2026 Southeastern Residency Conference

Authors: Cameron Howell, PharmD; Layla Marefat, PharmD 

Background: Asymptomatic bacteriuria (ASB) is the presence of bacteria [>100,000 colony forming units per milliliter (CFUs/mL)] in the urine without associated genitourinary symptoms.  Up to 60% of patients with ASB [and an additional 40% with asymptomatic pyuria and/or nitrituria (ASPN)] receive antibiotics when not indicated. Reflex urine culture algorithms are a tool used to decrease urine culture rates, which reduces unnecessary antibiotic use. Typically, the reflex criteria for these algorithms include urinalysis components, of which pyuria is the most reliable for predicting a clinically significant urinary tract infection (UTI). In 2018, reflex urine cultures were implemented at the Baptist Health System using a traditional cutoff of >5 white blood cells per high power field (WBC/HPF) for pyuria. A recent study found that <10 WBC/HPF has a similarly high negative predictive value for UTI than less stringent cutoffs. Thus, in July 2025, the definition for pyuria was refined to >10 WBC/HPF, leading to a threefold increase in overrides of the algorithm.  The aim of this study is to evaluate the impact of delivering education to providers on adherence to a urine culture guidance algorithm.
 
Methods: A retrospective chart review was conducted on adult patients at a community hospital who had a urine culture obtained from an override of established reflex criteria. The primary outcome was the percentage of inappropriate urine culture overrides. It was assessed for a pre-intervention phase from January 1, 2025, to April 30, 2025, and compared to the post-intervention phase from October 1, 2025, to January 31, 2026. Education was provided to hospitalists, emergency medicine providers, and intensivists.  Secondary outcomes included hospital length of stay (LOS), days of therapy (DOT) for patients with an inappropriate urine culture override that received antibiotics for UTI, and concordance of provider inputs for symptoms or "At Risk Population” on the urine culture order with patient chart documentation.

Results: 76 patients were evaluated in the pre-intervention group while 175 patients were evaluated in the post-intervention group. Most urine cultures obtained from overrides resulted in no growth or normal urogenital flora (76.3% vs. 62.3%, p = 0.030). Despite a reduction in inappropriate urine culture overrides compared to the pre-intervention phase, this difference was not statistically significant (57.8% vs. 48.0%, p = 0.15). Hospital LOS, DOT for those with inappropriate urine culture overrides, and concordance of provider inputs for symptoms on the order with patient chart documentation also were not significantly affected. The concordance of provider inputs for “At Risk Population” on the order with patient chart documentation was significantly higher in the post-intervention group (14.3% vs. 68.8%, p < 0.001).

Conclusions: Pharmacist education to providers was not effective in reducing inappropriate urine culture overrides. However, significant limitations were present, especially the difference in reflex criteria between groups. Nevertheless, most urine cultures did not yield clinically significant growth. Additional interventions must be pursued in addition to education to target higher adherence to a reflex urine culture algorithm.

Evaluating Antibiotic Overuse at Hospital Discharge for Uncomplicated Community Acquired Pneumonia and Urinary Tract Infections: A Retrospective Review
 
Blake McClellan, Sarah Grace Gunter, Noah Sanford, Braxton Clines, Elizabeth Covington

Abstract
Purpose: Inappropriate antibiotic prescribing at the time of hospital discharge represents a significant challenge to antimicrobial stewardship. Antibiotic overprescribing can carry serious consequences, such as antimicrobial resistance, adverse drug events, and increased healthcare costs. Studies have found high percentages of patients discharged with antibiotic durations exceeding guideline duration for urinary tract infections and community acquired pneumonia. This project evaluated discharge antibiotic prescribing at a community hospital located in the southeastern United States.

Methods: This retrospective chart review was approved by the Institutional Review Boards at East Alabama Medical Center (EAMC) and Auburn University. Study participants were screened from a pre-existing dataset of patients with infectious disease tests resulting post-discharge from August 2022 through October 2024. Inclusion criteria were as follows: findings consistent with uncomplicated urinary tract infection or community acquired pneumonia, discharged alive, and inpatient encounter with microbiology testing performed at EAMC. Exclusion criteria included patients with blood or urine culture contamination, Candida sp. growth in sputum, Pseudomonas sp. growth in stool, vaginal Group B Streptococcal swabs, no inpatient encounter, transfer to another facility at discharge, death prior to culture result, or classification as vulnerable population (<18 years or incarceration). The primary endpoint was percentage of patients with antibiotic overuse post-discharge based on the Vaughn et al. definition: unnecessary antibiotic use, excess duration of antibiotic use, and/or suboptimal use of fluoroquinolone therapy. Secondary endpoints included individual components of the antibiotic overuse definition, median days of antibiotic overuse after discharge, total antibiotic duration, duration of inpatient versus outpatient antibiotics, percentage of antibiotic course accounted for by outpatient antibiotics, percentage of patients with antibiotic order changes during hospital stay, percent overuse based on discharging services and presence of infectious diseases consult. Data were analyzed using descriptive statistics for the overall cohort, with additional comparative analyses performed between patients with and without antibiotic overuse using SPSS (IBM Corp., 2024).

Results: Nearly half (47/100, 47%) of patients experienced antibiotic overuse at hospital discharge. Overuse was driven primarily by excess duration of therapy, while unnecessary antibiotic initiation and suboptimal use of fluoroquinolones was less common. Among patients with overuse, the median number of excess antibiotic days was 3 days (IQR 2,5). The median total duration of therapy was 8 days (IQR 7,10), compared with a median ideal duration of 5 days (IQR 3,7). Most antibiotic exposure occurred in the outpatient setting (78%). When comparing patients with and without antibiotic overuse, there was no difference in overuse based on diagnosis, demographics, insurance status, or discharging service. More patients who experienced antibiotic overuse received a dose in the emergency department (17% vs. 3%, P = 0.044).

Conclusions: Antibiotic overuse at discharge for uncomplicated infections is common at this institution and is primarily driven by excess duration of therapy. The findings from this study help support prior literature and highlight opportunities for antimicrobial stewardship at transitions of care. Direction of future studies may include pharmacist-led interventions at the time of discharge to influence durations of therapy, and further evaluation of predictors of antibiotic overuse at discharge.

Title: Comparison of Ketamine Monotherapy versus Ketamine and Propofol for Procedural Sedation in the Pediatric Emergency Department and the Impact on Time to Discharge 
 
Authors: Francesco Mottola; Andrea Gerwin; Maggie Raker; Sarah Sterner; Morgan Padron 
Background/Purpose: Optimizing sedation for procedures in the pediatric emergency department (PED) is essential for effective pain control and timely discharge. Ketamine is commonly used as monotherapy, but its associated adverse effects may delay recovery. Combining ketamine with propofol may reduce these effects, potentially shortening time to discharge. However, whether this combination leads to faster discharge compared to ketamine alone remains unclear within current literature. The purpose of this study is to compare discharge times between ketamine monotherapy versus ketamine and propofol when used for procedural sedation in the pediatric emergency department. 
 
Methods: This study is a single-center, retrospective, chart review utilizing electronic health records of patients treated in the PED at the Children’s Hospital at Erlanger between January 1, 2023 and October 30, 2024. Patients were included if they were less than 18 years of age and received either ketamine or the combination of ketamine and propofol for procedural sedation with moderate depth sedation targets. Exclusion criteria included medically complex patients, patients with hypersensitivity to either ketamine or propofol, and patients admitted to the hospital after receiving procedural sedation in PED. The primary outcome is to evaluate whether the combination of ketamine and propofol leads to a quicker discharge time than the use of ketamine alone when used for procedural sedation in the PED. Secondary outcomes include the overall rate of adverse events, administration of pre‑sedation antiemetics, nausea, emesis, emergence reactions, and the mean sedation duration. 
 
