2026 Southeastern Residency Conference

Title: Characterizing the Microbial Landscape of Febrile Neutropenia at an Academic Medical Center
Authors:
Alexander Durant, PharmD1,2
Amber Clemmons, PharmD, BCOP, FHOPA1,2
Affiliations:
Wellstar MCG Health, Augusta, Georgia
University of Georgia College of Pharmacy, Athens, Georgia
Background:
Febrile neutropenia (FN) is a common and potentially life-threatening complication of myelosuppressive chemotherapy requiring prompt clinical evaluation and empiric antimicrobial therapy. Although historical trends have alternated between gram-positive (GP) and gram-negative (GN) predominance, contemporary literature reveals substantial institutional and regional heterogeneity. Reported culture positivity rates and organism distributions vary, with multidrug-resistant organisms (MDROs) being increasingly prevalent. Additionally, viral and fungal organisms are underrepresented in the literature. This variability limits generalizability and demonstrates a need for institution-specific data to guide practice at Wellstar MCG Health.
Objectives:
This study aimed to: 1) determine culture positivity rates among FN episodes, 2) characterize culture sources and organism distributions, 3) describe the prevalence of MDROs, and 4) identify associations between clinical risk factors and isolation of GP, GN, and other organisms using multivariable regression.
Methods:
This single-center retrospective chart review included adult patients admitted to Wellstar MCG Health with FN between January 1, 2023 and June 30, 2025. Patients admitted prior to the electronic health record transition (EPIC Go-Live, 11/02/2024) were identified using Cerner Discern Analytics and Theradoc based on concurrent fever, absolute neutrophil count (ANC) <1500 cells/microliter, and receipt of empiric antipseudomonal therapy (cefepime, piperacillin-tazobactam, or meropenem). Patients admitted after Go-Live were identified using EPIC SlicerDicer based on ICD-10 codes for fever (R50.81 or R50.9) and neutropenia (D70.1, D70.8, D70.9) during the same admission. Data was collected in REDCap for 500 patients total. Collected data included demographics, malignancy type, chemotherapy regimen, antimicrobial prophylaxis, culture results, organism classification, and MDRO status. Descriptive statistics encompassed microbiology and culture positivity results. Multivariable regression of these variables will identify potential predictors of GP, GN, and MDRO speciation.
Results:
Most episodes (82%) were associated with a hematologic malignancy or post-transplant diagnosis. Blood cultures were positive in 15.2% of FN episodes in our sample, with other positive sources accounting for fewer than 5.2% of episodes. In 68.8% of FN episodes, the ANC at the time of the qualifying fever was less than or equal to 1500 cells/microliter, with 11.2% of episodes being greater than or equal to 1500 cells/microliter, representing CML with blast crisis, AML not in remission, or a fall in the ANC to less than 500 cells/microliter within 48 hours. Additional data regarding microorganism types, resistance patterns, and multivariable regression modeling is pending further analysis.
Conclusion/Discussion:
This study will provide contemporary, institution-specific data describing the microbiologic profile of FN at Wellstar MCG Health. Findings will describe local culture positivity rates, pathogen distributions, and MDRO prevalence while identifying clinical predictors associated with specific organism types. These completed results will address the limitations of prior heterogeneous studies and support evidence-based empiric therapy, antimicrobial stewardship, and institutional risk-stratified management strategies.

Title: Systematic Use of the MORE Tool to Reduce Opioid-Related Adverse Events at a Community Teaching Hospital 
Authors: Mariam Diaby, Kimm Freeman  

Background: Opioids are widely used for the management of moderate to severe pain in hospitalized patients; however, their use is associated with significant risk of opioid-related adverse drug events (ORADEs), including respiratory depression, oversedation, delirium, gastrointestinal complications, and increased morbidity and mortality. ORADEs have been linked to prolonged hospital length of stay, higher healthcare costs, and poorer clinical outcomes. 

In response, opioid stewardship has become a major focus of inpatient quality improvement initiatives. Numerous stewardship efforts have emphasized multimodal analgesia, dose optimization, avoidance of high-risk medication combinations, and enhanced monitoring of sedation and respiratory status. Pharmacists play a critical role in these initiatives by conducting medication reviews, identifying inappropriate opioid prescribing, mitigating high-risk regimens, and implementing safety-focused interventions. However, sustaining consistent and standardized opioid stewardship practices within routine clinical workflow remains challenging. 

The Medication and Risk Factor Review, Optimize, Refer at Risk Patients, Educate and Plan (MORE) tool was developed as a structured framework to standardize opioid stewardship efforts among pharmacists. The MORE tool prompts systematic evaluation of opioid therapy, including assessment of risk factors, optimization of analgesic regimens, reassessment of safety parameters, and patient education. 

Methods: This retrospective observational study evaluated implementation of the MORE tool on 3 North Telemetry and 3 South Renal units at Wellstar Cobb Medical Center from December 22, 2025, to January 16, 2026. Adult patients admitted to study units who received at least one opioid medication during hospitalization were eligible. Patients admitted for hospice or comfort measures only, those hospitalized for less than 24 hours, and those who received naloxone for indications unrelated to opioid overdose were excluded. 

The primary objective was to quantify and characterize the types of medication-related interventions documented during daily MORE tool utilization. Secondary analysis evaluated potential associations between documented MORE tool interventions and the root causes of naloxone administration during the study period. 

Interventions were identified through pharmacist-documented I-Vents within the electronic medical record. Data collected included patient demographics, hospital length of stay, opioid administration records, sedation and risk assessment scores, naloxone administration events, and interventions. Descriptive statistics were used to summarize intervention frequency and type. Comparative analyses were performed to explore associations between MORE tool interventions and naloxone events. 

Results: A total of 108 interventions were documented across 67 patients. Of the 108 interventions, 88 were accepted and 20 were rejected. The most common intervention was the conversion of intravenous opioids to oral opioids, which accounted for 33 interventions with 27 being accepted by the provider.  Other frequently implemented interventions included the addition of opioid-induced constipation (OIC) prophylaxis (32 interventions), scheduling of Tylenol (4 interventions), and the discontinuation of benzodiazepines (4 interventions). 

The overall rate of accepted interventions was 81.5%, with the highest acceptance rates seen in optimizing OIC prophylaxis (100%) and converting intravenous opioids to oral opioids (81.8%). Notably, there were no NARCAN (naloxone) administration events documented during the study period. 

Conclusion: The systematic use of the MORE tool in this study demonstrated a high acceptance rate of opioid stewardship interventions, with 81.5% of the documented interventions being implemented. The tool effectively prompted appropriate adjustments in opioid management, particularly in optimizing OIC prophylaxis and converting IV opioids to PO opioids. During the study period, there were no naloxone administration events, suggesting that ORADEs may have been effectively mitigated through this proactive approach. These findings highlight the potential value of utilizing structured tools like the MORE tool in reducing ORADEs and optimizing opioid therapy, thus contributing to improved patient safety and clinical outcomes. Further research with larger cohorts is needed to confirm these findings and assess the long-term impact of such interventions.

