2026 Southeastern Residency Conference

Introduction:
Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, is increasingly utilized for analgosedation in mechanically ventilated intensive care unit (ICU) patients due to its analgesic and sedative properties. Its effects are dose dependent, with lower infusion rates (0.1–0.4 mg/kg/hr) providing analgesia and higher rates (0.4–1.0 mg/kg/hr) producing sedation. At higher doses, ketamine may cause dissociative or psychiatric effects that can resemble ICU delirium. However, existing data on the relationship between ketamine and delirium are limited and conflicting, often without adequate adjustment for confounders or consideration of dosing variability. This study aimed to evaluate the association between maximum daily ketamine infusion rate and ICU delirium. A secondary objective assessed the relationship between cumulative ketamine dose and delirium.
Methods:
This multicenter retrospective cohort study included adult medical ICU patients requiring mechanical ventilation and received ketamine infusions for sedation between January 1, 2013 and June 30, 2025 at two tertiary care hospitals. Patients were excluded if ketamine was used for non-sedation indications, administered for less than 24 hours, or if continuous neuromuscular blockade was used. Demographic and clinical data were collected, including age, race, sex, Sequential Organ Failure Assessment (SOFA) score, comorbidities, history of substance use or psychiatric illness, and sedation-related variables. Additional data included ketamine infusion rates, cumulative ketamine dose, duration of ketamine therapy, timing of ketamine initiation, concomitant sedative or analgesic use, Richmond Agitation-Sedation Scale (RASS) scores, and Confusion Assessment Method for the ICU (CAM-ICU) scores.  
The primary outcome was ICU delirium, defined by a positive CAM-ICU at any point during ICU stay. A modified Poisson regression evaluated linear associations of delirium with the primary exposure variable, highest daily ketamine rate, and secondary exposure variable, cumulative ketamine dose. Covariates included SOFA score, cumulative morphine milligram equivalents (MME), cumulative benzodiazepines, and ICU length of stay (LOS). Logistic spline models and multivariate logistic regression were also conducted for both exposure variables. Other secondary outcomes, including mortality and LOS were analyzed using descriptive statistics, Mann Whitney U, or Chi Square as appropriate. 
Results:
Of 837 screened patients, 114 met inclusion criteria and 42 (36.8%) developed delirium. Baseline characteristics were similar between groups, with a median age of 57–58 years. There was no difference between those who developed delirium and those who did not with regard to the maximum daily ketamine infusion rate (0.6 vs 0.43 mg/kg/hr, p=0.08) and cumulative doses (3440.6 vs 2461.4 mg, p=0.10). Patients with delirium had longer mechanical ventilation duration (210.7 vs 140.9 hours, p<0.01), longer ICU length of stay (364.7 vs 268.6 hours, p=0.04), and higher opioid exposure (5126.8 vs 2911.8 morphine milligram equivalents, p=0.85). Benzodiazepine use and mortality were not significantly different.
In the modified Poisson regression, there was no association between maximum daily ketamine infusion rate and delirium (Relative risk ratio (RR) 1.15, p=0.21) or cumulative ketamine dose and delirium (RR 1.0, p=0.97). Duration of mechanical ventilation was independently associated with delirium in both regression models (RR 1.0, p<0.01). No association between maximum daily ketamine infusion rate or cumulative ketamine dose with delirium was seen in logistic spline or multivariate regression models.   
Conclusion:
Neither maximum daily ketamine infusion rate nor cumulative dose was associated with ICU delirium after adjustment for confounders. As seen in previous literature, duration of mechanical ventilation was associated with delirium. These findings suggest ketamine infusion rate and dosing may not significantly influence delirium risk, though prospective studies are needed to confirm these results.