Results: Preliminary data included a total of 220 patients with 109 in the ketamine group and 111 in the combination of ketamine and propofol group, respectively. Preliminary results indicate that the mean dose of ketamine was 1.95 mg/kg ± 0.74 in the ketamine group compared to 1.21 mg/kg ± 0.43 in the ketamine and propofol group. The average dose of propofol was 2.38 mg/kg ± 1.12 when used in combination with ketamine. In the ketamine group, the mean duration of sedation was 23.08 minutes ± 16.4 with a mean discharge time of 155.7 minutes ± 105.6 (p< 0.001) compared to a mean sedation duration of 25.33 minutes ± 8.5 in the ketamine and propofol group with an average time to discharge of 112.40 minutes ± 39.57 (p< 0.001). In the ketamine group, 74 patients (67.3%) received pre‑sedation antiemetics, compared with 59 patients (53.2%) in the combination of ketamine and propofol group (p= 0.25). Overall adverse events were reported in 33 (30%) of patients in the ketamine group compared to 10 (9.1%) in the ketamine and propofol group (p < 0.0001). The most common adverse events reported in the ketamine group were emesis (33%) and nausea (45%). In the ketamine and propofol group, the adverse events reported were nausea (70%) and emesis (10%). No emergence reactions were observed between either group. 
Conclusions: The use of ketamine and propofol for procedural sedation within the pediatric emergency department may decrease the time to discharge when compared to ketamine alone. This is likely due to the lower incidence of adverse events seen with the combination of ketamine and propofol. When used in combination, lower doses of ketamine were more likely to be used, which may contribute to the lower reported rate of adverse effects. However, patients within the ketamine group were also more likely to receive pre-sedation antiemetics when compared to the ketamine and propofol combination group, which may also impact incidence of adverse effects. 

Title: The Impact of Inhaled Antibiotic Use in Critically Ill Neonatal and Pediatric Populations
Authors: Madeline DiCenso, Andrea Gerwin, Renee Hughes, Paige Klingborg
Background/Purpose: Pediatric and neonatal patients with chronic lung disease or tracheostomies face an elevated risk of pulmonary bacterial infections due to impaired airway clearance and chronic colonization. Prophylactic inhaled antibiotic (iAbx) use is described in cystic fibrosis (CF) patients but is minimally explored in tracheostomized and critically ill children without CF. Retrospective data suggests benefits to prophylactic iAbx therapy, including reduced rates of re-hospitalization and systemic antibiotic use with minimal associated side effects. However, published guidelines directing use do not currently exist. This study will describe our institution’s use of iAbx in critically ill pediatric and neonatal patients, evaluate optimal dosing strategies, and analyze potential improvements in clinical outcomes.
Methods: This was a single center, retrospective, observational chart review conducted using electronic health records from patients admitted to the neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) at Children’s Hospital at Erlanger between July 1, 2022, and July 1, 2025. Patients were included if they received iAbx during admission. Patients who did not receive iAbx or with Cystic Fibrosis were excluded. The primary outcome of the study was to describe the usage patterns of iAbx in the NICU and PICU. The secondary outcomes were to evaluate potential benefits of continuous or cycled use of iAbx and to analyze how use of inhaled antibiotics may impact clinical and functional outcomes, such as respiratory status, and days of systemic antibiotics. Due to the young age of our study population, we evaluated days of systemic antibiotics compared to days of life (DoL). Safety outcomes included resistance patterns, and hearing screen results.
Results: Preliminary results on utilization patterns indicate that mean age at initiation of therapy was 29.71 months (1–204-month range). Tobramycin was nebulized at a dose of 300 mg twice daily with the most common duration therapy of 28 days. Before iAbx therapy was initiated, patients had fewer average systemic abx days per DoL (1:14.07) compared to an increased ratio (1:9.54) after iAbx. Fraction of inhaled oxygen (FiO2) requirements were higher in the 14 days prior to iAbx initiation (average 36.7%) compared to the 14 days following iAbx initiation (average 29.7%). Data regarding the safety profile of inhaled antibiotic therapy is still in process.
Conclusions: The use of iAbx in critically ill pediatric patients at Children’s Hospital at Erlanger closely matches regimens presented in other primary literature. There may be an improvement in respiratory status represented by improved ventilator settings associated with use of inhaled antibiotic therapy. Although systemic antibiotic days normalized for DoL increased after therapy initiation, interpretation is limited by varied initiation times, with post‑treatment data constrained by the study’s fixed endpoint. Data regarding safety of inhaled antibiotic therapy and resistance patterns amongst the trial population is ongoing.

Impact of Opioid-Sparing Multimodal Pain Management Order Set on Opioid Use and Clinical Outcomes in Thoracic Surgery Patients

Authors: Kylie Michot, Michael Ezebuenyi, Monica Campbell, Jennifer Jones, Greggory Davis

Background: Multimodal analgesia optimizes postoperative pain management while reducing opioid use and associated risks. Pain management is achieved by optimizing the synergistic effects of non-opioid medications with complementary mechanisms of action. The Enhanced Recovery After Surgery (ERAS) Society recommends multimodal analgesia over scheduled opioid therapy for thoracic surgery postoperative pain management. While current evidence highlights the benefits of multimodal strategies, further research is needed to evaluate opioid-sparing effects and clinical impact after thoracotomy. This study evaluates whether implementation of a postoperative multimodal analgesia regimen within an ERAS protocol reduces opioid utilization among thoracic surgery patients undergoing thoracotomy compared to traditional opioid-based postoperative pain management.
Methods: This single-center, retrospective chart review evaluated patients admitted to FMOL Health – Our Lady of the Lake between March 2017 and September 2025 who underwent thoracotomy and received postoperative analgesics from a standardized order set. Patients were excluded if they were younger than 18 years or older than 80 years of age, receiving renal replacement therapy, pregnant, receiving comfort care, or had a documented allergy to a medication included in the order set.
The primary outcome was three-way comparison of opioid utilization, measured in morphine milligram equivalents (MMEs), in patients receiving a multimodal pain management protocol versus usual care with opioids for pain management after a thoracotomy on post-operative day (POD) 0, POD 1-3, and total postoperative length of stay (LOS). Secondary endpoints included chest tube duration, post-operative ventilator duration, intensive care unit (ICU) LOS, hospital LOS, average pain control score on POD 1 and POD 3, time to first dose of opioids after surgery, and opioid prescriptions upon discharge.
Results: A total of 156 patients were included in this study with 78 patients in each group. Regarding baseline characteristics, the majority of the multimodal group had a higher American Society of Anesthesiologists (ASA) Physical Status Score (ASA score >3, 17% vs. 46%; P < 0.001), an overall lower number of female patients (67% vs. 44%, P = 0.004), and patients over the age of 60 (median age, 60 vs. 66; P = 0.005). No difference in inpatient opioid consumption was seen between groups on POD 0 (17 vs. 20; ratio, 1.2; 95% CI 0.68 to 2.05; P = 0.78). There was a statistically significant reduction in inpatient opioid consumption between groups on POD 1-3 (83 vs. 20; ratio, 0.19; 95% CI, 0.11 to 0.34; P < 0.001) and total postoperative LOS (130 vs. 55; ratio, 0.38; 95% CI, 0.24 to 0.62; P < 0.001). Multimodal analgesia reduced pain score on POD 1 (median pain score, 4.6 vs. 3.5; P = 0.003) but had no difference in pain score on POD 3 (median pain score, 3.8 vs. 3.0; P = 0.07). Additionally, multimodal analgesia was associated with decreased chest tube duration (median chest tube days, 3.1 vs. 2.2; P = 0.003), and decreased hospital LOS (median LOS, 4 vs. 3; P = 0.010). There was no difference in discharge opioid prescription MMEs (median discharge MMEs, 225 vs. 300; P = 0.89).
Conclusion: Among patients undergoing thoracotomy, a multimodal analgesia regimen with an ERAS protocol was associated with significant reductions in opioid utilization during POD 1-3 and total postoperative hospitalization but did not demonstrate a difference on POD 0. Limitations include the retrospective nature of this single site study and the inability to access opioid usage data from patient-controlled analgesia (PCA) pumps.
Contact Information: [email protected]

AUTHORS: Brittany Shellhouse, Eric Shaw, Amy Taylor

BACKGROUND: National Healthcare Safety Network (NHSN) defines a surgical site infection (SSI) as an infection that was not present at time of surgery but occurred within 30 days post-operatively. Due to their significant effect on morbidity, hospital length of stay, and costs, national guidelines recommend initiation of most pre-operative antibiotics within 60 minutes of surgery. They also include specific guidance on the choice of agent to use with the various types of procedures, as well as dosing recommendations and re-dosing strategies. The purpose of this study was to examine if there is a correlation between timing of pre-operative antibiotics on the development of post-operative infections, and to examine other potential risk factors for the development of SSIs.