Contact: [email protected]

Title: Evaluation of Outcomes for HiDAC-135 Versus HiDAC-123
Investigators: Chelsea Hylton
Rachel Matthews
Darby Siler
Laura Beth Parsons
Practice site: Sarah Cannon Cancer Center at TriStar Centennial Medical Center
Background (464/600 words):  
Intermediate to high-dose cytarabine (IDAC/HiDAC) is a preferred consolidation chemotherapy regimen for patients with acute myeloid leukemia (AML) that have achieved remission [1]. IDAC/HiDAC is traditionally administered every 12 hours on days 1, 3, and 5 (HiDAC-135). Studies have explored administering cytarabine 3000 mg/m2 every 12 hours on days 1, 2, and 3 (HiDAC-123) to reduce the risk of neutropenia without compromising the clinical outcomes [2]. There was a significant difference in median overall survival of 79 months (HiDAC-123) versus 31 months (HiDAC-135) (P=0.031). HiDAC-135 was also associated with a longer course of hospitalization (P=0.008) and increase in transfusions (P=0.011) [2]. More recent studies have explored administering HiDAC-123 with or without granulocyte colony stimulating factors (G-CSF) to mitigate myelosuppression and relapse [3]. There was no statistically significant difference in overall survival and relapse-free survival, but there was a significant difference in the decreased duration of neutropenia (P<0.0001) [3].
This study compares HiDAC-135 and HiDAC-123 in a real-world setting.
Methods:
This institutional review board (IRB)-approved, single center, retrospective chart review included patients with AML that received 2 or more cycles of IDAC/HiDAC consolidation on the adult hematology service line between 02/01/2023-01/31/2025. The institutional practice changed from HiDAC-135 to HiDAC-123 in January 2024. Patients were excluded if they were enrolled in a clinical trial or were treated on the pediatric service line. Outcomes were compared across groups. Descriptive statistics was used for baseline characteristics and outcomes. Data was collected from electronic medical records after running our pharmacy surveillance platform to include cytarabine orders during the study timeframe.
Results: A total of 132 patients were screened; 12 patients met inclusion criteria (HIDAC-135: n=8; HIDAC-123: n=2;HIDAC-135 to HIDAC-123: n=2). There was a wide variation in age in the HIDA-123 arm, with one patient being over age. Total cycle delays varied across treatment arms: HIDAC-135 at 43%, HIDAC-123 at 100%, and HIDAC-135 to HIDAC-123 at 67%. The median duration of hospitalization was 5 days for HIDAC-135, 3 days for HIDAC-123, and 4 days for HIDAC-135 to HIDAC-123. G-CSF administration was 36% in HIDAC-135, 100% in HIDAC-123, and 60% in HIDAC-135 to HIDAC-123. There was an incidence of hospital readmission for febrile neutropenia (FN) seen in 27.2% in HIDAC-135 and 60% in HIDAC-123, with no FN readmissions in the HIDAC-135 to HIDAC-123 arm. Of note, all three readmissions for FN in HIDAC-123 received G-CSF. Only one of the FN readmissions in the HIDAC-135 arm received G-CSF.
Conclusions/Discussion: Outcomes of this study comparing HIDAC-135 to HIDAC-123 were not consistent with previous studies. Insufficient data due to small patient numbers may have impacted study results and ability to conduct statistical analysis. Though not collected, some patients underwent hematopoietic stem cell transplant instead of receiving all four cycles of HIDAC consolidation. Further analysis is needed to compare results with HIDAC-123 at this institution.
References:
1.  Mayer RJ, Davis RB, Schiffer CA, et al. Intensive postremission chemotherapy in adults with acute myeloid leukemia. N Engl J Med. 1994;331(14):896-903. doi:10.1056/NEJM199410063311402
2.  Krayem B, Horesh N, Frisch A, Zuckerman T, Ofran Y. Hidac consolidation in aml: comparable outcomes with reduced toxicity using a three-day schedule(HiDAC-123). Eur J Haematol. 2025;115(2):193-195. doi:10.1111/ejh.14432
3. Jaramillo, S - Blood Cancer J (2017) Condensed versus standard schedule of high-dose cytarabine consolidation therapy with pegfilgrastim growth factor support in acute myeloid leukemia.pdf
Contact information: Chelsea Hylton, PharmD
[email protected]

Early post-transplant conversion from tacrolimus to belatacept in kidney transplant patients
Authors: Mikayla Morrow, Kwame Asare, Victoria Burnette, Nicole Melby

1)Background
Ascension Saint Thomas Hospital West (ASTHW) began using belatacept, a selective T-cell co-stimulation blocker, in kidney transplant recipients more frequently in the fall of 2023. It is used if the patient has slow or delayed graft function post-transplant or experiences intolerance to or toxicity from calcineurin inhibitors. This was the first study at ASTHW evaluating outcomes of belatacept in this patient population. Previous studies that have compared calcineurin inhibitors, such as tacrolimus, to belatacept have found similar patient and graft survival between the groups, and found that belatacept recipients had superior renal function but experienced higher rejection. The purpose of this study was to assess the effect that early conversion from tacrolimus to belatacept post-kidney transplant has on patient renal function.

2)Methods
This retrospective chart review included adult kidney transplant recipients transplanted at ASTHW between April 1, 2023 and April 31, 2025, who received either tacrolimus or belatacept within the first six months post-transplant. Data collected included demographics, transplant characteristics, induction therapy, immunosuppressive regimens, renal function, biopsy-proven acute rejection, incidence of delayed or slow graft function, incidence of infection , hospital length of stay after transplant, readmissions, and cost of therapy. Outcomes were analyzed using descriptive statistics; continuous variables with unpaired t-test and categorical variables with Chi-square or Fisher’s exact tests (alpha < 0.05).

3)Results
Overall, 361 patients were screened and 285 were excluded for incomplete documentation. Of the 76 patients included, 19 were in the belatacept group and 57 in the tacrolimus group. There was a statistically significant difference in age between groups, with the belatacept group having an older median age (p = 0.045). The majority of patients were male and the study was split evenly between Caucasian and African American races. The majority of patients in both groups had slow graft function. Serum creatinine and estimated glomerular filtration rate were statistically significantly better in the tacrolimus-only group at 1, 3, and 6 months post-transplant (p = <0.00001). Survival of the patient and their graft, incidence of infection, and length of stay were not statistically different between groups. Biopsy proven acute rejection was statistically significantly higher in the belatacept group (p = 0.036). There was a statistically significant difference in the readmission rate between the groups, with the belatacept group having more readmissions (p = 0.0051).

4)Conclusions
In this study of kidney transplant recipients receiving either tacrolimus, de novo belatacept, or who underwent early conversion from tacrolimus to belatacept, we observed a significant difference in renal allograft function in favor of tacrolimus use. Further studies are necessary to assess short- and long-term clinical outcomes of utilizing belatacept in place of tacrolimus in patients with slow or delayed graft function.

Background: Daptomycin and ceftaroline combination therapy (combination therapy) has been used as a salvage treatment of persistent methicillin-resistant S. aureus (MRSA) bacteremia for its synergistic effect, with promising clinical data when compared with monotherapy. The ideal duration of combination therapy is currently unclear.


Methods: A retrospective, multi-hospital healthcare system, observational cohort study comparing adult patients with persistent MRSA bacteremia that cleared blood cultures while receiving daptomycin and ceftaroline combination therapy. Patients were grouped into those who received ≤ 7 days of combination therapy after blood culture clearance (short duration group) and those who received > 7 days of combination therapy (long duration group). The primary outcome is a composite of 30-day all-cause mortality and recurrence of MRSA bacteremia. Secondary outcomes include adverse events, 90-day all-cause mortality, 90-day recurrence of MRSA bacteremia, and hospital length-of-stay.


Results: 94 patients were included, with 55 patients in the short duration group and 39 in the long duration group. Within the primary outcome, 10 patients in the short duration group and 7 patients in the long group experienced mortality or MRSA bacteremia recurrence within 30 days of the end of treatment (18.2% vs 18%, p=0.98). The short duration group experienced numerically more 90-day all-cause mortality events than the long duration group (29.1% vs 25.6%, p=0.71). There were similar rates of 90-day MRSA bacteremia recurrence between groups (3.7% vs 2.5%, p=1). The long duration group had a longer median overall hospital length-of-stay (LOS) (40 vs 22 days; p=0.002) and a longer median hospital LOS post-blood culture clearance (13.1 vs 34 days; p=0.001). There was no statistically significant difference in incidence of adverse events. The long duration group had numerically more instances of thrombocytopenia (5.5% vs 18%, p=0.09). Two cases of C. difficile requiring treatment occurred, both in the long duration group.