Evaluating Different Bromocriptine Doses for Central Fever in the Intensive Care Unit 
Maggie Nobles, Zackery Moreo, Sam Pournezhad, Chelsea Wamsley 
[email protected]  
Grady Health System Department of Pharmacy 

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Background: Central fever is a diagnosis of exclusion characterized by persistent, noninfectious hyperthermia that is unresponsive to antipyretics and antimicrobial therapy. It is commonly observed in patients with acute neurologic injury and is thought to result from disruption of hypothalamic thermoregulatory pathways. Central fever has been associated with increased metabolic demand, prolonged ICU length of stay, and worse neurologic outcomes. Bromocriptine, a dopamine-2 receptor agonist, has been used off-label for central fever due to its ability to reduce hypothalamic set point and sympathetic activity. While prior studies support its antipyretic efficacy, there is limited evidence guiding optimal dosing strategies. This study aimed to evaluate the effectiveness of different bromocriptine doses for central fever in critically ill patients with neurologic injury to inform dosing decisions and institutional practice.  
Methods: This single-center, retrospective chart review was conducted at an academic safety-net hospital and included adult patients (≥18 years) admitted to the neurocritical care unit or surgical-trauma ICU between January 2023 and June 2025. Eligible patients received at least one dose of bromocriptine 2.5 mg, 5 mg, or 10 mg for suspected central fever. Patients were excluded if they had evidence of active infection, prior bromocriptine use before admission, death within 48 hours of bromocriptine initiation, or belonged to a protected population. Baseline demographic and clinical characteristics, neurologic diagnoses, and use of potential confounding therapies were collected. The primary outcome was fever resolution, defined as a temperature of ≤ 38.3°C within 2 hours of the initial bromocriptine dose, compared across initial dose groups. Secondary outcomes included sustained fever resolution at 8, 24, and 48 hours, assessed according to total daily bromocriptine dose. 
Results: A total of 274 patients were screened; 47 met inclusion criteria for the primary outcome analysis. Baseline characteristics were largely similar across groups, though differences in neurologic diagnosis and ICU admission location were observed. Fever resolution within 2 hours occurred in 78.6% of patients receiving an initial dose of 2.5 mg, compared with 37.5% in the 5 mg group and 47.1% in the 10 mg group. Fever resolution within 2 hours was significantly more frequent with 2.5 mg compared with 5 mg (p=0.024), while no statistically significant differences were observed between the 2.5 mg and 10 mg groups (p=0.073) or between the 5 mg and 10 mg groups (p=0.579). Secondary outcomes were similar across total daily dose groups, with no significant differences observed in sustained fever resolution at 8, 24, or 48 hours. Duration of therapy tended to increase with higher daily doses, though this did not reach statistical significance. No differences were observed in ICU length of stay or in-hospital mortality. 
Conclusion: More patients achieved fever resolution within 2 hours with the 2.5 mg dose, while no differences were observed between dose groups in sustained fever control. These findings suggest that bromocriptine’s antipyretic effect may not be dose dependent, and that lower initial dosing strategies may be reasonable for the management of central fever. Prospective studies are needed to further define optimal dosing strategies and evaluate safety outcomes. 

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​​​​Title: Evaluation of the Safety and Tolerability of Intravenous Push Dose Valproic Acid   
Authors’ names: Maryam Hashem, Kaitlyn Wallace, Olivia Morgan, Katleen Chester 
Email: [email protected] 

Background: Valproic acid (VPA) is an antiseizure medication that inhibits voltage-gated sodium channels and gamma-aminobutyric acid (GABA) transaminase and enhances GABA synthesis. Multiple VPA formulations are commercially available, but intravenous (IV) administration is preferred when patients lack oral access or require emergent treatment. Grady Memorial Hospital (GMH) transitioned from IV VPA maintenance doses administered via IV piggyback (IVPB) at a rate of 6 mg/kg/minute to slow IV push (IVP) over 2 to 5 minutes, due to the fluid shortages following Hurricane Helene. The transition to IVP VPA was based on limited available evidence evaluating the safety and operational efficiency of this administration strategy. The objective of this study was to investigate the safety, tolerability, and operational efficiency of IVP VPA compared to IVPB VPA.   

Methods: This was a single center, retrospective, observational study evaluating the safety, tolerability, and operational efficiency of IVP VPA maintenance doses (≤1500 mg) compared to IVPB from July 2024 to January 2025. Included patients were aged 18 years or older who received at least one dose of IV VPA. The primary outcome was the incidence of injection site reactions including injection site pain, discomfort, phlebitis, burning, infiltration, extravasation, or erythema. Secondary outcomes included number of doses received prior to a reaction, type of reaction, type of line medication was administered through, dispense location (central pharmacy or floor pyxis), and time from order verification to administration. Baseline characteristics such as age, gender, weight, location at the time of initial administration, and type of line were collected. Descriptive statistics were used to summarize baseline characteristics and outcoming using medians and interquartile ranges, or means and standard deviation, as appropriate. Continuous variables were compared using the Mann-Whitney U test, and categorical variables were compared using chi-square test.  