METHODS: This study was a retrospective, single-center, case-control study, which took place at a level-one trauma academic medical center in the United States. It included adults who received pre-operative antibiotics for colorectal and/or hysterectomy surgeries between January 1, 2023 through September 26, 2025. Patients were excluded if they had infections documented as present at time of surgery, or if they were pregnant or incarcerated at time of admission. The event group included patients with NHSN defined SSIs. The control group was matched 1:1 based on surgery type and consisted of patients who did not have a documented SSI. Patients were identified with assistance from the Infection Prevention Workgroup’s data collection of all surgical procedures.

The primary endpoint compared association of antibiotic timing with incidence of post-operative infection. Secondary outcomes included the comparative risk of antibiotic(s) selection, surgery type, emergent versus scheduled surgery, administration of repeat dosing during surgery, continuation of post-operative prophylactic antibiotics, and personnel present at surgery.

RESULTS: This study included 96 total patients matched 1:1 with events versus controls within each group for hysterectomy, colorectal surgeries, and colorectal plus hysterectomy surgeries (40 patients, 52 patients, and 4 patients respectively). For the primary outcome, the median time of antibiotic start and completion prior to surgery was 23 minutes and 15 minutes for the control group and 15.5 minutes and 9 minutes for the event group.
While all antibiotics selected for hysterectomy procedures were correct per guidelines, there was a numerical difference in optimized dosing for the control versus the event group (85% vs 65% respectively). Similarly, all patients were in compliance with repeat dosing per guidelines, but zero patients in the control group received antibiotics post-operatively compared with 5% of patients in the event group.

Appropriate antibiotic selection for colorectal procedures was 65% versus 54% for the control versus the event group; optimized dosing per guidelines was 67% versus 77% for controls versus event group. There was a numerical difference for control versus event group in required repeat per protocol (91% vs 70%), bowel prep administration (58% vs 19%), and use of post-operative antibiotics (27% vs 58%).
For combination colorectal surgery plus hysterectomy, there was a numerical difference in incidence of emergent surgeries for control versus event group (0% vs. 50%). However, this difference was inverse for antibiotic selection with 50% versus 100% compliance for control versus event group.

CONCLUSION: There was a numerical difference in perioperative timing of antibiotics, but no definitive trend in additional factors for increasing risk of SSI development. Limitations to this study were small sample size and inclusion of only two surgery types. Further research across various surgery types may be beneficial in distinguishing perioperative antibiotic timing.

Background: The treatment landscape for relapsed/refractory multiple myeloma (RRMM) has expanded with BCMA- and GPRC5D-directed CAR T-cell therapies and bispecific antibodies (BsAb), which differ in treatment logistics, durability of response, and toxicity profiles, including cytokine release syndrome (CRS), immune effector cell–associated neurotoxicity syndrome (ICANS), infections, and prolonged cytopenias. Comparative real-world data between these modalities remain limited. This study aims to compare treatment-related toxicities between CAR T-cell and bispecific antibody therapies in RRMM, with secondary objectives assessing duration of response, infection risk, hematologic recovery, and timing of CRS and ICANS.
Methods: This single-center, retrospective study included adult patients (≥18 years) with RRMM who received BCMA-directed CAR T-cell therapy with idecabtagene vicleucel or ciltacabtagene autoleucel or BsAb therapy with teclistamab, elranatamab, and talquetamab between March 1, 2021, and February 28, 2025. Descriptive and comparative statistical analyses were conducted to evaluate differences between treatment modalities. The primary objective was to compare treatment-related toxicities, including the incidence and severity of CRS, ICANS, cytopenia, and infections, between patients receiving CAR T-cell therapy and BsAb therapy for relapsed/refractory multiple myeloma. The key secondary objective included duration of response.
Results: A total of 59 adult patients with relapsed or refractory multiple myeloma were included in the study, with 34 receiving CAR T-cell therapy (idecabtagene vicleucel or ciltacabtagene autoleucel) and 25 receiving bispecific antibodies (teclistamab, talquetamab, or elranatamab). Mean age at treatment initiation was similar between CAR T and bispecific therapy groups (62 vs 65 years), as was the median number of prior lines of therapy (4 vs 4). CRS occurred in 66.1% (39/59) patients. Among those with CRS, the maximum documented grade was grade 1 in 69.2% (27/39) patients, followed by grade 2 in 25.6% (10/39), and grade 3 in 5.1% (2/39) patients. CRS occurred more frequently with CAR T therapy compared with bispecific antibodies (73.5% vs 56.0%). ICANS was observed in 18.6% (11/59) patients and occurred at similar rates between those receiving CAR T and bispecific antibody therapy (17.6% vs. 20%). Cytopenias, defined as neutropenia (ANC <1,000 cells/µL) and/or thrombocytopenia (platelets <50 ×10⁹/L), were identified in 39% (23/59) of patients and occurred more frequently with CAR T therapy compared with bispecific antibody therapy (65.2% vs 34.8%). Documented infections occurred in 10/59 (16.9%) patients and were observed at equal rates between CAR T-cell and bispecific antibody therapies. For secondary outcome, the analysis included a total of 35 patients, with 25 patients in the CAR T-cell therapy group and 10 patients in the bispecific antibody group. Patients who received CAR T-cell therapy had longer duration of response. There was a significant difference in duration of response between the two groups (p=0.012).
Conclusions: In this single-center retrospective study, CAR T-cell and bispecific antibody therapies demonstrated comparable overall safety profiles in patients with relapsed or refractory multiple myeloma. Incidence of grade 1 CRS was common and occurred more frequently with CAR T therapy. ICANS and infections occurred at similar rates between treatment groups, while cytopenias were observed more often in patients receiving CAR T therapy. These findings provide real-world insight into the safety profiles of emerging therapies used in the relapsed or refractory setting and may help inform clinical decision-making as use of these agents continues to expand.
  

---

 [KN1]included

Background:
Approximately 10% of patients report a penicillin allergy; however, fewer than 1% of the population have an IgE-mediated allergy. Penicillin allergy evaluation involves obtaining a detailed history of the reported reaction and may include diagnostic testing such as skin testing and/or an oral penicillin challenge. When appropriate, this process can result in the removal of the allergy label from a patient's medical record, a process known as allergy de-labeling. This practice has been well studied and is considered safe among the general population. Given its safety and effectiveness, the American College of Obstetricians and Gynecologists (ACOG) encourage penicillin allergy evaluation for any patient with a documented penicillin allergy; however, despite these recommendations, this patient population is less likely to undergo evaluation for allergy de-labeling.  
 
Antimicrobial use in pregnancy is common, particularly for managing Group B Streptococcus (GBS), cesarean section prophylaxis, and infectious complications such as chorioamnionitis. ACOG guidelines recommend beta-lactam antimicrobials, including ampicillin and cefazolin, as first-line agents for prophylaxis and treatment during the peripartum period. However, patients labeled as penicillin-allergic are often prescribed second-line, broad-spectrum antimicrobials instead. Wellstar MCG Health (WMCGH) implemented a new penicillin allergy screening assessment process for obstetrics and gynecology patients in September 2025. The purpose of this study is to expand upon existing literature by evaluating the outcomes of this new assessment.  