Conclusions: Among patients with persistent MRSA bacteremia, duration of combination therapy after blood culture clearance had no difference on 30-day mortality or recurrence. Results may help reduce unnecessary antibiotic exposure and hospital length-of-stay.

Abstract 
Title: Cefazolin vs. Clindamycin for Surgical Prophylaxis in Patients with a Beta-Lactam Allergy 
Authors: John Otasowie, Plamen Mangarov, Daniel Rogers, and Mydien Tran 
Background 
About 20% of all healthcare-associated infections are due to surgical site infections (SSIs), representing a substantial clinical and economic burden with an estimated annual cost exceeding $3.3 billion. Despite advances made in infection control practices by the implementation of preoperative prepping and prophylactic antibiotic administration, SSI remains a significant cause of morbidity and mortality. Appropriate use of perioperative antibiotics is imperative to reduce the rate of SSIs. For most procedures, cefazolin is the drug of choice for surgical prophylaxis due to its proven efficacy and safety, a desirable pharmacokinetic profile, an ideal spectrum of activity against commonly encountered organisms during surgery, and a relatively low cost.   
However, penicillin and cephalosporin allergy labels remain a significant barrier to cefazolin use. Approximately 10% of patients report a penicillin allergy, and 2% a cephalosporin allergy. Studies suggest that over 95% of patients labeled with a penicillin allergy do not have an actual immunoglobulin E-mediated allergy and could tolerate penicillin. However, clinicians often utilize alternative agents like clindamycin in the presence of a documented β-lactam allergy. Nevertheless, clindamycin use has been linked to higher rates of SSIs and Clostridioides difficile infection (CDI). Despite these concerns, clindamycin remains a popular prophylactic option for patients labeled with a β-lactam allergy, even when cefazolin may be safely administered. This study evaluated whether patients receiving cefazolin for surgical prophylaxis had comparable outcomes to those receiving intravenous clindamycin in the setting of a documented β-lactam allergy. 
Methods 
This single-center, retrospective cohort study included patients aged 18 years or older with a documented β-lactam allergy who received either cefazolin or clindamycin for surgical prophylaxis between October 1, 2022, and March 1, 2023. Patients were excluded if they received antibiotics for any indication other than surgical prophylaxis, underwent procedures requiring broader prophylaxis, or lacked documentation to assess 30-day post-op outcomes. The primary outcome was the incidence of SSI within 30 days post-surgery. Secondary outcomes included the incidence of CDI within 30 days post-discharge, the 30-day post-discharge rehospitalization rate, the percentage of perioperative anaphylaxis among cefazolin recipients, and the rate of inappropriate clindamycin use based on β-lactam allergy classification per Emory Guidance. Continuous variables were reported as median (interquartile range); categorical variables were reported as frequencies and percentages. Categorical outcomes were compared using Fisher’s exact test or chi-square based on observed cell frequency; statistical significance was defined as p<0.05. 
Results 
A total of 233 patients were included: cefazolin (n=139) and clindamycin (n=94). Baseline characteristics were comparable between groups. The 30-day SSI rate was significantly lower in the cefazolin group compared to clindamycin (0.0% vs. 4.3%, p=0.025). No cases of CDI within 30 days post-discharge were observed in either group. The 30-day rehospitalization rate did not differ significantly between groups (5.0% vs. 6.4%, p=0.773). No perioperative anaphylaxis events occurred among cefazolin recipients. Per institutional β-lactam allergy guidance, 93 of 94 clindamycin recipients (98.9%) had a cefazolin-indicated allergy classification, representing inappropriate clindamycin use; only 1 patient (1.1%) had a true contraindication to cefazolin. 
Conclusion 
Cefazolin demonstrated a statistically significantly lower 30-day SSI rate than clindamycin in β-lactam-allergic patients, with no perioperative anaphylaxis. The absence of CDI and comparable rehospitalization rates further support the safety of cefazolin in this population. Nonadherence to institutional guidance, underscores a substantial stewardship opportunity. These findings support initiatives to reassess β-lactam allergy labels and prioritize cefazolin for surgical prophylaxis in appropriately selected patients. 
 

Background/Purpose: Antimicrobial-resistant organisms are a growing public health threat and contribute to increased morbidity and mortality, longer hospital stays, and higher healthcare costs. In particular, the utilization of anti-pseudomonal beta-lactam antibiotics significantly contributes to the development of resistance in addition to increasing the risk of complications such as Clostridioides difficile infections. The purpose of this study is to review and evaluate the effectiveness and safety of empiric cefepime and piperacillin/tazobactam de-escalation through an implemented Pseudomonas aeruginosa risk stratification tool utilized by the antimicrobial stewardship team.  

Methodology: This study is a single-center, retrospective cohort study including patients admitted to St. Francis Hospital Downtown from January 2025 to August 2025. Data for this study was obtained from the electronic medical record, which includes clinical, pharmaceutical, and laboratory information. Patients were identified via antimicrobial stewardship intervention notes for P. aeruginosa risk stratification. The primary outcome sought to elucidate effectiveness, defined as re-escalation of antibiotics due to infectious cause or clinical deterioration. Secondary outcomes were centered around safety, defined as total days of antimicrobial therapy, development of Clostridioides difficile infection, readmission rate within 90 days, and NHSN Standardized Antimicrobial Administration Ratio (SAAR) data pre and post intervention. Patients were included in this study if they had an active order for cefepime or piperacillin/tazobactam, are 18 years of age or older, and have documentation of completed screening by the antimicrobial stewardship team. Patients were excluded if they had positive microbiological results at the time of audit before de-escalation by the antimicrobial stewardship team, duplicate patients, or de-escalation not pursued. The impact of antimicrobial stewardship intervention on the utilization and de-escalation rates of antipseudomonal beta-lactam antibiotics were evaluated using descriptive statistics. 

Results: A total of 523 patients were screened for inclusion, of which 278 were included in the analysis for the primary and secondary outcomes. The most frequent indication prompting anti-pseudomonal beta-lactam de-escalation was intra-abdominal infection (104/278, 37.4%). The mean duration of broad-spectrum anti-pseudomonal beta-lactam therapy prior to intervention was 2 days (SD 1.95). The total number of days on de-escalated therapy was 751 versus the total days of anti-microbial therapy (de-escalated + initial + re-escalated) was 1513 days. For the primary endpoint, 15 patients (15/278, 5.4%) required re-escalation of anti-microbial therapy. The most common regimen used for de-escalation was ceftriaxone plus metronidazole (104/278, 37.4%). The most common reason for re-escalation was suspected worsening infection or clinical deterioration (13/15, 86.7%), and the most frequently used medication for re-escalation was piperacillin/tazobactam (8/15, 53.3%). Regarding the secondary endpoint of safety, 1 patient developed Clostridioides difficile infection after intervention. Additionally, 106 patients (106/278, 38%) were readmitted within 90 days from initial admission.  

Conclusion: Based on the primary outcome findings, empiric de-escalation of anti-pseudomonal beta-lactams using risk stratification appears to be effective, as only a small proportion of patients (5.4%) required re-escalation of antimicrobial therapy. These results are consistent with previous studies demonstrating that patients without risk factors for Pseudomonas aeruginosa are unlikely to have infection with this organism and therefore be appropriately managed with narrower spectrum antimicrobial therapy. Regarding secondary outcomes, only one patient developed Clostridioides difficile infection following de-escalation. However, a relatively high readmission rate (38%) within 90 days from initial admission was observed. This may be attributed to factors such as inadequate source control and re-escalation of antibiotics initiated in the emergency department and continued during subsequent admissions. Future investigations evaluating further de-escalation beyond ceftriaxone may be warranted, given its relatively broad spectrum of activity compared to other antimicrobial options.