Results: A total of 200 patients met inclusion criteria and were included in the analysis. Baseline characteristics were similar between groups, with no significant differences in age between the IVPB and IVP groups or weight. In the IVPB VPA cohort, there were a total of 1,338 administrations; only 2 administrations resulted in a reaction. In the IVP VPA cohort, there were a total of 1,068 administrations; 8 administrations resulted in a reaction. Infiltration was the most common reaction, occurring in 2 patients in the IVPB group and 5 patients in the IVP group (p-value=0.07).  Burning occurred in two patients and erythema in one patient in the IVP group; neither finding was statistically significant (p-value=0.14 and 0.30, respectively). All patients continued to receive IV VPA after the initial reaction without a reported reoccurrence. Dispense location differed significantly between groups. All IVPB doses were prepared by the central pharmacy, whereas only 39% of IVP doses came from the pharmacy and 61% were dispensed from automated dispensing cabinets (p-value <0.001). The median time from pharmacist verification to administration of the first maintenance dose was 85 minutes in the IVPB group and 78 minutes in the IVP group; however, this finding was not statistically significant (p-value = 0.168).  

Conclusion: Injection site reactions were low overall. Implementation of IVP VPA did not result in a significant increase in injection site reactions when compared to IVPB VPA for maintenance doses, indicating that the switch to IVP for maintenance dosing is a safe and efficient practice. 
 

Evaluation of Updates to the Rabies Post-Exposure Prophylaxis Order Set
R. Tye Fobbs, Rachael Weingarten, Rachel Rumbarger
Cone Health at Moses Cone Hospital – Greensboro, NC
Background:
Rabies is a vaccine-preventable zoonotic viral disease affecting the central nervous system. The World Health Organization (WHO) recommends giving human rabies immune globulin (HRIG) to patients exposed to rabies if they have broken or punctured skin, or if their mucous membranes were contaminated with saliva from a mammal confirmed to have rabies or if the animal is not up to date on rabies vaccinations or the animal is unavailable for quarantine and observation. In the last 10 years, the utilization of rabies immunoglobulin and vaccinations has more than doubled in Cone Health emergency departments. There is no attributable cause to this increase in vaccination across our health systems. Inappropriate use of rabies post-exposure prophylaxis results in unnecessary costs and medical risks. A recent medication use evaluation explored the use of HRIG and rabies vaccines at Cone Health. Results showed that rabies post-exposure prophylaxis use in the emergency departments was not in accordance with WHO guidelines approximately 31% of the time.  In May 2025, Cone Health introduced a rabies post-exposure prophylaxis order set to help guide providers in assessing the need for post-exposure prophylaxis for individual patients who meet criteria as well as providing a dose rounding protocol to decrease waste. This study aims to evaluate the implementation of the new rabies post-exposure prophylaxis order set in relation to the recommended WHO guidelines.
Methods:
This was an IRB-reviewed, determined exempt retrospective, pre-post comparator study of patients who received human rabies immune globulin (HRIG) in Cone Health emergency departments. Data was collected between January to June 2024 for the pre-intervention group and June to December 2025 for the post-intervention group. Patients were excluded if they received immune globulin at an urgent care center, did not meet inclusion criteria for dose rounding or weighed less than 37.5 kg. The primary outcome was appropriate use of HRIG. Secondary outcomes included amount of HRIG given, amount that would have been given based on weight-based dosing, amount of waste saved, cost savings incurred, number of patients that received < 90% or > 110% of their weight-based dose, and re-presentation within 30 days for a suspected adverse reaction to HRIG.
Results: A total of 170 patients were screened with 70 patients in the pre-protocol group and 100 patients in the post-protocol group. The post protocol group was associated with a higher proportion of appropriate administration of HRIG when compared to the pre-protocol group [90 (90%) vs. 48 (68.5%); p = 0.0005]. There were no patients who represented within 30 days for a suspected adverse reaction to HRIG.
Conclusions: Implementation of a rabies post-exposure prophylaxis order set resulted in increased compliance with administration of HRIG per WHO guidelines. Dose rounding did not result in representation within 30 days for a suspected adverse reaction to HRIG and decreased overall waste. These findings suggest that having an established order set and dose rounding protocol increases compliance with WHO guidelines while decreasing waste.
 
