Full implementation of a management program for individualization of patient care was required by January 1, 2009. University Health System (UHS) has formed an anticoagulation safety committee consisting of nurses, dieticians, pharmacists, and physicians. Monthly meetings are held to assign projects and responsibilities and to report progress of ongoing tasks. Subcommittees involving selected members have been formed to conduct in-depth evaluations of specific agenda items. The committee has defined target anticoagulants, including unfractionated heparin, enoxaparin, dalteparin, argatroban, lepirudin, fondaparinux, and warfarin. Current practice has been evaluated by gathering baseline adverse events data, performing drug utilization reviews, and analyzing usage. A timeline of progress and expected completion dates for each milestone has been created. Future tasks include developing standard protocols for all anticoagulants and ensuring consistency in discharge counseling. Recently, UHS created a new anticoagulation clinical pharmacist position, and a long-term goal is creation of an anticoagulation team. Responsibilities of this team will include therapy management, discharge counseling, staff education, and maintenance of evidence-based protocols. Conclusion Implementing a program of this caliber to meet TJC's January 2009 deadline for full implementation of a management program posed a challenge to this large teaching institution. This article outlines the steps necessary for ensuring achievement of milestone deadlines.

ABSTRACT Infective endocarditis (IE) is the fourth leading cause of life-threatening infection in the United States and imposes significant morbidity and mortality. The American Heart Association guidelines for the diagnosis and treatment of IE do not address continuous-infusion (CI) oxacillin. This retrospective study compares outcomes between CI oxacillin and intermittent-infusion (II) oxacillin in the treatment of IE caused by methicillin-susceptible Staphylococcus aureus (MSSA). A total of 709 medical records were reviewed for inpatients with definitive IE treated between 1 January 2000 and 31 December 2007. Continuous data were analyzed by Student's t test or the Wilcoxon rank sum test. The chi-square test or Fisher's exact test was used to compare nominal data. A multivariate logistic model was constructed. One hundred seven patients met eligibility criteria for inclusion into the study. Seventy-eight patients received CI oxacillin, whereas 28 received II oxacillin. CI and II groups were similar with respect to 30-day mortality (8% versus 10%, P = 0.7) and length of stay (20 versus 25 days, P = 0.4) but differed in 30-day microbiological cure (94% versus 79%, P = 0.03). Sixty-three patients received synergistic gentamicin, whereas 44 did not. The gentamicin and no-gentamicin groups were similar with respect to 30-day mortality (11% versus 4%, P = 0.2) and 30-day microbiological cure (90% versus 89%, P = 0.8); however, times to defervescence (4 versus 2 days, P = 0.02) were significantly different. CI oxacillin is an effective alternative to II oxacillin for the treatment of IE caused by MSSA and may improve microbiological cure. This convenient and pharmacodynamically optimized dosing regimen for oxacillin deserves consideration for patients with IE caused by MSSA.