Comparative Safety of Inpatient versus Outpatient Step‑Up Dosing for Bispecific T‑Cell Engagers in Multiple Myeloma
Saumyaa Patel; Chynna Bambico; Jon Shaffer
AdventHealth Orlando, Orlando, FL, USA
BACKGROUND
Bispecific T-Cell Engagers (BiTEs) for relapsed/refractory multiple myeloma were approved with recommended inpatient step-up dosing and post-dose observation to mitigate early toxicities, primarily cytokine release syndrome (CRS) and immune effector cell–associated neurotoxicity syndrome (ICANS). Emerging literature suggests outpatient step-up dosing may be feasible with standardized monitoring and prophylaxis, but real-world data on patient safety outcomes remains limited. The objective of this study is to compare whether inpatient versus outpatient step-up dosing for teclistamab, talquetamab, and elranatamab affects the incidence and grade of CRS and ICANS.
METHODS
This single-center, retrospective chart review included adults with multiple myeloma initiated on teclistamab, talquetamab, or elranatamab at a tertiary academic hospital between June 1, 2023, and February 30, 2026. Patients were identified from the electronic health records after Institutional Review Board (IRB) approval. They were grouped according to care setting during step-up dosing: inpatient observation as recommended by Food and Drug Administration (FDA) label versus outpatient monitoring. Inclusion criteria included age ≥18 years and first step-up dose administered with follow-up per institutional protocol. Exclusion criteria included initial step-up performed elsewhere, concurrent enrollment in an interventional trial, or clinical instability at step-up initiation (for example, active infection or hemodynamic instability). Baseline variables included age, gender, Eastern Cooperative Oncology Group (ECOG) performance status, and number of prior therapy lines. Primary outcomes included incidence and grade of CRS and ICANS per the American Society for Transplantation and Cellular Therapy (ASTCT) criteria. Secondary outcomes included tocilizumab use, corticosteroid use, fluid bolus use, vasopressor use, supplemental oxygen use, emergency department visit or readmission, and readmission length of stay. Descriptive statistics will summarize baseline characteristics. Categorical outcomes will be compared using chi-squared or Fisher’s exact tests while continuous outcomes will be compared using Mann-Whitney U or student’s t-tests.
RESULTS A total of 41 patients were included, with 11 (27%) receiving outpatient and 30 (73%) receiving inpatient step-up dosing. Baseline characteristics were generally comparable, including age, gender, and prior lines of therapy. CRS occurred less frequently in the outpatient group vs. the inpatient group (9% vs. 47%). All outpatient CRS events were grade 2, while inpatient events were grade 1 (17%) and grade 2 (30%). ICANS was uncommon and occurred in 9% of outpatients vs. 20% of inpatients. All outpatient ICANS events were grade 2, while inpatient events were grade 1 (13%) and grade 2 (7%).
Supportive care interventions were similar overall. Tocilizumab use occurred in 9% of outpatients vs. 13% of inpatients, and fluid boluses were administered only in the inpatient group (23%). Off day corticosteroid use was more common in the outpatient group (91% vs. 30%). Lastly, no patients required vasopressors or intensive care unit admission, and thirty-day hospitalization rates were identical (27% vs. 27%).
CONCLUSIONS Outpatient step-up dosing of bispecific T cell engagers was not associated with increased incidence or severity of CRS or ICANS vs. inpatient initiation. Although CRS rates were lower in the outpatient cohort, escalation of care and healthcare utilization were similar. These findings support the feasibility and safety of outpatient BiTE initiation in appropriately selected patients with standardized monitoring and prophylactic strategies.

Purpose: Trastuzumab, with or without pertuzumab, is used in the treatment of human epidermal growth factor receptor 2-positive (HER2+) metastatic breast cancer. Both of these monoclonal antibodies require loading doses at treatment initiation and after specified dose delays per their package inserts. This dosing rationale is based on pharmacokinetic studies in patients with solid tumors, which evaluated the time required for serum drug levels to return to steady state after dose interruptions when a patient is not reloaded. Despite this guidance, it is suspected that not all providers prescribe reloading doses as recommended after delays in treatment. To our knowledge, there are no published studies investigating the real-world patient outcomes of not reloading these medications.

Methods: This IRB-approved, retrospective cohort analysis was designed to evaluate the incidence of reloading pertuzumab- and trastuzumab-containing products and their impact on disease progression. Patients were categorized into two groups: those who were appropriately loaded after a dose delay, as defined in the respective medication package inserts. and those who were not. Patients were randomized at a 1:1 ratio. The primary endpoint was to determine which patients were appropriately loaded compared to those who were not. Secondary endpoints included median time of dose delay, reason for dose delay, prescriber-dependent reloading dose practices, and time to disease progression. Descriptive statistics were used to define which patients were appropriately loaded compared to those who were not, the reason for dose delay, and which providers did or did not reload appropriately. A Kruskal-Wallis H test was used to determine the median time of dose delay. A Mann-Whitney U test was used to determine the time to disease progression.

Results: The study included a total of 29 patients. Of the 29 patients, seven patients (24.1%) were reloaded appropriately, and 22 patients (75.9%) were not reloaded appropriately after treatment delay. The median time of dose delay was 21 days (IQR 21-40 days). Many dose delays were not adequately documented with a reason for the delay (31%). The most commonly documented reason for dose delay was hospitalization (27%). When assessing the effect this had on disease progression, patients who were reloaded had a median time to progression of 1461 days (IQR 307-3302), and patients who were not reloaded had a median time to progression of 686 days (IQR 257-967). This difference was not statistically significant (p = 0.36).

Conclusion: This study showed the median time to progression of disease was longer in patients who were properly reloaded after a dose delay. However, this was not statistically significant and did contain a potential outlier in the appropriately reloaded group. The small sample size was a limitation, and therefore, the study was unable to meet power. Future studies are warranted to further assess the impact that reloading may have on disease progression with a larger patient population and potentially including patients with additional disease states that include HER2+ directed therapy.
  

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Background
Non-small cell lung cancer (NSCLC) encompasses 87% of lung cancer cases with a 5-10% five-year survival rate1. For non-squamous NSCLC without sensitizing mutations, the KEYNOTE-189 trial showed the combination of carboplatin/pemetrexed plus pembrolizumab increased overall survival and progression-free survival over chemotherapy alone.  However, pembrolizumab and pemetrexed are both nephrotoxic agents. When studied using pembrolizumab plus pemetrexed/carboplatin vs. placebo plus pemetrexed/carboplatin, there was a 5.2% vs. 0.5% instance of acute kidney injury (AKI) that occurred2. This study was designed to evaluate the duration of response for patients on carboplatin/pemetrexed/pembrolizumab who developed versus did not develop an AKI

Methods:
This was a multicenter, retrospective cohort study of patients who underwent treatment with carboplatin/pemetrexed/pembrolizumab for non-squamous metastatic NSCLC. Data was collected from January 1, 2022 to December 31, 2025 from patients at Atrium Health Levine Cancer.. A report via electronic medical records in Epic was generated to select patients who have received carboplatin/pemetrexed/pembrolizumab. Within the AKI and no AKI groups, random selection occurred with data collection entered into a RedCAP database. Inclusion criteria consisted of  ≥18 years old, stage IV non-squamous NSCLC, and completion of at least 1 cycle of carboplatin/pemetrexed/pembrolizumab. Exclusion criteria were a creatinine clearance < 45 mL/min, a baseline use of prednisone or equivalent ≥ 10 mg not utilized for pre-medication and receiving any oncology treatment outside of Atrium Health facilities. The primary endpoint was the duration of response of first-line treatment after developing an AKI compared to patients who did not. Duration of response was defined by time to death or time to initiating second-line therapy. Secondary endpoints included total cycles of first-line therapy received, cycle of therapy AKI developed in, and re-initiation of treatment after AKI development. Demographics and baseline characteristics were analyzed using Fisher’s exact test (categorical values) and Wilcox rank sum test (continuous values). Time to initiation of second line therapy or death was analyzed with a Kaplan-Meier curve, reporting the log-rank test result between those with versus those without an AKI. Patients were censored at the maximum follow up time if no event was experienced.