  

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Authors: Yasmeen A. Ettrick, Kelly M. Bodine, John Patka, Shauntrell Johnson
Background: Traumatic brain injury (TBI) is a major cause of morbidity and mortality and is frequently complicated by cerebral edema and elevated intracranial pressure. Osmotic therapy with hypertonic saline is a key intervention to mitigate secondary brain injury; clinical guidelines, however, recommend its use for symptomatic neurologic deterioration rather than prophylactic administration. At Grady Memorial Hospital, 3% sodium chloride is commonly used in the emergency department (ED), often prior to neuroimaging due to clinical urgency.
Methods: This single-center, retrospective cohort study was conducted at Grady Memorial Hospital, a Level I trauma center in Atlanta, Georgia. Adult patients (≥18 years) presenting to the emergency department with traumatic brain injury who received at least one dose of 3% sodium chloride between January 1 and June 30, 2024, were included. Patients were excluded for pregnancy, incarceration, non-traumatic indications, transfer from outside facilities, or initial administration after hospital admission. The primary outcome was appropriateness of 3% sodium chloride use, defined by the presence of clinical findings and radiographic evidence of herniation or midline shift. Secondary outcomes included total volume administered and changes in serum sodium and osmolarity.
Results: A total of 65 patients met inclusion criteria, of whom 57 received 3% hypertonic saline prior to CT imaging and 8 received it after imaging. Patients treated prior to CT were younger (median age 40 vs 62 years, p = 0.056) and had lower Glasgow Coma Scale scores (median 4 vs 11, p = 0.013), while hemodynamic parameters were similar between groups. Appropriateness of 3% sodium chloride use was observed in 54.4% of pre-CT administrations compared with 25% post-CT, though this difference was not statistically significant (p = 0.149). Median total volume administered was 500 mL prior to CT and 250 mL after CT, with no significant difference. Median serum sodium increased by 5 mEq/L in the pre-CT group and 4 mEq/L in the post-CT group (p = 0.635), while median serum osmolarity increased by 8 mOsm/L and 3 mOsm/L, respectively (p = 0.45).
Conclusion: In this cohort, 3% hypertonic saline was most often administered before CT imaging, typically in patients with more severe neurologic impairment. Pre-CT administrations were more frequent and more likely to meet guideline criteria than post-CT hypertonic administration, though some still lacked clinical or radiographic indications. Neither pre-CT nor post-CT administration was associated with harmful changes in serum sodium or osmolarity, suggesting that early use may be safe when clinically justified.
Objective: To evaluate the timing, utilization patterns, and physiologic effects of 3% sodium chloride administration in adult ED patients with TBI.
Self-Assessment Question: Identify the recommended indication for hypertonic saline use in adult patients with traumatic brain injury. 

Comparison of Tenecteplase versus Alteplase for Pulmonary Embolism During In-Hospital Cardiac Arrest  
Authors: Paola Reyes-Serrano, Jason Vilar, Emily To 
Background: Pulmonary embolism (PE) accounts for approximately 2–5% of in-hospital cardiac arrests (IHCA) and is associated with high mortality despite advanced resuscitative efforts. Current guidelines recommend systemic thrombolysis when PE is suspected or confirmed during cardiac arrest; however, evidence supporting thrombolytic use in this setting remains limited. Alteplase has historically been the most commonly used thrombolytic agent for PE, while tenecteplase offers potential advantages, including greater fibrin specificity, longer half-life, and administration as a single intravenous bolus. This study aimed to compare clinical outcomes and safety of tenecteplase versus alteplase for suspected or confirmed PE during IHCA following a system-wide formulary change. 