Methods:
This is a single center, retrospective, chart review study evaluating the outcomes of a newly implemented penicillin allergy screening assessment in obstetrics and gynecology patients. All patients 18 years or older who were seen at pre-specified WMCGH women’s clinic locations with a documented penicillin allergy were eligible for enrollment. Patients were excluded if they did not have established care with WMCGH prior to admission and if they were admitted for a non-related OB/GYN encounter. The primary outcome was the difference in the incidence of guideline recommended first-line antimicrobials received for GBS, chorioamnionitis, and surgical prophylaxis. Secondary outcomes included hospital length of stay, incidence of de-labeled penicillin allergy, rate of postpartum and surgical site infections, total days of antimicrobial use, 30-day hospital re-admission, and antimicrobial cost savings.  

Results:
A total of 140 patients were included with 97 patients in the pre-implementation group and 43 patients in the post-implementation group. For the primary outcome, 20% of patients in the pre-implementation group received first-line antimicrobials compared to 43% in the post implementation group (p = 0.106). Implementation of penicillin allergy screening was associated with a 29% relative risk reduction in patients receiving non-first line antimicrobial therapy. There was no difference in hospital length of stay between the two groups, and 30-day hospital re-admission was 10% vs. 5% in the pre- and post-implementation groups respectively. The rate of postpartum and surgical site infections was similar between pre- and post-implementation groups (4% vs 5%, p = 0.891) in addition to the total days of antimicrobial use (0.3 vs 0.2 days, p = 0.460). A total of 3 patients (7%) were de-labeled based on penicillin allergy assessment. The pre-implementation group demonstrated higher overall drug cost utilization, largely driven by more costly antimicrobial agents ordered. This difference may become more pronounced with a larger sample size, suggesting potential for meaningful cost savings at scale.

Conclusion:
Patients in the post-implementation group received guideline-recommended first-line antimicrobials more often than those in the pre-implementation group; however, this study was underpowered to detect statistical significance. Patients in the post-implementation group that were appropriately identified and screened were able to be successfully de-labeled. Most de-labeling occurred through an allergy/immunology referral consult and oral amoxicillin challenge. Further studies with larger sample sizes are warranted to better evaluate the impact of this intervention.  

[email protected]

Background/Purpose: Neonatal sepsis remains a leading cause of neonatal mortality in the United States despite advances in intrapartum screening and antibiotic administration. Late onset sepsis (LOS) is defined as suspected or confirmed sepsis at greater than seventy-two hours of life. Patient presentation is often nonspecific, creating a low threshold for empiric treatment, which may lead to unnecessary antimicrobial administration and increased development of resistant organisms. Previously, there was not a standardized workflow for treating LOS in our neonatal intensive care unit (NICU) and special care nursery (SCN). This led to variations in practices and created an opportunity for care optimization. A pharmacy-driven order set for empiric therapies in the treatment of LOS was implemented at our institution, composed of screening suggestions and empiric antibiotic recommendations based on specified patient risk factors. This review evaluated the appropriate use of this new order set and how effectively LOS is managed by evaluating appropriate antimicrobial selection and culture collection.
 
Methodology: This was a multi-center, IRB-reviewed determined exempt, retrospective cohort review conducted at the Moses Cone Memorial Hospital NICU and Alamance Regional Medical Center SCN in Greensboro and Burlington, NC, respectively. On November 1, 2024, a pharmacy-driven order set for empiric neonatal LOS treatment went live at both sites. For this evaluation, patients were included if they were admitted to either site and received antimicrobial agent(s) for the treatment of LOS. Patients were excluded if they received antimicrobial(s) for another known indication or if they received antimicrobial agent(s) but were not admitted to one of the study locations. Patients were then divided into a pre-group from December 1, 2023 through October 31, 2024 and a post-group from December 1, 2024 through October 31, 2025. The primary outcome was the composite of positive cultures covered by empiric antibiotics and adequate coverage of “culture negative” sepsis with empiric antimicrobials based on patient risk factors and suspected infection source. Secondary outcomes included number of instances in which 2 initial blood cultures were obtained, percentage of patients with positive blood cultures who had repeat blood cultures obtained, average days of therapy, use of the late onset sepsis order set, and whether appropriate doses of antimicrobials were utilized.  
 
Results: 89 instances of LOS in 60 patients were included in the study. There were 51 instances of LOS included in the pre-order set group, and 38 instances included in the post-order set group. The primary composite outcome of positive cultures covered by empiric antibiotics and adequate coverage for culture negative sepsis was 71% in the post-order set group and 66.7% in the pre-order set group (p=0.659). In the post-order set group, providers were more likely to obtain a set of two blood cultures (instances with 2 initial blood cultures obtained 5.9% vs 57.9%, p<0.001). The pharmacy-driven order set was utilized in 55.3% of instances in the post-order set group. Other secondary outcomes were similar between groups.
 
Conclusions: The implementation of a pharmacy-driven order set at our institution resulted in a clinically significant increase in empiric coverage of culture negative sepsis and significant trend in increase in number of initial blood cultures collected. There was not a significant difference in the percentage of positive cultures covered by empiric antibiotics. Common reasons that empiric therapy did not cover culture negative sepsis included lack of anaerobic coverage in suspected infections of intraabdominal sources and lack of MRSA coverage in patients with MRSA risk factors. Potential limitations to this evaluation include limited sample-size, single-institution review, and variability of provider preference. Future directions include assessing barriers to utilization of the LOS order set and implementation of strategies to increase utilization.

Evaluation of RSV hospitalizations in high-risk infants who received nirsevimab vs. palivizumab 
Authors: Allison Lopez, Courtney Campbell, Erica Gray, Katelyn Gibson 

Background 
Respiratory syncytial virus (RSV) is a common acute respiratory infection that can cause mild cold-like symptoms in most infants, but some high-risk infants, such as those born prematurely or with chronic lung or congenital heart disease, can develop severe disease requiring hospitalization. Prophylaxis is the most effective way to prevent severe RSV infection. Palivizumab and nirsevimab are monoclonal antibodies that provide passive immunity by preventing RSV from entering healthy cells. Palivizumab requires monthly dosing during RSV season, while nirsevimab is given as a single dose for the entire season. Our institution recently switched from palivizumab to nirsevimab following updated ACIP, CDC, and AAP guidance. There is established data supporting palivizumab use in high-risk infants, but limited evidence exists for nirsevimab in this population. This study aims to compare RSV-related hospitalizations in high-risk infants receiving nirsevimab versus palivizumab to inform RSV prophylaxis use at our institution. 

Methods 
This is a single-center retrospective chart review of high-risk infants who received palivizumab or nirsevimab for RSV prophylaxis during the 2022-2023 or 2024-2025 season, respectively. High-risk infants include those born prematurely and those with chronic lung disease or significant congenital heart disease. Infants were included if they met institutional criteria for RSV prophylaxis and received at least one dose of nirsevimab or palivizumab. The primary outcome was the number of hospitalizations with confirmed RSV infection. Secondary outcomes included risk factors for severe RSV, number and timing of prophylactic doses, timing of hospitalization relative to dosing, and the number of confirmed RSV cases in Georgia. The purpose of this study was to evaluate whether a single dose of nirsevimab is sufficient for high-risk infants throughout the RSV season through comparison of hospitalization rates between infants receiving palivizumab versus nirsevimab. 

Results 
A total of 146 patients were included in this study, with 82 patients receiving nirsevimab and 64 patients receiving palivizumab. The patients in the two groups were similar regarding baseline characteristics, and the majority of patients were African American. Of the patients included, four were hospitalized with confirmed RSV infection. Three of these patients had received nirsevimab and one had received palivizumab. There was no significant difference seen in the primary outcome comparing hospitalizations in the nirsevimab group and the palivizumab group (P = 0.63). 