Results
169 patients were screened with 80 patients included. The rate of AKI was 11%. Common baseline characteristics include 50-70 years old (59%), white (74%), with an average SCr <1.5 (96%). Eighty-three percent of  patients did not have a targetable mutation while 15% had KRAS G12C mutations and 2.5% had EBBR2 mutations. Tumor proportion score (TPS) <1% for the AKI group was 78% and 54% for the non-AKI group. Most deaths occurred in the non-AKI group (37/71 vs. 1/9, p=0.031), which failed to show a statistically significant difference in the two groups.

Conclusion
An early AKI during first-line non-small cell lung cancer treatment has been shown to reduce survival outcomes at 12 months4. This study aimed to evaluate the impact of an AKI could have on duration of response, which was found to have no statistically significant difference; however, the amount of people who had an AKI was larger than past literature studies2. Limitations that could have influenced the lack of statistical difference included not having enough patients to detect a statistically significant difference and different providers electing to use pembrolizumab and pemetrexed together versus pembrolizumab alone, influencing AKI occurrence.

Title: Association between Enterococcal Infective Endocarditis following a Transcatheter Aortic Valve Replacement
Authors: Felipe Gómez; Caren Azurin; Stefanie Pappas
Affiliation: Ascension Saint Thomas Hospital West, Nashville, TN
Introduction Transcatheter aortic valve replacement (TAVR) is standard therapy for severe aortic stenosis. A severe complication is infective endocarditis (IE), predominantly caused by Enterococcus species (historically 24–34% of cases) due to patient comorbidities and groin contamination during transfemoral access. Our institution’s current prophylaxis protocol utilizes cefazolin, which lacks enterococcal coverage. The primary objective was to assess the association between surgical antibiotic prophylaxis and enterococcal IE risk following TAVR. Secondary objectives evaluated the time to infection, all-cause inpatient mortality, and surgical intervention rates.
Methods A single-center, retrospective observational review was conducted on 102 patients (≥18 years) who underwent TAVR between January 2023 and December 2024. Exclusions included prior antibiotic therapy, concurrent infections, or incarcerated status. Data was collected via REDCap. Statistical analysis utilized Fisher’s exact test for categorical variables and the Mann-Whitney U test for continuous data, with significance defined as p<0.05.
Results Of the 102 patients evaluated, 5 (4.9%) developed IE. Enterococcus spp. was the predominant pathogen, responsible for 80% (4 of 5) of cases. All patients who developed IE received 2 grams of cefazolin prophylaxis. Consequently, no significant association was found between prophylactic choice and IE (p=1.000) due to the near-universal administration of cefazolin. The mean time from surgery to enterococcal IE onset was 497.8 days. The infection rate was 6.4% for transfemoral access versus 0% for the carotid approach (p=0.585). Among the patients who developed IE, mortality was 0%, while 40% (n=2) required surgical intervention.
Discussion & Conclusion Enterococcus caused 80% of TAVR-related IE cases in this cohort, significantly exceeding historically reported rates. The data indicates that current institutional prophylaxis with cefazolin leaves a critical coverage gap for this specific population. Additionally, the higher infection rate in the transfemoral group highlights the risk of groin-sourced enterococcal inoculation. Despite limitations surrounding sample size and retrospective design, these findings provide actionable clinical evidence supporting the revision of the institutional TAVR protocol to incorporate agents with enterococcal activity (e.g., ampicillin/sulbactam) to target the predominant pathogen and improve patient outcomes.

Impact of Time to Positive Blood Culture and Time to Definitive Antimicrobial Therapy on Mortality in Intensive Care Unit Patients with Bacteremia
Nicole Rios Serrano, Lena K. Tran, Christopher Lloyd
AdventHealth Kissimmee – Kissimmee, FL

Background: Bacteremia in critically ill patients is associated with a high risk of morbidity and mortality. Delays between blood culture collection, result availability, and adjustment to proper antimicrobial therapy can lead to worse clinical outcomes. Previous studies have linked delayed appropriate therapy to increased mortality, but the relationship between time to positive blood culture and treatment timing remains less defined. This study aims to evaluate the association between time to positive blood culture (TTP) and time to definitive antimicrobial therapy, and their effect on in-hospital mortality among critically ill patients with bacteremia.

Methods: This study was reviewed by the local investigational review board and deemed a quality improvement project. A retrospective analysis was performed on adult patients admitted to the intensive care unit (ICU) with positive blood cultures at AdventHealth Central Florida Division hospitals from July 1, 2023, through June 30, 2025. Data collected from the electronic health record included baseline characteristics, co-morbidities, baseline sepsis markers, pathogen identification, and timing of empiric therapy initiation. The primary outcome was in-hospital mortality. Secondary outcomes include time to definitive antimicrobial therapy, time to positive blood culture, appropriate empiric antibiotic coverage, length of definitive treatment, and hospital length of stay. Descriptive statistics, student t-tests, Mann–Whitney U, or chi-squared test were conducted, as appropriate. This study will identify gaps in diagnostic and treatment workflows and provide actionable data to enhance hospital protocols, strengthen antimicrobial stewardship programs, and improve outcomes for critically ill patients with bacteremia.

Results: After screening 669 patients for exclusion, 166 patients were included in the final analysis. Patients were divided into two separate groups, rapid time to initial positive blood culture (<360 minutes, n=81) and prolonged time to initial positive blood culture (>360 minutes, n=85). Demographics included an average patient age of 66 years for rapid TTP and 64 years for prolonged TTP. The rapid TTP group had 83% of patients meeting sepsis criteria, compared to 79% in the prolonged TTP group (p = 0.525). The predominant organism in the rapid TTP group was Klebsiella pneumoniae (25%) compared to Escherichia coli (24%) in the prolonged TTP group. Piperacillin-tazobactam and vancomycin were the most common antibiotics ordered empirically in both groups. 91% of patients in the rapid TTP group were started on appropriate empiric therapy compared to 84% in the prolonged TTP group (p = 0.129). Patients with rapid TTP suffered higher all-cause in-hospital mortality (47%) compared to the prolonged TTP group (39%; p = 0.292). The median TTP in the rapid group was 272 minutes compared to 567 minutes in the prolonged group (p = 0.001). The median time to definitive antimicrobial therapy was 22 hours for rapid TTP and 21 hours for prolonged TTP (p = 0.691). The hospital length of stay was 14 days for rapid TTP and 14 days for prolonged TTP (p = 0.676). Average time to empiric treatment initiation was 99 minutes for rapid TTP and 156 minutes for prolonged TTP (p = 0.290). Time between antibiotic administration and blood culture collection was on average 172 minutes for rapid TTP and 313 minutes for prolonged TTP (p = 0.0053).

Conclusions: These findings highlight that TTP may serve as an early indicator of illness severity. Although rapid TTP did not shorten time to definitive antimicrobial therapy, it may be associated with higher in-hospital mortality, suggesting that rapid microbial growth may reflect higher burden of infection. This underscores the importance of using rapid TTP as an early warning tool to recognize high-risk patients and guide timely clinical intervention.

Authors: Chase Arrington; Kelsey Bouwman; Dorothy Williams

Background: Urinary tract infections (UTIs) account for 30-32% of all healthcare-acquired infections, with Enterococcus species found in 15.9% of all catheter-associated UTIs. Standard treatment options include aminopenicillins, fosfomycin, nitrofurantoin, daptomycin, or vancomycin; however, resistance rates to these continue to climb. Linezolid offers an appealing alternative, but its ability to concentrate within the bladder could limit its clinical utility for UTIs. The manufacturer reports that approximately only 30% of the dose is excreted within the urine. Few retrospective studies exist looking at linezolid's effectiveness in UTIs, but the available data shows similar outcomes regarding clinical success. This study was conducted to assess linezolid’s effectiveness within lower UTIs caused by Enterococcus species in comparison to standard therapies.  