Methods: A retrospective cohort study was conducted across AdventHealth facilities. Adult patients who experienced IHCA and received systemic thrombolysis with alteplase or tenecteplase for suspected or confirmed PE between January 2024 and January 2026 were included. Suspected PE was defined by provider clinical assessment at the time of arrest. Baseline demographic characteristics, arrest characteristics, laboratory values, and PE risk factors were collected from the electronic health record. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included time from arrest to thrombolytic administration, time from thrombolytic administration to ROSC, cardiopulmonary resuscitation (CPR) duration, ICU and hospital length of stay, in-hospital mortality, and neurologic outcomes at discharge. Sustained ROSC was defined as ROSC maintained for at least 20 minutes. Safety outcomes included major bleeding events and blood transfusion requirements. Continuous variables were compared using Mann–Whitney U tests, and categorical variables using chi-square or Fisher’s exact tests. 

Results: A total of 48 patients met inclusion criteria, 26 received alteplase and 22 received tenecteplase. ROSC occurred in 16 patients (33%), 10 patients (38.5%) in the alteplase group and 6 patients (27.3%) in the tenecteplase group. Sustained ROSC occurred in 7 patients (15.4%), 4 patients (15.4%) in alteplase group and 3 patients (13.6%) in tenecteplase group. Median time from thrombolytic administration to ROSC was 9.5 minutes (IQR 1.75–12.75) with alteplase and 13.5 minutes (IQR 5.75–16.25) with tenecteplase. Median total CPR duration was 41.0 minutes (IQR 22.5–54.0) with alteplase and 33.5 minutes (IQR 22.0–48.8) with tenecteplase. CPR duration following thrombolytic administration was similar between groups (16.5 minutes in both groups). Median time from arrest to thrombolytic administration was 18.5 minutes (IQR 11–31.3) with alteplase and 14.5 minutes (IQR 6.75–27.3) with tenecteplase. In-hospital mortality occurred in 24 patients (92.3%) who received alteplase and 22 patients (100%) who received tenecteplase. Neurologic outcomes were similar, with a median modified Rankin Scale (mRS) score of 6 (IQR 6–6) in both groups. Major bleeding occurred in 2 patients (7.7%) in the alteplase group and 2 patients (9.1%) in the tenecteplase group. Blood transfusion requirements were low, occurring in 1 patient (3.8%) in the alteplase group and 2 patients (9.1%) in the tenecteplase group. Baseline characteristics differed between groups in several variables. Patients who received tenecteplase were older (66.5 vs 58.5 years) and had lower median weight (73.9 vs 99.5 kg). Tenecteplase dosing was appropriate based on weight in 19 of 22 patients (86%), while 3 patients (14%) received doses outside of recommended weight-based ranges.  

Conclusion: In this multicenter retrospective cohort of patients receiving systemic thrombolysis for suspected pulmonary embolism during in-hospital cardiac arrest, tenecteplase demonstrated clinical and safety outcomes comparable to alteplase. Rates of ROSC, bleeding events, and mortality were similar between treatment groups despite baseline differences in patient characteristics. Given its single intravenous bolus administration and comparable outcomes observed in this cohort, tenecteplase may represent a practical alternative to alteplase for thrombolytic therapy during cardiac arrest when pulmonary embolism is suspected. Larger prospective studies are needed to better define optimal thrombolytic selection in this high-risk population.

Introduction:   
Hepatitis C (HCV) remains a significant public health concern in the United States, with an estimated 2.4 million people living with chronic infection. Untreated HCV is a leading cause of chronic liver disease, and a major contributor to the development of cirrhosis, hepatic carcinoma and death. HCV management has been revolutionized by direct-acting antivirals (DAAs). Regimens such as sofosbuvir/velpatasvir (Epclusa™), glecaprevir/pibrentasvir (Mavyret™), ledipasvir/sofosbuvir (Harvoni™), and sofosbuvir/velpatasvir/voxilaprevir (Vosevi™) achieve cure rates exceeding 95%  with short, well-tolerated treatment courses.1Treatment success is assessed by sustained virologic response (SVR), assessed 4–12 weeks after therapy completion and indicated by an undetectable HCV RNA level. Treatment failure was a detectable HCV RNA during the same post-treatment assessment window. 
 