Conclusions 
This single-center retrospective chart review demonstrates that the use of nirsevimab for RSV prophylaxis does not increase the risk of hospitalization in high-risk infants compared to palivizumab. No statistically significant difference was seen between nirsevimab and palivizumab in terms of RSV-related hospitalizations. The results of this study support continued utilization of nirsevimab for RSV prophylaxis in high-risk infants. 

Contact: [email protected] 

Background: Acute pyelonephritis is a common and potentially serious bacterial infection of the upper urinary tract that frequently results in emergency department (ED) visits and hospitalizations. The most recent Infectious Diseases Society of America (IDSA) guidelines for the management of complicated urinary tract infections (cUTI), include levofloxacin, ciprofloxacin, and sulfamethoxazole-trimethoprim as first line options. Rising antimicrobial resistance among Enterobacterales rases concern for their effectiveness. Thus, clinicians often turn to oral beta-lactams. While well tolerated, their efficacy for pyelonephritis is less established due to lower renal tissue concentrations and variable oral bioavailability. However, recent evidence indicates favorable outcomes with oral beta-lactams. 
Additionally, given the increasing prevalence of extended-spectrum beta-lactamases (ESBLs), understanding the impact of antibiotic selection on the development of future resistance is essential to optimizing antibiotic selection.  
This study aimed to evaluate the comparative effectiveness and downstream resistance outcomes of oral beta-lactam therapy versus first-line agents for the treatment of acute pyelonephritis among adults discharged from the ED. 
 
Methodology: This was a multi-site, retrospective, observational cohort study comparing clinical outcomes and the emergence of ESBL organisms in patients treated for pyelonephritis using first-line agents versus beta-lactam antibiotics. Patients 18 years or older with an ICD-10 code diagnosis of pyelonephritis, a positive urine culture, and an outpatient antibiotic prescription for at least 7 days during the study period from April 1, 2024, to July 8, 2025, were included. Patients were excluded if they had polymicrobial cultures, prior ESBL-producing organism within 3 months, more than one dose of intravenous antibiotics, diagnoses of prostatitis, orchitis, epididymitis, or pregnancy, and patients requiring change of prescription from index visit. The primary outcome was rate of treatment failure within 30 days of the initial ED visit; secondary outcomes included antibiotic selection, dosing, duration, and rates of ESBL emergence.  
Data collection included baseline characteristics such as age, sex, comorbidities, and urine culture resistance patterns within 3 months prior to the ED visit. Statistical analysis was conducted using Pearson’s Chi-squared tests for categorical variables, Student’s t-tests for continuous variables, and univariate regression for association between antibiotic choice and treatment failure. 
Results: A total of 1,396 patients were included in the study between April 2025 and July 2025, 792 patients in the beta-lactam and 604 in the first-line therapy group. The most common reason for exclusion was a change in antibiotic therapy following identification of resistance to the initial agent. 
Patient characteristics and demographics were well balanced between the groups. Most patients were female (89%), non-Hispanic or Latino (78%), and 46% received intravenous antibiotics in the emergency department. The most frequently identified baseline pathogen was Escherichia coli (74%), followed by Klebsiella species (7.6%). 
The primary outcome, treatment failure, occurred in 78 patients (5.6%), including 53 (6.7%) in the beta-lactam group and 25 (4.1%) in the first-line group (p = 0.040). Guideline appropriate dosing was observed in 477 patients (64%) in the beta-lactam group compared to 571 patients (99%) in the first-line group (p < 0.001). Cefdinir was prescribed 142 (10.8%) times but is not recommended in the IDSA guidelines for pyelonephritis. The most frequently guideline non-compliant therapy was cephalexin, which was appropriately dosed in only 38% (14/68) of cases. ESBL emergence was rare, occurring in 5 patients (0.4%), with 4 cases in the beta-lactam group and 1 case in the first-line group (p = 0.4). 
Conclusions: Treatment failure was more frequent in the beta-lactam group.  This finding is potentially attributable to inappropriate antibiotic selection and suboptimal dosing. Specifically, the overuse of cefdinir and underdosing of cephalexin likely contributed to these treatment failures. Additionally, our investigation did not demonstrate a significant association between antibiotic choice and the development of ESBL. 

Effect of Antibiotic Selection on Clinical Outcomes in Patients with Bloodstream Infections Caused by AmpC β-lactamase–producing Enterobacterales
Phuong Giao Nguyen Tran, Christopher M. Bland, Susan E. Smith, Caroline Turpin, Rachel Musgrove
St. Joseph's/Candler Health System

Background: Antibiotic resistance remains a major global health threat. Bacterial production of β-lactamases is a key resistance mechanism, with AmpC β-lactamases commonly identified in some Enterobacterales isolates. Mortality from bacteremia caused by AmpC-producing organisms has been reported to be significant. The 2024 Infectious Diseases Society of America (IDSA) guidance recommends cefepime or carbapenems for the treatment of infections caused by organisms at moderate risk of significant AmpC production and advises against ceftriaxone and piperacillin/tazobactam due to concerns about inducible resistance. However, clinical studies have not yet demonstrated superior outcomes with cefepime or carbapenems compared with ceftriaxone or piperacillin/tazobactam in this setting.

Methods: A multicenter, retrospective chart review was conducted during the period of January 2015 to December 2025. Eligible patients were adults 18 years of age or older and admitted to either St. Joseph’s Hospital or Candler Hospital with at least one blood culture isolating Hafnia alvei, Enterobacter cloacae, Citrobacter freundii, Klebsiella aerogenes, Yersinia enterocolitica, or Serratia marcescens. Patients were excluded if the initial antibiotic regimen was started at an outside hospital, if empiric therapy included a fluoroquinolone, or if blood cultures were polymicrobial. The primary objective was to determine if the use of IDSA-nonpreferred antibiotics (ceftriaxone, piperacillin/tazobactam) as empiric therapy in patients with bloodstream infections caused by AmpC β-lactamase–producing Enterobacterales results in increased incidents of suboptimal patient outcomes, as measured by greater rates of mortality, compared with IDSA-preferred agents (cefepime, meropenem). Secondary outcome measures include requirement of change of antibiotic therapy, total duration of antibiotic therapy, incidence of relapsed bacteremia, and incidence of Clostridium difficile infection while inpatient. All qualitative data points were evaluated using Chi-square analysis. All quantitative data points were evaluated using t-test analysis. A p-value of less than 0.05 was considered statistically significant.

Results: A total of 184 patients were screened and 146 of those patients were included in the analysis. The remaining 38 patients were excluded based on the criteria mentioned above, with the most common being polymicrobial blood cultures. The breakdown of the organisms isolated is as follows – 59 Enterobacter cloacae isolates (40%), 48 Serratia marcescens isolates (33%), 29 Klebsiella aerogenes isolates (20%), 9 Citrobacter freundii isolates (6%), and 1 Hafnia alvei isolate (1%). There was no statistically significant difference with regards to in-hospital mortality between the IDSA-nonpreferred antibiotics (ceftriaxone, piperacillin/tazobactam) and the IDSA-preferred agents (cefepime, meropenem) (p > 0.05). Secondary objectives were comparable between the two groups as well.

Conclusions: Use of IDSA-preferred agents, such as cefepime or meropenem, did not lead to improved clinical outcomes in patients with bacteremia caused by AmpC-producing organisms. However, this study has several important limitations. Notably, the study period spanned the COVID-19 pandemic, which may have introduced confounding factors affecting patient outcomes, including mortality. The true clinical significance must be assessed in larger, prospective, randomized control trials.

