In 2021, the American College of Gastroenterology (ACG), the Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America (IDSA/SHEA), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published updated clinical practice guidelines (CPGs) for the management of Clostridioides difficile infections. The differences, sometimes subtle, between these guideline recommendations have caused some debate among clinicians. This paper delves into select key recommendations from each respective CPG and analyzes the differences and evidence associated with each. One primary difference between the CPGs is the preference given to fidaxomicin over vancomycin for initial treatment in non-severe and severe disease endorsed by IDSA/SHEA and ESCMID guidelines, while the ACG-sponsored CPGs do not offer a preference. The emphasis on cost effective data was also a noticeable difference between the CPGs and thus interpretation of the available evidence. When using guidelines to help support local practice or institutional treatment pathways, clinicians should carefully balance CPG recommendations with local patient populations and feasibility of implementation, especially when multiple guidelines for the same disease state exist.

Prompt treatment of candidemia, especially in immunocompromised hosts, is known to improve outcomes. We present a case of discordance among results of Gram stain, multiplex polymerase chain reaction (PCR)-based rapid diagnostic technology, and conventional cultures that subsequently resulted in delayed therapy and hospitalization. An immunocompromised patient presented to the outpatient oncology clinic with signs and symptoms of systemic infection. Blood cultures were obtained, and Gram stain showed gram-negative rods, while multiplex PCR results (BioFire® FilmArray® BCID 1) returned positive for both Enterobacter cloacae and Candida parapsilosis. Conventional cultures only grew E. cloacae. Because of the discordant results, the primary team elected to give ertapenem monotherapy and defer antifungal therapy. The patient’s symptoms progressed, and 11 days later, the patient was admitted with subsequent positive blood cultures for C. parapsilosis. The patient required a 9-day hospitalization due to complications associated with candidemia. This case highlights the value of understanding and interpretation of rapid diagnostics, shared decision-making in antimicrobial management of high-risk patients, and the important responsibility of antimicrobial stewardship teams across the continuum of care.

Objective: Many studies have evaluated the safety and efficacy of oral stepdown therapy for treatment of gram-negative bacteremia (GNB). There are currently no studies comparing the safety and effectiveness of various dosing strategies of sulfamethoxazole-trimethoprim (SMX-TMP) in these patients. Methods: This retrospective cohort study included adult patients at 6 hospitals within a health system with GNB, excluding Stenotrophomonas spp. that received at least 72 hours of oral SMX-TMP. Patients were grouped based on high- (≥8 mg/kg) or low-dose (<8 mg/kg) SMX-TMP. The primary outcome was a composite of all-cause mortality and recurrence at 30 days. Secondary outcomes included readmission, hyperkalemia requiring intervention, acute kidney injury, and intolerance leading to SMX-TMP discontinuation. Results: There were 176 patients included (25.6% high-dose, 74.4% low-dose) in this study. Baseline characteristics were similar except for age, sex, and dosing body weight. Median total duration of therapy for both groups was approximately 14 days; time to initiation of antibiotics was similar between groups. Six patients met the composite outcome (high-dose: 4.4% vs. low-dose: 3.1%; P = .646). Secondary outcomes did not differ significantly between groups. Conclusions: SMX-TMP is commonly used as oral stepdown therapy in GNB. Results of this study indicate that low-dose (<8 mg/kg) SMX-TMP may be sufficient, as outcomes were similar between the groups. To date, this is the first study evaluating different dosing strategies of SMX-TMP for this indication.