A key consideration in DAA therapy, Mavyret excluded, is their requirement for an acidic gastric pH, raising concerns for patients prescribed acid-suppressive agents such as proton-pump inhibitors (PPI) and histamine-2-receptor antagonists (H2RA). Guidelines recommend modifying PPI dose when they exceed 20 mg of omeprazole or an equivalent, as pharmacokinetic studies demonstrate reduced DAA exposure at higher doses.  H₂RAs have a less pronounced interaction, with coadministration permitted up to 40 mg twice daily of famotidine or an equivalent. Although the clinical impact is not fully established, reduced exposure may affect efficacy. PPIs remain among the most commonly prescribed medication classes in the United States, with many available over the counter, increasing the risk of unreported use and overlooked interactions. This study evaluates virologic response rates in patients treated for HCV with and without concurrent acid-suppressive therapy at Grady Memorial Hospital. 
 
 
Study Design and Methods:  
A retrospective analysis was conducted to compare SVR achievement in patients who did and did not receive acid suppressive therapy during HCV treatment. Patients were included if they are ≥18 years of age, diagnosed with HCV, completed treatment and had a documented post-treatment HCV RNA level. Patients were excluded if they had an incomplete treatment course for HCV, were lost to follow up or had no documented viral load 4-12 weeks after completion of therapy. Patients were stratified by use of acid suppressive therapy. The primary outcome was the rate of SVR achievement after treatment of HCV between groups. Secondary outcomes include differences in SVR between PPI’s including the drug and dose, differences in SVR between PPI and H2RA and differences in SVR based on cirrhosis state. Descriptive statistics were utilized for baseline characteristics, and demographic information. Chi Square test was used to analyze the rates of SVR between groups. 
Results:  
Among 736 adults who completed HCV treatment and had follow-up viral load testing, 359 (48.8%) received concomitant acid-suppressant therapy and 377 (51.2%) did not. Baseline characteristics were similar between groups. SVR rates were high overall and did not differ significantly between the two groups (96% vs 95%; p = 0.578). SVR differed by specific acid-suppressant agent (p < 0.001). Among patients receiving acid suppression, SVR was highest in those receiving omeprazole (98%) and ranitidine (98%), followed by famotidine (97%) and pantoprazole (94%). Patients receiving esomeprazole had the lowest SVR rate at 87%, corresponding to a higher proportion of treatment failures (13%) compared with other agents (2–6%). Overall, cure rates remained above 90% for all agents except esomeprazole. Patients receiving guideline-recommended acid-suppressant dosing achieved higher SVR compared with those receiving non-recommended dosing (97% vs 74%; p < 0.001). 
 
Conclusion:  
Concomitant acid-suppressant use was not associated with reduced SVR achievement, supporting current guideline recommendations that PPIs and H2RAs, when used at guideline recommended doses, can be safely continued during HCV therapy. 