Background:
Auto‑verification enables medication orders to bypass pharmacist review and verify automatically upon entry. Its use is limited to settings, such as the emergency department (ED), where a licensed practitioner oversees ordering, preparation, and administration. While this workflow improves efficiency in emergency departments (EDs), there are concerns regarding the safety of auto‑verifying high‑alert medications, which when used incorrectly can cause significant patient harm. At Cone Health, certain high‑alert agents, including opioids such as oxycodone, are permitted to be auto‑verified. Opioids carry risks for respiratory depression, overdose, and dizziness/lightheadedness leading to instability. A quality improvement evaluation was performed to assess whether auto‑verification of oxycodone-containing medications results in clinically meaningful errors or overlooked interventions.
Methods:
This IRB reviewed, determined exempt retrospective chart review included auto‑verified oxycodone immediate‑release 5 mg tablets and oxycodone/acetaminophen 5/325 mg tablets ordered in Cone Health EDs between January 1 and July 31, 2025. There were no exclusion criteria. A random sample of 140 orders (70 from each product) was selected using random date and order number generation. Outcomes measured in this study were incidence of order modification, prevalence of adverse effects, and quantity of documented pharmacist interventions. Adverse effects evaluated included overdose (naloxone use as a proxy) and allergic reaction.
Results:
A total of 9,456 auto‑verified orders were identified during the study period. Among the 140 orders analyzed, 82% (n = 140) had at least one modification during initial order entry. Frequency was the most modified order parameter (79%, n= 140). Dispense location changes occurred in a further 12% (n = 140) of all orders. No dose, route, start time, or stop time adjustments were observed. Oxycodone/acetaminophen orders had a higher rate of modification compared with oxycodone IR (91% vs. 73%).   None of the order modifications were made by a pharmacist. Rather, order modifications were made by providers and mid-level providers. Additionally, there were no documented pharmacist interventions and no adverse effects in the sample.
 Conclusion:
Auto‑verification of oxycodone products in the Cone Health ED was not associated with patient harm. Although modifications at initial order entry were common, these changes did not lead to errors. Expansion of this quality improvement process to additional opioids and other high‑alert medications is warranted.  

---

Title: Impact of Ciprofloxacin/Dexamethasone Utilization in Pediatric Tracheostomy Patients
Authors: Rachel Dickey, Andrea Gerwin, Stephanie Conrad
Background/Purpose: Ciprofloxacin/dexamethasone (cip/dex) is a combination antibiotic and corticosteroid that is available in a topical otic formulation. Current approved indications include the treatment of acute otitis externa and post-tympanostomy tube otorrhea. Cip/dex has been used off-label for reducing granulation tissue formation in pediatric tracheostomy patients by pediatric otolaryngologists for many years despite limited supporting data, mostly anecdotal. With long term use of cip/dex, there is theoretical concern for development of resistance to fluoroquinolone (FQ) antibiotics, such as ciprofloxacin and levofloxacin, the only enteral antibiotic formulations with effective broad-spectrum gram-negative coverage. The purpose of this review is to examine the influence of FQ exposure on antimicrobial resistance in our pediatric tracheostomy patients.
Methods: This study is a single center, retrospective review conducted using electronic health records of patients followed by Children’s Hospital at Erlanger between January 1, 2018 and December 31, 2025. Included patients had a tracheostomy and microbiological data available in the EHR. Patients were excluded if they received cip/dex drops via alternative route, were lost to follow up, or had care transferred to another institution. Patients were divided into groups based on history of FQ resistant or sensitive organisms. The primary outcome will evaluate total topical and systemic FQ exposure in patients who received cip/dex drops. Secondary outcomes will include number of respiratory cultures and rate of hospitalizations. Standardization of reported outcomes was achieved by normalizing cip/dex exposure, FQ exposure days, and days of hospitalization to patient tracheostomy days.
Results: Preliminary results include 16 patients in the FQ-sensitive cohort and 15 patients in the FQ-resistant cohort. Mean days of cip/dex per tracheostomy day were 0.06 (0-0.34) in FQ-sensitive group as compared to 0.05 (0-0.27) in the FQ-resistant group. The mean days of hospitalization per tracheostomy day were 0.76 (0.06-2.96) in the FQ-sensitive group as compared to 0.75 (0.01-8.42) in the FQ-resistant group. Approximately 56 % of the FQ sensitive group were male as compared to 60% of the FQ resistant group. Mean age (months) at tracheostomy was 8.73 (0.9-23.37) and 8.18 (1.70-29.70) in sensitive group and resistant group, respectively. The average number of cultures in the sensitive group and resistant group were 9.9 (2-34) and 10.9 (6-20).
Conclusions: There is a paucity of data on the impact of cip/dex drops on bacterial resistance patterns. The FQ-resistant cohort had more cultures than the FQ-sensitive patients. Patients with FQ-resistance had similar hospitalization days per tracheostomy days and tracheostomy duration when compared to the FQ-sensitive cohort. Both cohorts had similar ratios of systemic FQs and topical cip/dex exposure.

Title: Characterization of Extravasation Events in Brain and Spinal Cord Injury Rehabilitation Patients 

Authors: Muhan Wang, Lauren Wilcox, Virginia Montgomery 

Background: Extravasation injuries are a significant source of treatment-related harm in hospitalized patients, with reported incidences of non-vesicant extravasation ranging from 0.1% to 6% in adult patients. Extravasation events can result in tissue injury, necrosis, and increased healthcare costs if not promptly recognized and managed.  In the acute rehabilitation setting, caring for patients with acquired brain injury (ABI) and spinal cord injuries (SCI), identification of extravasation is particularly challenging. Impaired sensation, altered cognition and communication barriers can limit patients’ ability to perceive or report symptoms associated with infiltration and extravasation, leading to delayed recognition and more severe injury. Additionally, variability in documentation and management, including the use of non-pharmacologic interventions such as warm or cold compresses, can contribute to inconsistent care. This study evaluates current practices in the management and documentation of extravasation and infiltration events and to identify opportunities for standardization and process improvement to enhance patient safety. 
 
Methods: This retrospective, single-center cohort study included ABI and SCI rehabilitation inpatients admitted between July 1st, 2019, and July 31st, 2025. Adult patients (≥18 years) with peripheral intravenous lines (IV) who had documented extravasation or infiltration events within the institution or received phentolamine injection, terbutaline injection, or topical nitroglycerin 2% for extravasation or infiltration were included. Patients with central lines only or no IV access were excluded. Baseline characteristics were collected via EPIC electronic medical records. The primary outcome was to describe cases of extravasation. Secondary outcomes included identification of patient and treatment-related factors potentially contributing to extravasation risk. 
 
Results: A total of 43 documented events were identified among 33 patients. After excluding two patients due to one central line associated event and one event occurring outside the institution, 31 patients with 40 documented events were included in the final analysis. Among these patients, 16 had ABI, nine had SCI, and six had dual ABI and SCI. The study population was majority male (n=27, 87%) with a mean age of 49 years (SD 17). Of the 40 events, 12 (30%) could be attributed to IV medication administration. Medications administered within 24 hours of documented infiltration or extravasation events included anti-infectives (n=4), multiple medications administered during the same period (n=3), IV fluids (n=2), dopamine (n=2), or dexamethasone (n=1). No pharmacologic antidotes were administered in any documented extravasation cases. The majority of events (n=28, 70%) were not associated with medication administration reflecting line occlusion rather than extravasation or infiltration. Documentation review identified one instance of warm compress recorded as an intervention for line occlusion.  

Conclusion/Discussion: The results demonstrate most documented events were likely not true extravasations associated with medications, and no cases required pharmacologic antidote use. One of the limitations of the study is inconsistency in documentation. Discussions with nursing staff suggested documentation of infiltration or extravasation may represent an occluded IV line rather than medication leakage, contributing to misclassification. The development of a standardized order set presents an opportunity to further align documentation and management efforts. These findings highlight the important role of physical assessments, informed staff, and accurate and detailed documentation with appropriate details in identifying infiltration and extravasation events in a high-risk neurorehabilitation population. The findings offer a strong foundation for quality improvement focused on improving documentation accuracy, streamlining management approaches, and strengthening education. Collaborative education and the use of standardized tools may promote consistency and support patient safety within the rehabilitation setting. 