Methods: This is a single system, retrospective cohort study assessing linezolid's effectiveness in UTIs caused by Enterococcus species. The study included patients admitted between August 15, 2022, and August 15, 2025. Patients were included if they were 18 years or older, had a positive urine culture reporting an Enterococcus species, and it was their first encounter within the timeframe of this study. Patients were excluded if they had polymicrobial infections, negative urinalysis (<10 white blood cells per high-power field or leukocyte esterase negative), positive blood cultures, received fewer than three days of effective therapy, were pregnant or incarcerated, received both linezolid and another active antibiotic, or had been diagnosed with pyelonephritis. The primary outcome was a composite of bacterial persistence or antibiotic reinitiation within 14 days. Secondary outcomes included length of stay, 30-day recurrence or readmission related to UTI, development of resistance to linezolid, and mortality.  

Results: A total of 128 patients were included, with 37 receiving linezolid and 91 receiving conventional therapy. For the primary outcome of bacterial persistence or antibiotic reinitiation, no significant difference was found between linezolid and conventional therapy (13.51% vs. 9.89%, p=0.545).  No differences were observed between groups in the secondary outcomes of 30-day UTI readmission rate (24.32% vs. 15.38%, p=0.309), median length of stay (5.83 vs 6.76 days, p=0.592), or 30-day mortality (2.70% vs 8.79%, p=0.446). No patients developed resistance to linezolid within 30 days. Rates of thrombocytopenia during treatment were also comparable between groups (2.70% vs. 3.30%, p=1).  

Conclusion: In this retrospective cohort study, linezolid demonstrated comparable outcomes and safety to conventional therapies for the treatment of Enterococcus UTIs. This supports the potential utility of linezolid in UTIs despite concerns regarding urinary drug concentrations, particularly in cases involving resistant Enterococcus species. Larger randomized controlled studies are needed to confirm the findings seen within this study.  

Email: [email protected]

Title: Assessment of Antiresorptive Therapy Utilization in Prostate Cancer Patients Receiving Abiraterone with Prednisone + Androgen Deprivation Therapy

Authors: Makenzie Boyd & Barbie Gleaton

Background: Abiraterone is an oral anticancer agent widely used for the treatment of metastatic prostate cancer in combination with prednisone and androgen deprivation therapy (ADT). One of the adverse effects associated with this regimen is bone density loss, leading to an increased risk of fractures and skeletal-related events. Bone health is critically important in these patients to maintain quality of life and reduce morbidity. The veteran population may be at greater risk of bone density loss due to multiple factors, including advanced age, higher comorbidity burden, and potential exposure to hazardous substances during military service, which could contribute to decreased bone health. Rapid bone loss without preventive measures can lead to severe complications, including pathological fractures, spinal cord compression, and reduced mobility. Assessing the current practices regarding the use of antiresorptive therapies in this high-risk population is essential to improving care and outcomes.

Methods: This study is a retrospective chart review of veterans with metastatic prostate cancer treated at the Birmingham VA Medical Center between January 1, 2024, and July 31, 2025. Patients were identified via fill history for active prescriptions of abiraterone. Included patients were at least 18 years old with a documented diagnosis of metastatic castrate-resistant prostate cancer who received at least 3 months of treatment and had at least 30 days of follow-up in the VA electronic medical record. Patients were excluded if they were followed by non-VA providers, had secondary malignancies, used steroids chronically for other comorbidities, had less than 180 days of life expectancy at the initiation of treatment, or had unspecified metastatic disease. The primary data point of this study was the appropriate utilization of antiresorptive treatment. Other data points included analysis of adjunctive supportive therapy for bone health and examination of pharmacist intervention in initiating supportive care. Baseline demographics and comorbidities were also collected to describe the study population and identify risk factors for bone mineral density loss.

Results: There were 131 patients reviewed, of which 38 met inclusion criteria. Of these, 12 patients had metastatic castration-resistant prostate cancer (mCRPC) and 26 had metastatic castration-sensitive prostate cancer (mCSPC). All patients with mCRPC were receiving appropriate antiresorptive therapy, including zoledronic acid or denosumab. In contrast, three patients in the mCSPC group received inappropriate bone-modifying therapy based on current guideline recommendations. At baseline, 86.8% of patients had a vitamin D level <30 ng/mL, indicating a high prevalence of vitamin D deficiency. Despite this, 65.3% of patients did not undergo bone mineral density screening with DEXA. Additionally, clinical pharmacists initiated 65.8% of vitamin D monitoring and prescribed 55.3% of supportive care supplementation.

Conclusions: Overall, it was determined that antiresorptive therapies were used appropriately for patients with mCRPC. However, inappropriate use of these therapies for patients with mCSPC, highlighting the need for review of current guideline recommendations. Gaps in supportive care were also identified, particularly in the underutilization of bone mineral density screening. Limited use of DEXA scanning restricted the ability to fully assess fracture risk and identify patients who may benefit from additional bone-modifying therapy while on this treatment regimen. Pharmacists played a significant role in driving laboratory monitoring and supportive care interventions. Future efforts should focus on implementing standardized bone health screening for all patients receiving androgen deprivation therapy to improve early identification and prevention of skeletal-related events in this high-risk population.

Title:
Treatment of Staphylococcus Aureus Bacteremia and the Impact of Infectious Disease Consultation

Authors:
Westley Eccles, Stephen Eure, Doug Carroll

Practice Site:
DCH Regional Medical Center-Tuscloosa, AL

Background: Staphylococcus aureus (S. aureus) remains a highly virulent pathogen causing infections worldwide. The pathogen frequently invades into the bloodstream to cause S. aureus bacteremia, which currently has an in-hospital mortality range of 10% to 30%. The Infectious Diseases Society of America (IDSA) guidelines on methicillin-resistant S. aureus (MRSA) remain an important backbone on proper management of S. aureus bacteremia. The IDSA guidelines outline antibiotic selection, classification, and duration of therapy, as well as recommended additional tests to manage the infection. These guidelines are still commonly followed to this date, with some notable differences in current best practice. It is highly important that patients receive optimal antibiotics and proper duration of antibiotic treatment to improve outcomes and reduce mortality. Other research projects have been conducted to compare patient outcomes when an infectious diseases (ID) specialist is directly involved in the management of S. aureus bacteremia. These studies suggest an improvement in both guideline-adherent management of the infection and a reduction in patient mortality. This project aims to assess the overall performance in managing S. aureus bacteremia in our facility, with a comparison between two groups (ID consultation versus no ID consultation).

Methodology: This study was a retrospective chart review of patients ≥18 years of age with positive blood cultures for either methicillin-sensitive S. aureus (MSSA) or MRSA between January 2024 to June 2025. A total of 140 patients were identified within our time period and screened for inclusion. After a chart review to confirm eligibility, 99 patients were included in the project. These patients were divided based on presence of ID consultation, where 42 patients received an ID consult and 57 patients did not receive an ID consult. Individual elements of performance (i.e., antibiotic selection, repeat blood cultures, echocardiography, and duration of therapy) were created to assess patient care based on the standard set by current practice and guidelines. Outcomes were compared between patients who had ID specialist consultation to those without ID specialist consultation. The primary outcome was a composite of all elements of performance, where compliance with all elements of performance was required to meet the primary outcome. Additional secondary outcomes included each individual element of performance, inpatient mortality, average duration of therapy, and hospital readmissions within 30 days, due to infectious process.

Results: Thirty-two (76%) patients with ID consult met the primary outcome compared to twenty-two (39%) patients without ID consult. Secondary outcomes included each individual element of performance alone. For ID consult, each individual element of performance was met as follows: thirty-five (83%) patients for antibiotic selection; Forty-one (98%) for repeat blood cultures; Forty-one (98%) for echocardiography; thirty-eight (91%) for guideline-compliant therapy. For no ID consultation, each individual element of performance was met as follows: forty-two (74%) patients for antibiotic selection; forty-nine (86%) for repeat blood cultures; Forty-four (77%) for echocardiography; thirty-four (60%) for guideline-compliant therapy. Ultimately, there was greater adherence to all elements of performance in the group of patients that had an ID specialist onboard in their care.