• Title: Incidence of Chronic Opioid Use Post-Surgical Exposure in Opiate Naïve Patients 
• Authors: Rachel Peña, PharmD, Caitlin Thomas, PharmD, BCCCP, James Neilen, PharmD
• Objective: The purpose of this study was to evaluate the association between discharge opioid supply ( ≤3 days vs ≥7 days) and the development of chronic opioid use in opioid naive post-surgical patients. 
• Background: Opioids are used as an effective treatment for post-operative management, trauma, or chronic pain, but can be limited by their side effects and undesirable dependence if dosed improperly or lead to recreational misuse. Current literature states that by limiting opioid supply to 3 or fewer days post-operatively after discharge, there are fewer conversions to long term opioid users among opioid naïve patients.  Evaluating similar opioid prescribing practices as in the literature may help to inform safer prescribing practices at our institution.  
• Methods: A single center retrospective study was performed in a large acute care community teaching hospital from January 1, 2024 through December 31, 2025. Patients were identified between January 1, 2024 to December 31, 2024, with follow up Prescription Drug Monitoring Program (PDMP) data collected for up to one year post discharge through December 31, 2025 to track prescription opioid fills.  Adults admitted to the hospital who underwent surgery and were opiate naïve (defined  as patients who have not filled an opioid prescription in the previous 6 months prior to surgery) were included in the study. Patients were excluded if they had a history of substance abuse, had cancer or chronic pain, had a cardiac, spinal, or oncological related surgery, and if they underwent another surgery within the 1-year study period after the initial surgery. Patients who were discharged with an opioid supply of 3 days or less were compared to patients discharged with an opioid supply of 7 days or more. Chronic opioid use was defined as having filled 10 or more prescriptions or 90 days of continuous use within a 1-year period after surgery. The primary endpoint was the incidence of new, persistent opioid use defined as more than 10 opioid prescription fills or more than 90 days of continuous use. Secondary endpoints included the types of opioids prescribed, inpatient and outpatient MME (daily and total), type of surgery, 3-month, 6-month, and 1 year prescription fill quantities post discharge.  
• Results: Of the 676 patients screened, a total of 332 patients (281 in comparator group, 51 in study group) met inclusion criteria. Of this population, 229 (69%) were male, the average hospital length of stay was 3.31 days, the average opioid supply in days on discharge was 7.02, average morphine milligram equivalent (MME) for discharge opioid supply was 35.56. The most prescribed opioid on discharge was oxycodone 5 mg immediate release tablet (42.2%) and most common surgery type among the population was cesarean section (26.5%). Of the 332 patients, 4 (1.2%) filled more than 10 opioid prescriptions within 1 year after discharge, and 4 (1.2%) had more than 90 days of continuous use of opioids within 1 year after discharge. Of the patients who filled more than 10 opioid prescriptions and had more than 90 days of continuous use of opioids, all 4 of the patients were from the comparator group that had been discharged with 3 days or less supply of opioid upon discharge (P=1.000) . None of the patients in the study group filled more than 10 opioid prescriptions or had more than 90 days of continuous opioid use after discharge. The average number of fills at 3 months after discharge was 1.09, at 6 months was 1.18, and after 1 year was 1.36. 
• Conclusion: Patients who were prescribed ≥ 3 days of opioids post-operatively at discharge did not have an increase in long term usage of opioids after 1 year.  

Lauryn Malone, Ben Casey, Darby Siler 
TriStar Centennial Medical Center – Nashville, TN 

Background: Febrile neutropenia (FN) is a common complication of cancer treatment and is considered to be an oncologic emergency. Vancomycin is primarily used to treat infections caused by methicillin-resistant Staphylococcus aureus. FN guidelines do not recommend routine use of MRSA coverage as empiric therapy for FN unless pre-specified criteria are fulfilled. Despite these recommendations, previous studies suggest vancomycin is often prematurely added to empiric antibiotic therapy regimens in patients with febrile neutropenia. Utilization of vancomycin empirically in FN has been increasing, though its clinical utility remains uncertain due to the lower incidence of resistant gram-positive organisms causing FN. The purpose of this study was to evaluate the utilization and prescribing patterns of empiric vancomycin for febrile neutropenia at our facility. 
 
Methods: Patients were identified based on having vancomycin ordered for the indication of febrile neutropenia. Patients were included if they had a fever and were neutropenic. Exclusion criteria consisted of patients ages 18 years of age or younger, patients receiving care under the pediatric oncology service, patients without a diagnosis of cancer, and patients with vancomycin ordered for less than 24 hours. The primary outcome was to evaluate the incidence of guideline-directed utilization of empiric vancomycin for febrile neutropenia. Secondary outcomes included the duration of fever, appropriateness of gram-positive and gram-negative coverage, incidence of positive blood cultures, and prescribing patterns among various specialties. Descriptive statistics were used to report outcomes. 
 
Results: A total of 153 patients were screened; 38 patients met inclusion criteria, and 115 patients were excluded due to receiving vancomycin for less than 24 hours. Of the 38 patients included, 89% (n =34) had hematologic malignancies, with a cohort age range of 28–80 years. Among the 38 patients evaluated, 26 (68%) received empiric MRSA coverage consistent with established FN guidelines. The most common indication for empiric vancomycin was concerns for pneumonia on imaging (13/38 patients; 34%). The average duration of MRSA coverage was 93.8 hours (SD: 63.7 hours). Emergency medicine providers initiated empiric vancomycin for 17/38 patients (45%). No adverse reactions were noted for included patients.
 