Utility of β-hydroxybutyrate as a defining criterion for diabetic ketoacidosis resolution in adults 
Kevin Fenter, Tyler Bui, Alvin Tomika 
 
Background: The criteria for determining resolution of diabetic ketoacidosis (DKA) have varied over the years. The most recent position statement published in 2024 by the American Diabetes Association (ADA) significantly modified the criteria for DKA resolution to include the use of beta-hydroxybutyrate (BHB). With the development of point-of-care ketone measurement devices it is more feasible to measure serum ketones to define DKA resolution; however, limited data exists on the benefit of serum ketones compared to traditional criteria historically used to define DKA resolution. The objective of this study is to evaluate the utility of BHB as a criterion for DKA resolution to successful transition from intravenous (IV) to subcutaneous (SUBQ) insulin. 
 
Methods: This study was a single center retrospective chart review of electronic health records between November 1, 2023, and October 31, 2025 of patients with DKA treated with intravenous regular insulin as well as additional standard of care therapy. The study included adult patients 18 years of age or older admitted to the hospital with a primary diagnosis of DKA. Patients must have been treated with IV regular insulin and transitioned to SUBQ insulin prior to discharge. Patients were excluded if received insulin infusions related to conditions other than DKA, if treated outside the institutional DKA order set/protocol, received concomitant treatment with IV regular insulin and SUBQ insulin, died, were discharged or enrolled in comfort care prior to insulin transition, pregnant or lactating, or if were missing key clinical data. 
 
Patients were stratified into two groups dependent on if BHB was collected and normalized (Group 1) or not BHB not normalized/collected prior to transition to subcutaneous insulin (Group 2). The primary outcome was post transition treatment failure within 48hrs defined as resumption of IV insulin or meeting two out of the three criteria for DKA diagnosis. Secondary outcomes include duration of ICU stay, duration of hospitalization, time from regular insulin initiation to initiation of SUBQ insulin, duration of IV insulin, hypoglycemia events during admission, IV insulin requirements prior to transition, and post transition insulin requirements. Outcomes were evaluated using statistical methods such as Fisher’s exact test and Mann-Whitney U test as appropriate. Demographics and baseline characteristics were evaluated using descriptive statistics.  
 
Results: A total of 105 patients met criteria for inclusion with 31 patients included within Group 1. The mean age was 44 years with 66% on home insulin prior to admission; of which 61% reported not compliant. Baseline characteristics were similar, however; Group 1 saw 90.3% of patients admitted to the ICU while Group 2 saw 46% admitted to the ICU. For the primary outcome of transition failure there was no statistically significant difference between the two groups (16.1% vs 13.5%, p=0.16). For the secondary outcomes there was no statistically significant difference for hospital length of stay, ICU length of stay, insulin requirements before and after transition as well as hypoglycemic events. In Group 1 there was a non-statistically significant trend toward longer duration of IV insulin therapy and time to transition to subcutaneous insulin.  
 
Conclusion: Among adults admitted for treatment of DKA and transitioned from intravenous insulin to subcutaneous insulin, resolution criteria utilizing normalization of beta-hydroxybutyrate to <0.6 mmol/L were not associated with decreased rates of transition failure.  
 
Contact Information: [email protected] 

Authors’ Names: Madison Moncus, Ashton Dickinson, Mary Massaro, Brandon Hawkins, Alexandra McBrayer, Clark Cutrer, Samantha Walker 

Background: Febrile neutropenia is a life-threatening complication in patients with malignancy and hematopoietic stem cell transplant (HSCT) recipients. Empiric anti-pseudomonal beta-lactam therapy is recommended; however, the optimal strategy for narrowing therapy based on culture data remains uncertain.  While de‑escalation to pathogen‑directed regimens is widely endorsed when microbiologic data is available, the evidence supporting this practice remains limited. Emerging data suggests de-escalation may safely reduce broad-spectrum antibiotic exposure; though evidence in high-risk populations, such as those with hematologic malignancy and HSCT recipients, is limited. This study evaluates the safety and efficacy of narrowing empiric therapy to pathogen-directed therapy in adults with malignancy and HSCT recipients. 

Methods: This retrospective cohort evaluates adult hospitalized patients with cancer-associated febrile neutropenia between January 2020 and January 2025. Eligible patients received initial empiric antipseudomonal beta-lactam therapy and had a positive bacterial culture obtained within 72 hours of fever onset. Patients with pseudomonal infections, organisms resistant to definitive therapy, ANC recovery (ANC > 500 cells/mm³) within 72 hours of initiating antibiotic therapy, or death within 72 hours were excluded. Patients were stratified into two groups: those who remained on empiric anti-pseudomonal therapy for more than 72 hours after susceptibility results became available, and those who were narrowed to pathogen-directed therapy within 72 hours. Data was collected securely via RedCap. The primary composite outcome included escalation of antibiotic therapy or infection recurrence within 30 days. Secondary outcomes included incidence of new onset Clostridioides difficile infection (CDI), hospital length of stay, all-cause mortality at 30 days, new positive culture with resistance demonstrated to initial treatment agents within 30 days, and time to de-escalation. Data collected included baseline demographics, cancer type, culture results, antibiotic regimens, fluoroquinolone prophylaxis, resistance patterns, and readmissions. Categorical variables were analyzed using chi-square or Fisher’s exact test, and continuous variables were analyzed using the Mann-Whitney U test. Data was analyzed utilizing SPSS. 

Results: A total of 44 patients met inclusion criteria, with 32 patients in the empiric therapy group and 12 patients in the pathogen‑directed therapy group. Baseline demographics, malignancies, and microbiologic characteristics were similar between groups, with most patients having hematologic malignancies and comparable distributions of gram‑positive and gram‑negative organisms. Patients de‑escalated to pathogen‑directed therapy received significantly shorter durations of antipseudomonal therapy (median 3 vs. 18 days, p < 0.001). De‑escalation typically occurred within 24 hours of susceptibility reporting (58%). The composite primary endpoint occurred in 72% of the empiric group and 42% of the pathogen‑directed group (p = 0.085). Antibiotic escalation was more frequent among patients who remained on empiric therapy (50% vs. 8%, p = 0.015), with meropenem accounting for most escalations (94%, p = 0.003). Rates of recurrent fever, repeat positive cultures, readmission due to infection, CDI, and 30‑day mortality were low and did not differ significantly between groups. Hospital length of stay was shorter in the pathogen‑directed group (7 vs. 20 days, p = 0.005). 

Conclusions: De‑escalation of empiric antipseudomonal therapy to pathogen‑directed therapy was associated with substantially reduced broad‑spectrum antibiotic exposure and shorter hospital length of stay without increased treatment failure, recurrent infection, or mortality. These findings support the safety of culture‑guided de‑escalation in adults with malignancy‑associated febrile neutropenia, including HSCT recipients, and highlight the need for larger multicenter studies to confirm generalizability across diverse oncology populations. 

TITLE: Impact of Vasopressin Initiation Timing on Outcomes of Septic Shock Patients Receiving Norepinephrine 

AUTHORS: Somer Pye, Steven Robinette, Jacquelyn Bryant, Logan Doriety 

OBJECTIVE: Assess the timing of vasopressin addition to norepinephrine in intensive care unit patients experiencing septic shock and the potential impact it has on patient outcomes. 

SELF-ASSESSMENT QUESTION: According to the 2026 Surviving Sepsis Guidelines, which vasopressor is recommended second line to norepinephrine in septic shock?

BACKGROUND: According to the 2021 Surviving Sepsis Guidelines, norepinephrine is recommended as the first-line vasopressor, with the addition of vasopressin as a second-line agent when mean arterial pressure cannot be maintained above 65 mmHg. However, the optimal timing for vasopressin initiation remains undefined.