Conclusions: Adherence to current guidelines and best practice was more commonly seen in patients with an ID specialist onboard. Overall, ID specialist involvement improved the appropriate management of patients diagnosed with S. aureus bacteremia.

A RETROSPECTIVE EVALUATION OF THE IMPACT OF VANCOMYCIN AUC DOSING ON ACUTE KIDNEY INJURY AND DRUG EXPOSURE IN HOSPITALIZED PATIENTS.
Shemaiah Caine, Deanne Tabb, Tushar Patel, Aayush Patel Piedmont Columbus Regional Midtown Columbus, GA


Background/Purpose: Vancomycin trough-based monitoring is associated with excessive exposure and increased acute kidney injury (AKI). however, trough-based monitoring is associated with excessive drug exposure and increased risk of acute kidney injury (AKI). ASHP/IDSA consensus guidelines recommend AUC guided dosing with a target AUC of 400 - 600 mg·hr/L to improve safety and efficacy. In January 2025, Piedmont Columbus Regional Midtown implemented InsightRX®, a Bayesian dosing platform designed to support individualized AUC guided vancomycin dosing. The purpose of this study is to assess the impact of this transition on AKI incidence and drug exposure.




Methodology: This retrospective single center pre/post cohort study will include adult patients who received ≥ 72 hours of intravenous vancomycin, comparing a trough-based cohort (Oct-Dec 2024) with an AUC guided cohort after InsightRX® implementation (Jun-Aug 2025). Data from Epic and InsightRX® will capture demographics, baseline renal function, vancomycin dosing characteristics, and nephrotoxin exposure. The primary outcome is AKI during therapy or within 48 hours after the last dose, defined per KDIGO criteria. Secondary outcomes include time to target AUC, number of levels drawn, trough distributions, and total vancomycin exposure. Continuous variables will be analysed using a two-sample t-test, and categorical variables using Fisher’s exact test.




Results:  For the primary outcome, AKI occurred in approximately 9% of patients in the trough-based group compared with 7% in the AUC-guided group. The p-value of 1.00 suggests there was no statistically significant difference between groups. However, given the small sample size and descriptive design, this analysis was likely underpowered to detect meaningful differences in AKI risk. For secondary outcomes, average vancomycin exposure within the first 72 hours was similar between groups, at approximately 2,300 mg/day in the trough-based cohort and 2,208 mg/day in the AUC-guided cohort, with no statistically significant difference observed, p=0.64. However, a greater proportion of patients in the AUC-guided group achieved target therapeutic exposure within 48 hours compared with the trough-based group, 56% versus 18%, respectively, which was statistically significant with a p-value of 0.005. Within the trough-based cohort, most patients, 68%, had trough concentrations between 11 and 14.9 mcg/mL, while 27% were between 15 and 20 mcg/mL. Only one patient had a trough concentration greater than 20 mcg/mL.


Conclusions: AUC guided vancomycin dosing was associated with a significantly higher rate of early target attainment within 48 hours compared to trough-based dosing. Despite this difference, overall vancomycin exposure within the first 72 hours of therapy was similar between groups, suggesting comparable initial dosing intensity. There was no statistically significant difference in the incidence of acute kidney injury between the two strategies; however, this study was likely underpowered to detect meaningful differences in safety outcomes. Overall, these findings suggest that AUC guided dosing may improve early pharmacokinetic target achievement without increasing nephrotoxicity, though larger studies are needed to further evaluate its impact on renal outcomes.




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Impact of Pharmacist-Led Discharge Interventions in the Multi-Visit Patient Population

Background: Multi-visit patients (MVPs), defined as individuals with three or more hospital admissions within a 12-month period, represent a high-risk population with significant chronic disease burden and increased risk of early readmission. Frequent hospitalizations, particularly similar conditions, are associated with worse clinical outcomes and increased healthcare utilization. Pharmacist involvement during care transitions has been shown to improve medication management and patient outcomes; however, data evaluating the impact of pharmacist-led interventions in MVP populations remain limited. This study aimed to assess the impact of pharmacist-led post-discharge medication review in this high-risk population.

Methodology: This retrospective chart review included Medicare enrolled MVPs who were discharged from AdventHealth Celebration between September 15, 2025, and January 16, 2026. Patients were excluded if they were discharged to an inpatient rehabilitation unit (IPR), skilled nursing facility (SNF), hospice, left against medical advice, transferred to an outside hospital, expired during hospitalization, or patients with current malignancy treated with systemic therapy. Eligible patients were identified by a nurse educator and referred for a post-discharge medication review call conducted by a clinical pharmacist. All eligible patients received an attempted telephone outreach.  The primary outcome was 30-day hospital readmission rate. Outcomes were compared between patients who successfully completed the post-discharge pharmacist call and those who were unable to be reached or declined participation. Secondary outcomes included the rate of identical (potentially preventable) 30-day readmissions, defined as readmissions for the same or clinically similar condition as the index admission. Secondary outcomes also included the number of medication discrepancies identified and resolved. Additional process measures included the incidence and type of patient counseling and education provided (e.g., medication-related, disease state, lifestyle, self-monitoring, and adherence counseling), as well as the number and type of pharmacist recommendations, including medication initiation, discontinuation, dose adjustment, and laboratory or immunization recommendations.

Results: A total of 40 MVPs were identified during the study period. Of these, 22 patients met inclusion criteria, leaving 18 patients eligible for inclusion who received an attempted post-discharge medication review call from a clinical pharmacist. Among the 18 eligible patients 12 (66.7%) successfully completed the pharmacist-led telephone encounter, while 6 (33.3%) were either unable to be reached or declined participation. The 30-day readmission rate was 50% (n=6) among patients who completed the call, compared to 33% (n=2) among those who did not complete the call. Among patients who completed the intervention, a total of 33 medication discrepancies were identified and resolved (mean 2.8 per patient). Additionally, over 50 patient counseling interventions were performed, with the majority categorized as medication-related or disease state-related education. A total of 33 pharmacist recommendations were made, most commonly involving medication dose adjustments. Other recommendations included medication initiation, discontinuation, and laboratory or immunizations.
 
Conclusion: Pharmacist-led post-discharge medication review in a high-risk multi-visit patient population identified a substantial number of medication discrepancies and generated clinically meaningful interventions, including medication optimization and patient education. Although no reduction in 30-day readmissions was observed, these findings highlight the potential role of pharmacists in improving care transitions and addressing medication-related problems in medically complex patients. Larger studies are needed to further evaluate the impact of these interventions on clinical outcomes in this population.