Conclusions: This study found that in patients presenting with FN who were empirically started on vancomycin, therapy was routinely discontinued within 24 hours. This study also found that in patients who received vancomycin for greater than 24 hours, vancomycin utilization was discordant with guideline recommendations for MRSA directed therapy in FN, highlighting the potential need for antimicrobial stewardship intervention for this patient population. 
 
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Authors: Mackenzie G. Pearsall, John Williamson, Mary Banoub, Charles Hartis, Elizabeth Palavecino, Vera Luther, Erin Barnes, Erika Swintosky, Michael DeWitt, Jennifer J. Wenner, Olivia Randazza

Background/Purpose: Staphylococcus aureus is a common organism associated with bone and joint infections (BJI).  Historically, the standard of care (SOC) treatment for BJIs is prolonged intravenous (IV) antibiotic therapy. Studies have compared alternative BJI treatments, including oral antibiotics and long acting lipoglycopeptides like dalbavancin, to SOC with no significant differences in clinical outcomes. This study aims to compare the clinical success of dalbavancin with or without an oral antibiotic versus oral antibiotics alone for the treatment of S. aureus BJI after IV lead-in.   
 
Methods: This is a multisite, retrospective, cohort study including adult patients with a documented S. aureus BJI. Patients were randomly identified using microbiologic culture data until there were 52 matched pairs on initial or recurrent infection. Eligible patients were those treated with dalbavancin with or without an oral antibiotic or an oral antibiotic alone who received 50% or less of the planned total treatment duration as IV lead-in. Patients were excluded if they had a polymicrobial BJI, concomitant endocarditis, valvular abscess, or infectious central nervous system involvement, if the S. aureus isolate was resistant to the antibiotic received, or if they had persistent bacteremia.  The primary outcome was clinical success at 90 days from the end of therapy. Secondary outcomes included identification of factors associated with clinical failure, incidence of adverse events, therapy discontinuation, incomplete therapy, and hospital readmission at 30 and 90 days. The results were analyzed using descriptive statistics. Categorical data was analyzed using Pearson’s chi-squared or Fisher’s exact test, and continuous data was analyzed using the Wilcoxon rank sum test. A univariate logistic regression was completed to identify factors associated with clinical failure. 
 
Results: In total, 1287 patients were screened, and 104 patients were included in the study with 52 patients in each cohort. The sample size was limited by the number of patients who received dalbavancin within the study period. 
  
The median age of the overall cohort was 50 years. There was a significant difference in the incidence of current or history of illicit intravenous drug use (IVDU) between the two cohorts, representing 19.2% of the oral cohort compared to 55.8% of the dalbavancin cohort (p<0.001).  Types of BJI were similar between the groups (dalbavancin vs. orals), including native osteomyelitis (37% vs. 50%, p=0.2), native joint septic arthritis (21% vs.17%, p=0.6), and prosthetic joint or hardware-associated infection (35% vs. 25%, p=0.3). However, the dalbavancin cohort contained significantly more cases of vertebral osteomyelitis (15% vs.1.9%, p=0.031) and MRSA isolates (77% vs. 52%, p=0.008). There was no difference in presence of source control (81% vs. 92%, p=0.085), however the dalbavancin group had significantly longer duration of IV lead-in (median 160 vs. 96 hours, p<0.001). 
 
The incidence of clinical success was 71% in the dalbavancin cohort compared to 69% in the oral cohort (p=0.8). There was a non-significant trend towards a higher rate of incomplete therapy in the dalbavancin cohort compared to the oral cohort (21% vs 9.6%, p=0.10). There were no significant differences in the rates of other secondary outcomes. The estimated cost savings were not significantly different between cohorts, with a median savings of $79006 in the dalbavancin cohort compared to $65580 in the oral cohort (p=0.5). 
 
None of the factors assessed in the univariate logistic regression (bacteremia, retained prosthetic material, IVDU, source control, incomplete therapy, isolate resistance to methicillin, and vertebral osteomyelitis) were significantly associated with clinical failure. Patients who obtained source control had a numerically lower rate of clinical failure (OR 0.36, p=0.084). 
 
Conclusions: In this cohort, there was no difference in clinical success between the oral antibiotic and dalbavancin treatment strategies after IV lead-in in S. aureus bone and joint infections.