METHODS: This is a retrospective, single-center cohort study of adult patients in the ICU at McLeod Regional Medical Center that received norepinephrine and vasopressin for at least 8 hours with an electronic diagnosis grouper (EDG) coded diagnosis of severe sepsis with septic shock between August 1, 2023 and July 31, 2025. The primary outcome of this evaluation includes length of time to achieving and maintaining a MAP of 65 mmHg for at least 4 hours without the need for additional vasoactive agents. Secondary outcomes included norepinephrine dose at 3 hours after vasopressin was initiated, incidence of in-hospital mortality, and ICU length of stay.  

RESULTS: A total of 170 patients were screened with 120 patients meeting the inclusion criteria. Of these, 33 were included in the vasopressin <3 hours group, and 87 belonged to the vasopressin ≥3 hours group. All baseline characteristics were similar across the two groups including age, sex, comorbidities, and initial resuscitation strategies with borderline differences in SOFA scores. The primary outcome was achieved in 4.5 hours ([IQR] 4-5) in the vasopressin <3 hours group and 4.3 hours ([IQR] 4-5) in the vasopressin ≥3 hours group (p= 0.55). Secondary outcomes in both groups are as follows: norepinephrine dose at 3 hours (mcg/kg/min) (0.45 [IQR] 0.24-0.5 vs. 0.3 [IQR] ) 0.2-0.5, p=0.33), in-hospital mortality (63.6% vs. 66.6%, p= 0.75), ICU length of stay (days) (5 [IQR] 3-7 vs. 7 [2-13], p=0.12). A subgroup analysis was performed to analyze patients that survived through vasopressor discontinuation. The primary outcome was achieved in 4.5 hours ([IQR] 4-4.7) in the early vasopressin group and 4.2 hours ([IQR] 4-4.7) in the late vasopressin group (p= 0.65).Secondary outcomes for both groups were as follows: norepinephrine dose at 3 hours (mcg/kg/min) (0.3 [IQR] 0.21-0.5 vs. 0.3 [IQR] 0.18-0.4, p=0.40), in-hospital mortality (42.1% vs. 34%, p= 0.26), ICU length of stay (days) (6 [IQR] 4.5-8.5 vs. 11.5 [IQR] 7-16, p=<0.001). Exploratory outcomes of renal dysfunction were as follows: improvement in Scr over 72 hours (57.9% vs. 41.7% p= 0.22), total UOP over 72 hours (mL/kg/hr) (1.80 [IQR] 1.30-2.50 vs. 1.35 [IQR] 0.37-2.5, p=0.59), and new requirement of renal replacement (25.9% vs 34.7%, p= 0.41). Additionally, average time to vasopressin initiation once norepinephrine dose reached 0.15 mcg/kg/min was analyzed between the two groups and was 1.5 hours ([IQR] 0.73-2) and 8 hours ([IQR] 4.46-25.32), respectively.   

CONCLUSION: In this retrospective cohort study, early vasopressin initiation (< 3 hours) was not associated with a statistically significant difference in time to achieving goal MAP or in-hospital mortality compared to later initiation (≥ 3 hours). A shorter ICU length of stay was observed in the subgroup analysis but should be interpreted cautiously. These findings contribute to the existing body of evidence suggesting that vasopressin timing alone may not significantly impact clinical outcomes. Future studies with larger sample sizes should further evaluate optimal timing of vasopressin initiation while accounting for patient severity and dynamic clinical factors.

Title: Evaluating The Risk of Hypertension Exacerbations in Women Taking Combined Oral Contraceptives with a Pre-Existing Diagnosis of Hypertension
Authors: Taylor Paris, Lisa Ambrose
Background: The purpose of this research is to evaluate the risk of women who are diagnosed with hypertension and are prescribed a combined oral contraceptive (COC) experiencing an exacerbation of their hypertension.  COCs have been shown to cause a modest increase in blood pressure, and their use is generally not recommended in patients with uncontrolled or significant hypertension. However, COCs still continue to be routinely prescribed for women with an existing hypertension diagnosis.
Methods: This single-center, retrospective study aimed to assess the association between combined oral contraceptive (COC) use and hypertensive exacerbations in women with preexisting hypertension. Eligible patients were identified through the electronic health record (EHR) by having an active COC prescription with a concurrent hypertension diagnosis at the time of COC initiation. Chart review was conducted using a standardized abstraction tool that evaluated five criteria: an increase in average blood pressure, an increase in the dose of existing antihypertensive medication(s), initiation of an antihypertensive agent, addition of another antihypertensive to current regimen, and the occurrence of a hypertensive event (i.e. stroke, MI). Binary yes/no responses were for each criterion to determine the presence or absence of hypertensive exacerbation. The goal of this analysis was to quantify the risk of hypertensive exacerbation associated with COC use and inform contraceptive decision‑making in this population.
Results: 14 patients were identified and reviewed within the EHR. 85% of patients met at least one defined criterion, and 64% met two or more criteria. Only 14% of patients did not meet any of the defined criteria. There was a 26% occurrence of 3 of the defined criteria (initiation of BP lowering therapy, dose titration of existing therapy, and increase in average BP reading) and a 22% occurrence of patients requiring addition of another medication. No patients experienced a hypertensive event.
Conclusion: These results suggest that contraceptive options other than COCs may be more appropriate for individuals with established hypertension. The findings highlight the importance of active blood pressure monitoring and medication management to reduce the risk of hypertensive exacerbations within this patient population. Ongoing provider education remains essential to ensure both clinicians and patients can make informed decisions for contraception that account for existing comorbidities.

Background: Opioids are analgesic medications that are commonly used for the management of moderate to severe pain. In hospitalized patients, opioid administration carries risks including respiratory depression, delirium, constipation, and potential long-term dependence, with opioid-naïve individuals being particularly at risk for adverse outcomes when exposed. While opioids are appropriate for moderate to severe acute pain, inpatient prescribing frequently occurs without documented acute pain indications. Characterizing opioid use in this population represents an important opportunity for opioid stewardship and quality improvement. 
Methods: This single-center, retrospective observational study evaluated opioid-naïve adult patients admitted to medical floors at a community teaching hospital between September 2024 and October 2025. Patients were included if they were ≥18 years of age, admitted to selected medical floors for at least 24 hours, had the “Admit to Med Surg” orderset added within 24 hours of admission, and opioid-naïve based on medication history and insurance claims data. Patients were excluded if they had operative procedures requiring anesthesia, chronic pain, acute pain indications, active cancer, opioid use disorder, pregnancy, incarceration, or enrollment in hospice or palliative care. Eligible patients were grouped based on patients with the as-needed (PRN) pain orders and patients without the PRN pain orders within the “Admit to Med Surg” orderset. The primary outcome was inpatient opioid exposure, measured in morphine milligram equivalents (MME), during the first seven days of hospitalization. Secondary outcomes included the rate of patients who received over the first seven days of admission, opioid prescription at discharge (MME and duration) and opioid-related adverse events requiring naloxone administration or intubation.  
Results: A total of 198 patients were included (65 with PRN pain orders, 133 without PRN pain orders). Mean opioid exposure over the first seven days of admission was significantly higher in patients with an PRN pain orders compared to those without (p<0.001, 95% CI 1.66(1.4997 - 1.8203)). For secondary outcomes, 61.5% of patients with the opioid orders received at least one dose of opioid medication, and only 17.2% of patients without the opioid orders received an opioid medication during admission. There was no difference between groups in opioid-related adverse events requiring naloxone.  Discharge opioid prescribing rates showed 4.6% of patients received a prescription in the group with the PRN pain orders compared to only 0.6% of patients without the PRN pain orders received an prescription for an opioid at discharge. Of patients who received a prescription at discharge, the average days supply of 3.67 days in the group with the PRN pain orders with an average MME of 80, whereas the group without the PRN pain orders had an average days supply of 2 with average MME of 75.  
Conclusion: Opioid-naïve patients without acute pain indications who had an PRN pain orders within 24 hours of admission experienced significantly higher inpatient opioid exposure at 7 days than those without. These findings highlight an opportunity for standardizing pain management strategies to help minimize unintended opioid exposure in this population.