Evaluation of Phosphorus Replacement Protocol Implementation during Continuous Renal Replacement Therapy (CRRT)
Emma Smits, Morgan Vincent, Mike Maccia
Cone Health at Moses Cone Hospital - Greensboro, NC

Background:
Continuous renal replacement therapy (CRRT) is a common modality of renal replacement therapy among critically ill patients. However, hypophosphatemia is a frequent complication of CRRT, with several studies reporting incidence of at least 60%. This risk increases with CRRT duration, especially when a phosphorus-free dialysate is utilized. The pre-filter, post-filter, and dialysate fluids for CRRT at Cone Health do not contain phosphorus.  Hypophosphatemia in critically ill adults has been associated with increased duration of ventilatory and vasopressor support, prolonged hospital and intensive care unit (ICU) stay, and increased 28-day mortality. In June 2025, Cone Health introduced a protocol for pharmacist-driven replacement of phosphorus among patients receiving CRRT. This study aimed to evaluate the effectiveness of this protocol in reducing the incidence of hypophosphatemia and related clinical outcomes.
Methods:
This was a retrospective, pre-post comparator study of adults hospitalized within Cone Health ICUs who received CRRT. Data was collected from February to May 2025 for the pre-intervention group and July to November 2025 for the post-intervention group. Patients were excluded for receipt of total parenteral nutrition (TPN), death within 72 hours of CRRT initiation, or receipt of CRRT for less than 72 hours in duration. The primary endpoint was the incidence of hypophosphatemia within the first 72 hours. Secondary endpoints included percentage of phosphorus levels in goal range, change in phosphorus level following replacement, number of phosphorus replacements, ordering user type, time to development of hypophosphatemia, time to phosphorus replacement from low phosphorus level, mechanical ventilation duration, and in-hospital mortality. Endpoints were compared using Chi square, t-test, Fischer’s exact test, or Mann-Whitney U test as appropriate.
Results:
Ninety patients were included in the evaluation (n=45 in each group). The rate of hypophosphatemia was 60% in the pre-protocol group and 68% in the post-protocol group (p=0.51). In the post-protocol group, pharmacists served as the ordering provider more frequently than either physicians or advanced practice providers (75% vs 45%, p=0.028).  Most secondary outcomes were similar between groups.
Conclusions:
Implementation of a pharmacist-driven phosphorus replacement protocol during CRRT did not reduce incidence of hypophosphatemia but did increase the proportion of phosphorus replacements completed by pharmacists. Potential limitations include limited sample-size, single-institution study, and possible variation in workflow or practice between individual ICUs. Future directions include assessment of barriers to utilization of the phosphorus replacement protocol and identification of strategies to increase utilization.

Title: Impact of Antibiotic Therapy on Weight in Adult Patients

Authors: Nghi Nguyen, Kate O’Connor, Joshua Eudy, Elizabeth Spitzer, Bintaben Patel, Emmie Wu, Daniel Anderson

Objective: To evaluate short‑ and long‑term weight changes and metabolic effects associated with antibiotic use in adults.

Background: Approximately 80–90% of antibiotic prescriptions occur in the outpatient setting, and an estimated 30% are considered inappropriate. This unnecessary overuse of antibiotics is often cited as a risk factor for increased rates of antimicrobial resistance and adverse drug events. Another often-overlooked consequence of antibiotic use is gut dysbiosis, a disruption of the microbial composition involved in host energy metabolism, such as modulation of Glucagon-like peptide-1 (GLP-1). As such, gut dysbiosis associated with antibiotic exposure may contribute to unintended weight gain. While pediatric studies have linked early and broad-spectrum antibiotic exposure to increased rates of obesity by age five, data on weight and metabolic changes following antibiotic exposure in adults are limited. Understanding these long‑term physiological effects is necessary to support personalized antimicrobial stewardship and improve shared decision-making with patients in the ambulatory care setting.

Method: This was a single-center retrospective cohort study evaluating adult patients at the Wellstar MCG Health Internal Medicine Clinic between December 1, 2024, and February 28, 2025. Cohorts included patients who received at least three days of antibiotics and those who received no antibiotics. Patients were excluded if they were prescribed a GLP-1 receptor agonist, if they were pregnant or postpartum during the inclusion window, had a recent major surgery, had prolonged hospitalization (intensive care unit stay > 72 hours and/or medical‑surgical unit admission > seven days), active cancer treatment, or uncontrolled HIV. The primary outcome was the change in weight from baseline at 12-months. Secondary outcomes included weight changes at three and six months and changes in A1C at six and twelve months. Statistical analysis was completed using an independent t-test for continuous data and a chi-squared test for categorical data.

Results: A total of 158 patients were included (66 antibiotic‑exposed and 92 controls). Baseline characteristics were balanced, although a higher proportion of patients in the antibiotic arm were receiving medications with potential for weight gain than in the control arm (54.5% and 27.2%, respectively). Antibiotic‑exposed patients also had a higher median number of clinic visits per year than controls: 8.5 and 6.5 visits. Patients received a mean of 2.8 antibiotic courses and a median of 15 days per course. Amoxicillin/clavulanate, azithromycin, and doxycycline were the most frequently prescribed antibiotics. There was no difference in weight change at 12 months between the antibiotic and no-antibiotic groups (0.84 kg vs -0.2 kg, p=0.16). No differences were observed in weight at three or six months, nor in A1C at six and twelve months.

Conclusion: There was no difference in 12‑month weight change between antibiotic-exposed and unexposed adults. However, this data indicates a need for further investigations that include a prolonged follow-up period, targeted evaluation of high-dysbiosis-risk antibiotics, and cumulative antibiotic consumption, while accounting for exposure to other weight-impacting factors such as medications and comorbid conditions.  

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Background: Urinary tract infections (UTIs) are among the most common bacterial infections worldwide, with Enterobacterales being the predominant pathogens. The rise in prevalence of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) has led to increased antimicrobial resistance and recurrence rates. This prompts evaluation of alternative treatments such as amoxicillin-clavulanate, in which clavulanate may restore amoxicillin activity against common ESBL enzymes. The IDSA 2024 Antimicrobial-Resistant Gram-Negative guidelines recommend against its use but fail to cite high-quality evidence studying its efficacy in UTIs caused by ESBL-E. Other studies, limited by small sample size, suggest clinical efficacy of amoxicillin-clavulanate in the treatment of UTI caused by ESBL-E. This study attempts to bolster the body of data showing amoxicillin-clavulanate can be as effective as standard of care (SOC) antibiotics for the treatment of UTI caused by ESBL-E. 

Methods: This multi-site, retrospective cohort study is approved by the Institutional Review Board. Adult patients (≥18 years) with either uncomplicated or complicated UTI with a urine culture positive for ESBL-E (confirmed via susceptibility testing) treated between April 1, 2024, and July 1, 2025, at Atrium Health Wake Forest Baptist facilities were included. Patients must have received at least 72 hours of amoxicillin-clavulanate or SOC therapy. Patients were excluded if they had concurrent bacterial infections, polymicrobial urine cultures, a previous UTI within 90 days already captured in the dataset, anatomic urinary tract abnormalities or instrumentation, renal abscesses, prostatitis, received in-vitro active antibiotic lead-in therapy for >50% of treatment duration, were immunosuppressed, or used methenamine or antibiotics for prophylaxis. The primary endpoint is clinical failure within 90 days, defined as retreatment with antibiotics and either recurrence of UTI symptoms or a repeat urine culture positive for the same organism as the index infection. Secondary endpoints include recurrence of resistant organisms (carbapenem-resistant Enterobacterales, SOC-resistant, or amoxicillin-clavulanate-resistant strains) within 90 days and time to clinical failure. Chi-square or Fisher’s exact tests tested categorical variables, and t-tests or Mann-Whitney U tests will test continuous variables. Kaplan-Meier survival analysis and Cox regression will assess time-to-event outcomes, and multivariable analysis will be used to identify patient factors associated with clinical failure. 

Results: A total of 688 patients were screened; 274 patients met the inclusion criteria and were analyzed. Fifty-four patients were included in the amoxicillin-clavulanate group, and 220 in the SOC group. No statistically significant difference was observed in the primary outcome of treatment failure between the SOC and amoxicillin-clavulanate groups (p = 0.11). Patients with a prior history of ESBL infection had more than twice the odds of treatment failure (OR 2.09; p = 0.04), a finding that remained significant after adjustment for antibiotic selection and UTI type (OR 2.11, p = 0.047). Additionally, the use of sulfamethoxazole-trimethoprim for treatment of the index infection was associated with an 80% reduction in clinical failure compared to amoxicillin-clavulanate (p = 0.008). 

Conclusions: Among patients treated with antibiotics for urinary tract infections caused by ESBL-producing Enterobacterales species, there was no statistical difference in effectiveness between amoxicillin-clavulanate and SOC within the limits of this study design.